Background Neonatal sepsis is one of the leading problem of neonatal death, causes the neonatal...
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An Overview of Neonatal SepsisDr.M.Mizanur RahmanNeonatal and Pediatric SpecialistKing Khaled Civilian HospitalTabuk, Saudi Arabia
BackgroundNeonatal sepsis is one of the leading problem of neonatal death, causes the neonatal morbidity and mortality.The incidences of neonatal death due to neonatal sepsis varies from 3 14 per 1000 newborns.It is higher in preterm babies(up to 26 per 1000 live babies). Incidence is even higher in the underdeveloped countries like Bangladesh, where the proper treatment facility is not sufficient
DefinitionNeonatal sepsis is a clinical syndrome of systemic illness accompanied by bacteremia in the first 28 days of life.Early Onset Sepsis (EOS):Culture proven infection within the first 72 hours of life85% present within 24 hrs ,5% present in between 24-48 hrs, a small % present in between 48-72 hrs.
Late Onset Sepsis (LOS):Culture proven infection after 72 hours of life
Etiology Infectious agents associated with neonatal sepsis have changed since the mid-20th century1950 - S. aurus, E. coli; later s. aurus replaced by GBS1990 GBS and E .coliNow coagulase-negative S. epidamis frequently observedCan also be caused by adenovirus, enterovirus, coxsakie virus.Gonorrhea, syphilis, herpes simplex virus, CMV, hepatitis, HIV, TORCH infection have also been implicated in neonatal infection.Early-onset SepsisAssociated with acquisition of microorganisms from the mother transplacental infection or ascending infection Onset is most rapid in premature neonatesGBS, E. coli, Coagulase-negativeStaphylococcus, Stepto coccus , H. influenzae, L. monocytogenes are common pathogens. In Bangladesh context Klebsiella, Pseudomonas, E.coli, Acinobactor are commonPneumonia is more common in early-onset sepsis
Risk Factors of Early-onset SepsisMaternal GBS colonization (especially if untreated during labor)Premature rupture of membranes (PROM)Prolonged rupture of membranesPrematurityMaternal urinary tract infectionChorioamnionitis
AcinetobacterKlebsiellaE coliSerratiaPseudomonasS. aureusEnterobacterCandidaGBSAnaerobesCoagulase negetive staphilococcus
Etiology of Late-onset Sepsis
Meningitis and bacteremia are more common in late-onset sepsis
Risk Factors of Late-onset SepsisPrematurityCentral venous catheterization (duration >10 days)Nasal cannula or continuous positive airway pressure (CPAP)H2-receptor blocker or proton pump inhibitor (PPI)GI tract pathologyNumerous host factors in Neonatal sepsis Cellular immunity Humeral immunity Complement factors And other Barrier function
Clinical ExaminationClinical signs of neonatal sepsis are nonspecific and are associated with Characteristics of the causative organism Bodys response to the invasion. These nonspecific clinical signs are also associated with other neonatal diseasesRespiratory distress syndrome (RDS)Metabolic disordersIntracranial hemorrhageTraumatic delivery
Clinical SymptomsCommon /Non-specificRespiratory distress (90%) - RR, apnea (55%), hypoxia/vent need (36%), flaring/gruntingTemperature instability, feeding problemsLethargy-irritability (23%)Gastrointestinal poor feeding, vomiting, abdominal distention, ileus, diarrheaColorJaundice, pallor, mottlingHypo- or hyperglycemia,MetabolicacidosisCardiovascular Hypotension (5%), hypo perfusion, tachycardia,overt shock with pallor & odema.This late signs of shock are indicative of severe compromise & strongly associated with mortalityNICHD dataLess comSeizureDICPetechiaeHepatosplenomegalySclerema
Meningitis symptomsBuiging anterior frontaneleIrritability, lethargy, poorly responsiveChanges in muscle tone, etc.
Differential DiagnosesBowel Obstruction in the Newborn Congenital PneumoniaHeart Failure, Congestive Hemolytic Disease of Newborn Meconium Aspiration Syndrme Necrotizing Enterocolitis Pediatric Congenital Diaphragmatic Hernia Pediatric Infective Pericarditis Pulmonary Hypoplasia Imaging Respiratory Distress SyndromeApproach ConsiderationsComplete blood count (CBC) and differentialBlood cultureQuantity measurement of CRP and possibly other infection markersIn some cases, serial CBC and CRP studies may be appropriateGram stain provides early identification of the gram-negative or gram-positive status of the organism for preliminary identificationCSF analysis and culture
Approach Considerations contdEmerging technology using PCR could eventually help achieve faster identification of causative organism. Rapid pathogen detection with multiplex PCR may facilitate more timely selection of targeted antibiotic therapy while limiting exposure to broad-spectrum antibioticsImaging studies may include:Chest radiography to evaluate pulmonary involvementCT scan, MRI and ultrasonography of the head in cases of meningitisResults Trigger Points CBCWBC 22.0, abs neutro 2.0I/T ratio > 0.2*Platelets < 100,000CRP > 1.0 mg/dlCSF > 20 WBCs with few or no RBCs Radiographs: infiltrates on CXR, ileus on KUB, periosteal elevation, etc.
Treatment & ManagementWhen neonatal sepsis is suspected, treatment should be initiated immediately because of the neonates relative immunosuppression Begin antibiotics as soon as diagnostic tests are performedCardiopulmonary support and parenteral nutrition may be required during the acute phase of the illness until the infants condition stabilizesMonitoring BP & vital signs, HCT, platelets, and coagulation studies is vitalNot uncommonly, blood product transfusion, including packed red blood cells, platelets and FFP are indicated
Treatment & Management contdInfant with temperature instability needs thermoregulatory support with a radiant warmer or incubator. Once the infant is stable from a cardiopulmonary point, parental contact is important, kangaroo management can be applicable in this regardSurgical consultation for central line placement may be necessary in infants who require prolonged IV antimicrobial therapyIf an abscess is present, surgical drainage may be necessary; IV antibiotic therapy cannot adequately penetrate an abscess, and antibiotic treatment alone is ineffective
Treatment & Management contd
The infant may require transfer to a level III perinatal center, especially if he or she requires cardiopulmonary support, parenteral nutrition, or prolonged IV access. The multidisciplinary services available at larger centers may be necessary if the neonates condition is acutely compromisedAdditional therapies can be apply for the treatment of neonatal sepsis, including granulocyte transfusion, IVIg infusion, exchange transfusion, and the use of recombinant cytokines
Antibiotic TherapyIn the United States and Canada, the current approach to the treatment of early-onset neonatal sepsis includes combined IV aminoglycoside and expanded-spectrum penicillin antibiotic therapyThe specific antibiotics to be used are chosen on the basis of maternal history and prevalent trends of organism colonization and antibiotic susceptibility in individual nurseries
Antibiotic Therapy contd
If an infection appears to be nosocomial (late-onset sepsis), antibiotic coverage should be directed at organisms implicated in hospital-acquired infections, including S. aureus, S epidermidis, and pseudomenous sp.Vancomycin has been favored for this coverage; however, concern exists that overuse of this drug may lead to vancomycin-resistant organisms, For this reason, some clinicians prefer oxacillin therapy in this setting.
Antibiotic Therapy contd
Cephalosporins are attractive in the treatment of nosocomial infection because lack of dose-related toxicity and ability to reach adequate serum and CSF concentrations; however, their use has led to resistance in gram-negative organisms. Ceftriaxone displaces bilirubin from serum albumin and should be used with caution in infants with significant hyperbilirubinemiaAminoglycosides and vancomycin both have the potential to produce ototoxicity and nephrotoxicity and should therefore be used with caution
PrognosisMortality from neonatal sepsis may be as high as 50% for infants who are not treated. Low birth weight and gram-negative infection are associated with adverse outcomes.In preterm infants who have had sepsis, impaired neurodevelopment is a concern.Residual neurologic damage occurs in 15-30% of neonates with septic meningitis.preterm infants with sepsis who did not have meningitis had higher rates of cognitive deficits, cerebral palsy, and other neuro developmental disabilities than infants who did not have sepsis.Infants with meningitis may acquire hydrocephalus or periventricular leukomalacia. They may also have complications associated with the use of aminoglycosides, such as hearing loss or nephrotoxicity.
Long time -Follow UpFollow up- The primary care provider (PCP) should evaluate the infant with neonatal sepsis within 1 week of discharge from the hospital.1st week, Then Two weekly up to 3 Month Monthly up to 18 month If need to continueThe PCP should evaluate growth and determine whether the feeding regimen and activity have returned to normal.
ROP Screening,Hearing test- audiology test, audio screenRSV prophylaxisNeonatal sepsis is associated with meningitis, prolong hypoxia, ECMO therapy or brain abscess should be folowed for several yrs,
PreventionHAND-WASHING- the gold slandered measure for prevention Aseptic precaution during examination For GBS antibiotic treatment & prophylaxis during labor and deliveryPediatrician especially neonatologist all over the world continuously pay great attention to the unsolved questions of new born babies with sepsis, to reduce neonatal morbidity & mortality of this contingent of babies, hope to reduce to single digit.