Neonatal Sepsis

Maria Angelica M. Geronimo

Epidemiology

Newborn Health in the Philippines: A Situation Analysis June 2004.

Newborn Health in the Philippines: A Situation Analysis June 2004.

Neonatal Sepsis

• Clinical syndrome of bacteremia with systemic signs and symptoms of infection in the first 4 weeks of life

• 1-4/1000 live births • Term male infants 2x higher than female • Pre Term have 3-10x higher incidence of infection

than term • Low Birth Weight

Sepsis

• Systemic inflammatory response syndrome resulting from a suspected or proven infection

Nelson Textbook of Pediatrics 18th edition

Clinical Spectrum

Systemic Infection

Localized infection

Severe sepsis

Death

Multiple organ dysfunction syndrome

Septic shock

Nelson Textbook of Pediatrics 18th edition

SIRS• 2 out of 4 criteria, 1 of which must be abnormal temperature or

abnormal leukocyte count 1. Core temperature >38.5°C or <36°C2. Tachycardia

Nelson Textbook of Pediatrics 18th edition

SIRS

3. Respiratory rate >2 SD above normal for age or acute need for mechanical ventilation not related to neuromuscular disease or general anesthesia

4. Leukocyte count elevated or depressed for age (not secondary to chemotherapy) or >10% immature neutrophils

Nelson Textbook of Pediatrics 18th edition

Severe Sepsis• Sepsis plus 1 of the following 1. Cardiovascular organ dysfunction

– Despite >40 mL/kg of isotonic intravenous fluid in 1 hr– Hypotension <5th percentile for age, systolic blood pressure <2 SD

below normal for age – Need for vasoactive drug to maintain blood pressure – 2 of the following: Unexplained metabolic acidosis or oliguria – Prolonged capillary refill 5 sec– Core to peripheral temperature gap >3°C

Nelson Textbook of Pediatrics 18th edition

Severe Sepsis

• 2. Acute respiratory distress syndrome (ARDS) • PaO2/FiO2 ratio ≤300 mm Hg

• Bilateral infiltrates on chest radiograph• No evidence of left heart failure

OR Sepsis plus 2 or more organ dysfunctions (respiratory, renal, neurologic, hematologic, or hepatic)

Nelson Textbook of Pediatrics 18th edition

Septic Shock

• Sepsis plus cardiovascular organ dysfunction as defined above

Nelson Textbook of Pediatrics 18th edition

Multiple Organ Dysfunction Syndrome

• Presence of altered organ function such that homeostasis cannot be maintained without medical intervention

Nelson Textbook of Pediatrics 18th edition

Epidemiology

Nelson Textbook of Pediatrics 18th edition

Etiology

AGE PATHOGENSNeonates Group B streptococcus

Escherichia coliListeria monocytogenes

EnterovirusesHerpes simplex virus

Children Streptococcus pneumoniaeNeisseria meningitidis

Staphylococcus aureus (methicillin-sensitive or resistant)

Nelson Textbook of Pediatrics 18th edition

Predominant Pathogens for Sepsis

Nelson Textbook of Pediatrics 18th edition

Clinical Manifestation

Nelson Textbook of Pediatrics 18th edition

WHO study (2003) Predict Severe Bacterial Illness in Infants

1. Feeding ability reduced 2. No spontaneous movement 3. Temperature >38° C 4. Prolonged capillary refill time 5. Lower chest wall indrawing 6. Respiratory rate > 60/minute 7. Grunting8. Cyanosis 9. Convulsions

Diagnosis

• Isolation– Blood– CSF– Urine– Pleural fluid– Pus

Diagnosis• CBC and differential count• ANC < 1800/ cmm –

indicator of infection• Neutropenia• Immature neutrophils

(Band+myelocytes+metamyelocytes) to total neutrophils ratio (I/T) > 0.20

• Platelet count <100,000/cmm

• Toxic granules on peripheral smear and gastric aspirate - > 5 leukocytes/hpf

• Micro ESR – elevated with sepsis and fall of > 15 mm during the 1st hour indicates infection

• C-reactive protein

Diagnosis• Sepsis screen• 2 or more– Leukopenia (TLC < 5000/cmm)– Neutropenia (ANC <1800/cmm)– Immature neutrophil to total neutrophil (I/T) ratio (>0.2)– Micro ESR (<15mm 1st hour)– CRP +

• CXR• Lumbar puncture – late onset of sepsis– symptomatic early onset of sepsis

ManagementManagement

• High index of suspicion• Antibiotics• Supportive care

Antibiotic Therapy

AGE ANTIBIOTIC

Neonate Ampicillin plus aminoglycoside or cefotaxime+ vancomycin if nosocomial infection

+acyclovir if HSVChild Cefotaxime or ceftriaxone

+ vancomycin for meningitis or in areas of high staphylococcal or pneumococcal resistance to methicillin or cefotaxime, respectively

Nelson Textbook of Pediatrics 18th edition

Antibiotic TherapySepticemia or Pneumonia

Antibiotic Dosage Frequency Route Duration

<7 days of age

>7days of age

Ampicillin 50 mkdose Q12 Q8 IV, IM 7-10 days

Cloxacillin 50 mkdose Q12 Q8 IV 7-10 days

Gentamicin 2.5 mkdose Q12 Q8 IV,IM 7-10 days

Amikacin 7.5 mkdose q12 Q8 IV, IM 7-10 days

Antibiotic Therapy

Meningitis

Antibiotic Dosage Frequency Route Duration

<7 days of age

>7days of age

Ampicillin andGentamicin

100 mkdose

2.5mkdose

Q12 Q8 IV

IV

21 days

Cefotaximeand Gentamicin

50 mkdose

2.5 mkdose

Q12 Q8 IV

IV

21 days

SEPSIS PROTOCOL

M. Jeeva Sankar, Ramesh Agarwal, Ashok K Deorari, Vinod K PaulDivision of Neonatology, Department of Pediatrics

All India Institute of Medical SciencesAnsari Nagar, New Delhi –110029

SEPSIS PROTOCOL

M. Jeeva Sankar, Ramesh Agarwal, Ashok K Deorari, Vinod K PaulDivision of Neonatology, Department of Pediatrics

All India Institute of Medical SciencesAnsari Nagar, New Delhi –110029

WHO Guidelines

• Chorioamnionitis– Elevated maternal temperature

– Uterine tenderness

– Foul smelling vaginal discharge

– Maternal leucocytosis WBC>18

– Fetal tachycardia

WHO Guidelines• Term and near term baby or birth wt. Of 2 kg or more with

maternal history of chorioamnionitis and or fever with or without rupture of membranes

– Blood CS (+) or baby develops signs and symptoms antibiotic for 10 days

– Blood CS (-) and baby is asymptomatic after 5 days discontinue antibiotics

– Blood CS not done and baby is asymptomatic after 5 days discontinue antibiotics

WHO Guidelines

• Observe the baby for 24 hours after discontinuing antibiotics

– Baby remains well, feeds well and there are no problems Discharge the baby

– Explain to the mother the signs of sepsis or ask to return with the baby if signs of sepsis develops

WHO Guidelines

• Term and near term baby or birth wt. of 2 kg or more with maternal history ruptured bag of water with or without chorioamnionitis, fever

– Blood sample for Culture and sensitivity do not start antibiotics

– Observe the baby for signs of sepsis every 4 hours for 48 hours

WHO Guidelines– Blood CS (-) and baby is well after 48 hours observation

discharge the baby– Explain to the mother the signs of sepsis or ask to return

with the baby if signs of sepsis develops– Blood CS (+) is positive or baby develop signs of sepsis

(during the 48 hours observation) treat for sepsis and start antibiotics

– Blood CS is not possible observe the baby for additional 3 days remains well discharge baby

WHO Guidelines

• Gestational age less than 35 weeks of birth weight less than 2 kg with maternal history of either or both of the following:– Maternal fever / chorioamnionitis– PROM more than 18 hours

WHO Guidelines– Blood CS (+) or if baby develops signs and

symptoms continue 10 days treatment with antibiotics

– Blood CS (-) and baby is asymptomatic after 5 days of treatment discontinue antibiotics

– Blood culture is not possible but baby remains asymptomatic after 5 days of treatment discontinue antibiotics

WHO Guidelines

• Observe the baby for 24 hours after discontinuing antibiotics

– Baby remains well, feeds well and there are no problems Discharge the baby

– Explain to the mother the signs of sepsis or ask to return with the baby if signs of sepsis develops

Prevention

• Good antenatal care• All mothers should be immunized against

tetanus• Babies should be fed early and exclusively with

breast milk• Cord should be kept clean and dry• Immunization with the conjugate H. influenzae

type b and S. pneumoniae vaccines is recommended for all infants

Prevention• Hand Washing• Nursery environment should be clean and dry

with 24 hour water and electricity• Adequate ventilation• Nursery temperature maintained between

30 – 32 C• Avoid overcrowding• Mask and gloves• Every baby must have separate thermometer and

stethoscope

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