Neonatal Sepsis3

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NEONATAL SEPSIS
Dr. L. Manglem Singh
Paediatrician,
J. N. Hospital, Porompat
Imphal, Manipur.

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Neonatal Sepsis
Clinical syndrome of bacteraemia
characterized by systemic signs and symptoms of
infection in the first four weeks of life

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Early vs Late onset sepsis

Early onset Late onset
Age <72 hours >72 hours
Risk factor Prematurity Prematurity
Amnionitis,
Maternal infection
Source Maternal genital Environmental
tract (nosocomial)
Presentation Fulminant slowly progressive
Multisystem focal
Pneumonia frequent Meningitis frequent
Mortality 5-50% 10-15%

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Natural course of sepsis

Bacteria
Focal infection Bacteraemia
sepsis
Sepsis syndrome
Early septic shock
Refractory septic shock
MODS
DEATH

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Incidence
In India
- 3.9 % of all imtramural births
- 20 – 30 % develop meningitis
In developed countries
- 1 in 1000 live births - Term
- 4 in 1000 live births - Preterm
- 300 in 1000 VLBW babies

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Etiology

Escherichia coli
Staphylococcus aureus
Klebshiella pneumonae

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Risk Factors associated with Neonatal Sepsis

Maternal Risk Factors

1. Intrapartum Maternal Infection
- Purulent / foul smelling liquor
- Fever (>38
0
C)
- Leucytosis (WBC >18000 / mm
3
)
2. Premature rupture of membranes
3. Prolonged rupture of membranes > 12 hours
4. Premature onset of labour (<37 weeks
5. Maternal UTI

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Neonatal Risk factors
1. Low Birth Weight Baby
2. Perinatal asphyxia
3. Male gender

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Symptoms of Neonatal Sepsis
CNS
Lethargy, Refusal to suckle, Limp, Not arousable,
poor or high pitch cry, Irritable, Seizures
CVS
Pallor, Cyanosis, Cold and clammy skin
Respiratory
Tachypnoea, Apnoea, Grunt, Retractions

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Symptoms of Neonatal Sepsis
GIT
Vomiting, Diarrhoea, Abdominal distension
Haematological
Bleeding, Jaundice
Skin
Rashes, Purpura, Pustules

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Laboratory Diagnosis of Neonatal Sepsis
1. Direct methods
- Blood culture
- CSF culture
- Urine culture
2. Indirect methods
- Total leucocyte count
- Absolute neutrophil count
- Total immature neutrophils
- Immature to total neutrophols
- Neutrophil Morphology
- Platelet count
- Micro ESR
- Acute phase reactants
- Buffy coat examination
- Smear of gastric aspirate / External ear canal fluid
- C3d

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SEPSIS SCREEN
At Birth

Major risk factors
1. Rupture of membranes > 24 hours
2. Maternal intrapartum fever > 100.4
0
F
3. Chorioamninitis
Minor risk factors
1. Rupture of membrane > 12 hours
2. Maternal intrapartum fever > 99.5
0
F
3. Maternal WBC > 15000 / mm
3

4. Low apgar score(< 5 at 1 min, < 7 at 5 min)
5. LBW ( < 1500 g )
6. Preterm labour ( < 37 weeks)

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SEPSIS SCREEN

1. Leucopenia (TLC < 5000 / mm3)
2. Neutropenia (ANC <1800 / mm3)

3. Immature neutrophil to total neutrophil
( I / T) ratio ( > 0.2)
4. Micro – ESR ( > 15 mm / 1
st
hour )
5. CRP - positive

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Approach to Neonatal Sepsis


Antenatal Postnatal
Mothers with risk factors
Symptomatic Asymptomatic
infants infant with risk
factors

Term Preterm

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Evaluation of symptomatic infant for sepsis
- Sepsis screen
- Chest X-ray
- Lumbar puncture
- Blood culture

Begin Antibiotics
Culture positive No risk factors for sepsis
Presence of focal infection Culture negative
Sepsis screen positive Sepsis screen negative
LP abnormal Symptoms resolve by 24 hrs
Symptoms persists 72 hrs
Treat pneumonia 7-10 days Treat for 48-72 hrs
Septicaemia 10-14 days and discharge
Meningitis 14-21 days

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Evaluation of asymptomatic infant for sepsis
Sepsis screen
Sepsis screen Sepsis screen Blood culture, LP
negative positive
Begin Antibiotics
Observe for 48-72 hrs Culture positive Culture negative
and discharge LP abnormal LP normal
Treat septicaemia 10-14 days Treat for 48-72 hr
Meningitis for 14-21 days and discharge

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Supportive Care
- Keep the neonate warm
- Start IV Fluid, Infuse 10% Dextrose 2ml / Kg

stat to maintain normoglycaemia
- Maintain fluid and electrolyte balance and
tissue perfusion
If CRT > 3 sec infuse 10 ml / Kg normal
saline

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Supportive Care
- Avoid enteral feed, if sick
- Start oxygen by hood, if cyanosed
and support breathing

- Consider exchange blood transfusion,
if there is sclerema, DIC, Neutropenia

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Choice of Antibiotics
Pneumonia or Sepsis

Penicillin + Aminoglycoside
(Ampicillin or Cloxacillin) (Gentamicin or Amikacin)

Meningitis
Ampicillin + Gentamicin
or
Cefotaxime + Gentamicin or Amikacin

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Superficial Infections

- Pustules - After puncturing, clean with
betadine and apply antimicrobial
- Conjunctivitis- Chloramphenicol eye drops
- Oral thrush - Local application of Nystatin
or Clotrimazole

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Prevention of Infection
- Exclusive breastfeeding
- Keep cord dry
- Hand washing by care givers
- Hygiene of Baby
- No unnecessary intervention
- Better management of IV Lines
- Disinfection of Equipments

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Hand Washing

- Single most important means of
preventing nosocomial infections
- Very Simple
- Cheap

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Hand Washing
- Two minutes, hand washing to be done
before entering baby care area
- 10 seconds hand washing to be done before
and after touching every baby, and after
touching unsterile surfaces and fomites

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Steps of effective hand washing
- Roll sleeves above elbow
- Remove wrist watch, bangles, ring etc
- Using plain water and soap, wash parts of the
hand in the following sequence
- Palm and fingers (web spaces)
- Back of hands
- Fingers and Knuckles
- Thumbs
- Finger tips
- Wrists and forearm up to elbow

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Steps of Effective Hand Washing
- Keep elbow always dependent
- Close the tap using elbow
- Dry hands using single use sterile
paper / napkin
- Do not keep long or polished nails

Rinsing hands with alcohol is
NOT A SUBSTITUTE for PROPER HAND WASHING

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Medication preparation

( Prepare IV fluid under aseptic conditions )
- Never use stock solution for flushing
- Do not use a single bottle for > 24 hrs

- Label bottle with date / time
- After seal is removed, use betadine soaked
sterile cotton to cover the stopper of bottle
- Use disposable needle each time

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Better management of IV Lines
- Thorough hand washing
- Wear gloves
- Use disposable IV cannula
- Thorough skin preparation
- All IV ports should be wiped with alcohol
- Early identification of extravasation
- Avoid unnecessary IV infusion

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Conclusion
- High index of clinical suspicion
- Look for Lab evidence of sepsis
- Start parenteral antibiotics (intravenous)

- Provide supportive care
- Review culture reports
- Practise barrier nursing to prevent
Cross–infection

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Thank you