. rahat bin habib

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  1. 1. Dr. Rahat bin Habib. MDDr. Rahat bin Habib. MD ICMH, Matuail, Dhaka.ICMH, Matuail, Dhaka.
  2. 2. SEPSIS IN NEWBORNSEPSIS IN NEWBORN All newborns enter an unsterileAll newborns enter an unsterile environment,but infection develops inenvironment,but infection develops in only a few.only a few.
  3. 3. ABSTRACTABSTRACT ****Infections are the single largest cause of neonatalInfections are the single largest cause of neonatal death globally.death globally. **Clinical features of sepsis are non-specific in**Clinical features of sepsis are non-specific in neonates and a high index of suspicion is requiredneonates and a high index of suspicion is required for the timely diagnosis of sepsis.for the timely diagnosis of sepsis.
  4. 4. **It is responsible for about 30-50%of the total**It is responsible for about 30-50%of the total neonatal deaths in developing countries.neonatal deaths in developing countries. **Neonatal death in our country is 37/1000 live**Neonatal death in our country is 37/1000 live birth.birth. **sepsis related mortality is largely preventable**sepsis related mortality is largely preventable with rational antimicrobial therapy and aggressivewith rational antimicrobial therapy and aggressive supportive care.supportive care.
  5. 5. DEFINITIONDEFINITION Neonatal sepsis is a clinical syndrome ofNeonatal sepsis is a clinical syndrome of bacteremia characterized by systemic signs andbacteremia characterized by systemic signs and symptoms of infection in the first month of life.symptoms of infection in the first month of life.
  6. 6. Factors influencing neonatal septicemiaFactors influencing neonatal septicemia 1. Transmission of infection1. Transmission of infection .transplacental.transplacental .vertical.vertical .from environment.from environment 2. Immunologic deficiency2. Immunologic deficiency .immunoglobulin.immunoglobulin .complement.complement .leukocyte.leukocyte .cytokines.cytokines .antibody.antibody
  7. 7. Factors influencing neonatalFactors influencing neonatal septicemia..contsepticemia..cont 3. Gestational age & birth weight3. Gestational age & birth weight 4. Physical defence4. Physical defence poor skin condition.poor skin condition. raw umbilical stump.raw umbilical stump. 5. Advanced neonatal care.5. Advanced neonatal care.
  8. 8. Classification of neonatal sepsisClassification of neonatal sepsis Neonatal sepsis can be classified into two majorNeonatal sepsis can be classified into two major group :group : 1. Early onset sepsis: It presents1. Early onset sepsis: It presents within 7 days of life , usualywithin 7 days of life , usualy within 72 hours.within 72 hours. 2. late onset sepsis: It usually2. late onset sepsis: It usually presents after 7 days of lifepresents after 7 days of life
  9. 9. Charecteristics differenceCharecteristics difference charecteristicscharecteristics EONSEONS LONSLONS Age of onsetAge of onset Birth to 7 days,Birth to 7 days, usually within 72usually within 72 hourshours 7 to 30 days7 to 30 days Maternal obstetricMaternal obstetric complicationcomplication commoncommon uncommonuncommon prematurityprematurity frequentfrequent variesvaries Organism sourceOrganism source Maternal genitalMaternal genital tracttract Maternal genitalMaternal genital tract, environmenttract, environment menifestationmenifestation multisystemmultisystem Multisystem, focalMultisystem, focal
  10. 10. Risk FactorsRisk Factors Low birth weight (3 sterile vaginal examination. Prolonged labor.Prolonged labor. Severe perinatal asphyxia.Severe perinatal asphyxia.
  11. 11. EtiologyEtiology Most common bacterial causes ofMost common bacterial causes of neonatal sepsis are:neonatal sepsis are: KlebsiellaKlebsiella ActinatobacterActinatobacter E.ColiE.Coli PseudomonasPseudomonas Strep.pyogenStrep.pyogen Strep.PneumoniaeStrep.Pneumoniae Staphylococcus aureusStaphylococcus aureus
  12. 12. Organism responsible for sepsisOrganism responsible for sepsis study in Dhaka Shishu Hospitalstudy in Dhaka Shishu Hospital .E. coli..30%.E. coli..30% .Klebsiela.23%.Klebsiela.23% .Staph. Aureus.17%.Staph. Aureus.17% .Pseusdomonus..10%.Pseusdomonus..10% .Streptococcus sp10%.Streptococcus sp10% .Acinatobacter..10%.Acinatobacter..10%
  13. 13. Organism responsible for sepsisOrganism responsible for sepsis According to Nelson textbook.According to Nelson textbook. coagulase neg. staph. Aureus..29%coagulase neg. staph. Aureus..29% staph aureus..08%staph aureus..08% B hemolytic streptococci..21%B hemolytic streptococci..21% ..E. coli.11%..E. coli.11% ..Klebsiella11%..Klebsiella11% Pseudomonus03%Pseudomonus03% Fungus..08%Fungus..08%
  14. 14. Organism responsible for sepsisOrganism responsible for sepsis study in indiastudy in india Klebsiela .32.5%Klebsiela .32.5% staph. Aureus13.6%staph. Aureus13.6% pseudomonus13%pseudomonus13% study in nepalstudy in nepal staph aureus.38.8%staph aureus.38.8% coagulase neg. staph. Aureus21%coagulase neg. staph. Aureus21% .Klebsiela pn11.6%.Klebsiela pn11.6% .enterobac.9.7%.enterobac.9.7%
  15. 15. ICMH DATA -2009ICMH DATA -2009 Total blood culture sample - 924Total blood culture sample - 924 Growth of organism 101Growth of organism 101 Percent of growth 11%Percent of growth 11%
  16. 16. ICMH DATA 2010ICMH DATA 2010 January AprilJanuary April Total Sample 306Total Sample 306 Growth of organisms - 86Growth of organisms - 86 % of growth 28%% of growth 28% Among the organismsAmong the organisms ..Staph. Aureus.51%Staph. Aureus.51% .Acenatobacter..25%.Acenatobacter..25% .E. coli..14%.E. coli..14% .Klebsiela. 03% .Klebsiela. 03% .Pseudomonas..03%.Pseudomonas..03%
  17. 17. Clinical featuresClinical features General:General: fever or hypothermia,fever or hypothermia, poor feeding,poor feeding, Lethargy,Lethargy, poor activity,poor activity,
  18. 18. Skin changeSkin change:: purpura, petechiae, Multiplepurpura, petechiae, Multiple pustules, Abscess, Sclerema,pustules, Abscess, Sclerema, Umbilical redness and dischargeUmbilical redness and discharge CNSCNS:: Irritability, seizure, hyporeflexiaIrritability, seizure, hyporeflexia Abnormal Moro reflexAbnormal Moro reflex Bulge fontanels ,Bulge fontanels , Vacant stare,Vacant stare, High-pitched cryHigh-pitched cry
  19. 19. RespiratorRespiratory :y : cyanosis,cyanosis, apnea, tachypnea,apnea, tachypnea, chest indrawning,chest indrawning, nasal flaring,nasal flaring, intercostal recession,intercostal recession,
  20. 20. GITGIT :: feed intolerance,feed intolerance, vomiting, diarrheavomiting, diarrhea abdominal distension,abdominal distension, paralytic ileus,paralytic ileus, necrotizing enterocolitis.necrotizing enterocolitis.
  21. 21. CVSCVS:: Poor perfusion, tachycardia,Poor perfusion, tachycardia, bradycardia, hypotension, shockbradycardia, hypotension, shock HepaticHepatic :: hepatomegaly, direct hyperbilirubinemiahepatomegaly, direct hyperbilirubinemia RenalRenal :: acute renal failureacute renal failure
  22. 22. INVESTIGATIONINVESTIGATION Treatment should be initiated in a neonate withoutTreatment should be initiated in a neonate without any delay, Only minimal and rapid investigationsany delay, Only minimal and rapid investigations should be undertaken.should be undertaken. 1.1. BLOOD CULTUREBLOOD CULTURE :: It is the gold standard for diagnosis ofIt is the gold standard for diagnosis of septicemia and should be performed in all casessepticemia and should be performed in all cases of suspected sepsis prior to starting antibiotics.of suspected sepsis prior to starting antibiotics. blood c/s (-).80% caseblood c/s (-).80% case blood c/s (+)..20% caseblood c/s (+)..20% case single org.97%single org.97% ( ref : 2 yrs study in nepal 2006 & 07)( ref : 2 yrs study in nepal 2006 & 07)
  23. 23. INVESTIGATION..contINVESTIGATION..cont 2.2. SEPTIC SCREENSEPTIC SCREEN :: Total leukocyte count 0.2 Micro ESR- >15 mm in 1Micro ESR- >15 mm in 1stst hourhour C-reactive protein- >1o mg/dlC-reactive protein- >1o mg/dl Comes atComes at Peak level atPeak level at CRPCRP 7 hr7 hr 24 hr24 hr ANC, I/T ratioANC, I/T ratio 22 hr22 hr 48 hr48 hr Micro ESRMicro ESR 26 hr26 hr 48-72 hr48-72 hr
  24. 24. Investigation.contInvestigation.cont 3.3. Lumber puncture:Lumber puncture: In EOS:In EOS: Positive blood culturePositive blood culture oror Clinical picture is consistent with septicemia.Clinical picture is consistent with septicemia. In LOS:In LOS: LP should be done in all infants prior toLP should be done in all infants prior to starting antibiotics.starting antibiotics.
  25. 25. Investigation......contInvestigation......cont 4.4. Chest X-ray:Chest X-ray: Should be considered in the presence ofShould be considered in the presence of respiratory distress or apnea.respiratory distress or apnea. 5.5. Urine for R/M/E & C/S.Urine for R/M/E & C/S. from suprapubic puncture or catheterization.from suprapubic puncture or catheterization. 6. Hb%, platelet count, Blood sugar, Serum6. Hb%, platelet count, Blood sugar, Serum electrolytes, X-ray abdomen-(if necessary)electrolytes, X-ray abdomen-(if necessary)
  26. 26. ManagementManagement Supportive:Supportive: 1. Maintain body temperature.1. Maintain body temperature. 2. Provide oxygen if indicated.2. Provide oxygen if indicated. 3. Monitoring and correction of hypoglycemia.3. Monitoring and correction of hypoglycemia. 4. Infusion Normal saline if perfusion is poor.4. Infusion Normal saline if perfusion is poor. 5. Blood transfusion if indicated.5. Blood transfusion if indicated. 6. Ensure feeding if possible breast feeding,6. Ensure feeding if possible breast feeding, or give N-G tube feed with EBM, if theor give N-G tube feed with EBM, if the baby is very sick, can not tolerate oral feedbaby is very sick, can not tolerate oral feed or suspected NEC give I/V