Neonatal Sepsis - web2.aabu.edu.jo · Causes of Neonatal Sepsis The primary causes of Neonatal...
Transcript of Neonatal Sepsis - web2.aabu.edu.jo · Causes of Neonatal Sepsis The primary causes of Neonatal...
Miss: Kamlah Olaimat 1
Neonatal Sepsis
Presented by
Kamlah olaimat
Miss: Kamlah Olaimat 2
Welcome !!
Causes
Symptoms
Diagnosis
Treatments
Summary
What is Neonatal Sepsis?
Objectives
Miss: Kamlah Olaimat 3
Tutorial Objectives
Completing this tutorial will provide the learner with a better
understanding of Neonatal Sepsis:
* Pathology
* Causes
* Symptoms
* Diagnosis
* Treatments
What will I learn?
Miss: Kamlah Olaimat 4
What is Neonatal Sepsis?
Neonatal Sepsis is a term
used for a severe infection
in newly born infants.
Clinical syndrome of systemic illness accompanied by bacteremia occurring in the first month of life
Image used with permission and provided by www.steliz.org/newborn_center.htm
Miss: Kamlah Olaimat 5
More facts about Neonatal Sepsis
Neonatal Sepsis affects approximately 2 infants per 1000 births with a higher incidence in premature & low birth weight infants [2].
Mortality rate is 13-25% Higher rates in premature infants and those with early disease
There are two types of Neonatal Sepsis: Early OnsetLate Onset
Miss: Kamlah Olaimat 6
Causes of Neonatal Sepsis
The primary causes of Neonatal Sepsis are bacteria, such
as Staphylococcus and Group Beta Strep (GBS).
Bacteria may be the cause of neonatal sepsis, but neonates are more susceptible to these bacteria for two reasons [3&6]:
Immature immune response
Genetic predisposition
Miss: Kamlah Olaimat 7
What makes a neonates immune system immature?
Normally an immune system
responds to a pathogen in a specific manner, but if there are problems with any
element the immune system is unable to function properly
Pathogen enters body
Neutrophils move in
Chemotaxis occurs
Opsonization causes
phagocytosis
Monocytes kill pathogen
Miss: Kamlah Olaimat 8
pathogens can enter a neonates body in many ways !
Pathogens can enter through the prenatal, perinatal, and postnatalperiods [6].
Prenatal Maternal Substance Abuse
Premature Rupture of Membranes (>18 Hours)
Maternal Infection
Perinatal Microbial Colonization at Birth
Maternal Infection
Vaginal Exam of Mother
Postnatal Invasive Catheters
Endotracheal Intubation
Exposure to Nosocomial Microorganisms
Miss: Kamlah Olaimat 9
Neutrophils: An important cell in immunity against pathogens
Neonatal neutrophils are deficient in
their ability to adhere to vessel walls at site of infection [2&6].
Further release of neutrophils
depletes a neonatal storage
pool because the bone marrow
storage of a neonate is only 20-30%
of the pool in an adult [2&6].
Neonatal neutrophils have a
decreased ability to deform &
migrate into tissues [2&6].Neutrophils
Red Blood Cells
Image provided with permission from
http://en.wikipedia.org/wiki/Image:Segmented_neutrophils.jpg
Miss: Kamlah Olaimat 10
Chemotaxis
Imagine: Being in a dark tunnel without any direction or a way out. Finally you see light. You move towards the light and get out of the tunnel. Well this is like chemotaxis. The sun is the chemoattractant attracting you out to the world!!
Neonatal neutrophils have
decreased chemotaxis due to
decreased chemoattractant
Production [2&6].
Chemoattractants attract
neutrophils to the site of infection
[2&6].
Neonatal neutrophils therefore
cannot reach the site of infection
because of the chemotaxis
deficiency caused by decreased
chemoattractant production.
Miss: Kamlah Olaimat 11
Opsonization
Opsonization is the coating of a pathogen with antibodies that makes it susceptible to phagocytosis [2&6].
Phagocytosis is the process of cells (phagocytes) engulfing, ingesting, &
destroying pathogens [2&6].
Neonates have a decreased amount of opsonins (antibodies that promote
opsonization) [2&6].
Opsonization
Pathogen
Miss: Kamlah Olaimat 12
Monocytes: Another important cell in the fight against pathogens
Monocytes are a type of White Blood Cell that ingests
pathogens.
Neonates have a sufficient amount of
monocytes and full capability to kill organisms [2], but because of a neonates deficiencies previously
discussed very few monocytes get to
the site of infection.
Image provided with permission and copyrighted by amaxa GmbH at
www.amaxa.com/mission3.html
Miss: Kamlah Olaimat 13
What makes a neonates immune system susceptible to sepsis?
OR
Maturity
Immaturity
Miss: Kamlah Olaimat 14
Youre Right!!!!
The immaturity of a neonates immune system makes them MORE SUSCEPTIBLE to sepsis.
Miss: Kamlah Olaimat 15
Not Quite! Try Again
Miss: Kamlah Olaimat 16
Genetic Predisposition to Sepsis
Multiple factors play into a neonates response to infection and the
possible development of sepsis. One of these factors is genetics. As
science has moved into recognizing the human genome there have
also been advances with finding genetic contributions to sepsis.
The bodys first response to infection requires recognition of the presence of a pathogen. After recognition has occurred the body responds appropriately to resolve the problem [3&14]. Many polymorphisms have been recognized within both of these phases and they have been implicated in
influencing the susceptibility to and/or outcome from sepsis [3&14].
Lets look further into these two phases to see the effect
polymorphisms have on neonatal sepsis:
Recognition Phase Response Phase
Miss: Kamlah Olaimat 17
Recognition Phase
The bodys initial response to infection requires recognition of the
presence of a pathogen [3].
Polymorphisms in genes coding for proteins involved in the recognition
of pathogens can influence the susceptibility to and/or outcome of
neonatal sepsis [3].
Lets look into two of these:
Mannose-Binding Lectine (MBL)
Lipopolysaccharide (LPS)
Miss: Kamlah Olaimat 18
Response PhaseAfter the initial recognition of a pathogen occurs the body responds by releasing elevated levels of proinflammatory cytokines followed by a release of anti-inflammatory cytokines [3]. This dual release of opposite cytokines helps the cytokines return to a baseline level and that enables the start of tissue repair to start [3].
It is generally accepted that an imbalance between proinflammatory and anti-inflammatory cytokines result in clinical manifestations of sepsis [3]. This Imbalance is due to polymorphisms in various proteins involved in the response to pathogens.
Miss: Kamlah Olaimat 19
Not quite! Try again.
Miss: Kamlah Olaimat 20
Great answer! Youre correct!
Polymorphisms cause either an over expression or under expression of
proteins and/or genes that have significant roles in the immune
response to infection. This alters their ability to properly function
which makes a neonate more susceptible to sepsis.
Miss: Kamlah Olaimat 21
Early Onset
First 5-7 days of life Usually multisystem fulminant illness with
prominent respiratory symptoms (probably due to aspiration of infected amniotic fluid)
High mortality rate 5-20%
Typically acquired during intrapartum period from maternal genital tract Associated with maternal chorioamnionitis
Miss: Kamlah Olaimat 22
Late Onset
May occur as early as 5 days but is most common after the first week of life
Less association with obstetric complications
Usually have an identifiable focus Most often meningitis or sepsis
Acquired from maternal genital tract or human contact
Miss: Kamlah Olaimat 23
Nosocomial sepsis
Occurs in high-risk newborns
Pathogenesis is related to the underlying illness of the infant
the flora in the NICU environment
invasive monitoring
Breaks in the barrier function of the skin and intestine allow for opportunistic infection
Miss: Kamlah Olaimat 24
Risk factors
Prematurity and low birth weight Premature and prolonged rupture of
membranes Maternal peripartum fever Amniotic fluid problems (i.e. mec, chorio) Resuscitation at birth, fetal distress Multiple gestation Invasive procedures Galactosemia Other factors: sex, race, variations in immune
function, hand washing in the NICU
Miss: Kamlah Olaimat 25
Symptoms of Neonatal Sepsis
The symptoms of neonatal sepsis are not concrete and vary widely [9].
TachpneaHeart Rate Changes
Feeding difficulties
Difficulty Breathing Temperature Instability
Jaundice Irritability
Why are symptoms so broad?
Miss: Kamlah Olaimat 26
Clinical presentation Temperature irregularity (high or low) Change in behavior
Lethargy, irritability, changes in tone
Skin changes Poor perfusion, mottling, cyanosis, pallor, petechiae,
rashes, jaundice
Feeding problems Intolerance, vomiting, diarrhea, abdominal distension
Cardiopulmonary Tachypnea, grunting, flaring, retractions, apnea,
tachycardia, hypotension
Metabolic Hypo or hyperglycemia, metabolic acidosis
Miss: Kamlah Olaimat 27
Inflammation in Neonatal Sepsis
It is widely known that sepsis occurs
because of an exaggerated
systemic inflammatory response (SIR) [12].
Lets find out how this is true Inflammatory Process
Miss: Kamlah Olaimat 28
Inflammatory Process
[12]
Pathogen enters body
Inflammatory mediators released (cytokines)
Injury to endothelium
Tissue factors released
Production of thrombin
Coagulation promotes clot formation
Increased activity of fibrinolysis inhibitors
Decreased fibrinolysis
Miss: Kamlah Olaimat 29
Inflammation
Overall, the imbalance among inflammation, over coagulation, and decreased fibrinolysis are the cause for the majority of deaths
in sepsis [12].
Miss: Kamlah Olaimat 30
How is Neonatal Sepsis Diagnosed?
There is no definite marker in neonatal sepsis, but there are determinants of infection.
When a neonate presents with sepsis symptoms a septic work-up
is completed [2]. What is included in a septic work up?
* Complete Blood Count (CBC)
* Blood & Urine cultures
* Lumbar Puncture (LP)
* Chest X-Ray
* Line cultures
Miss: Kamlah Olaimat 31
Is there a diagnostic marker for neonatal sepsis?
True
False
Miss: Kamlah Olaimat 32
Yeah!!! You are correct!
There is NOT a specific diagnostic marker, only determinants of infection (labs, x-rays).
Miss: Kamlah Olaimat 33
Are you sure? Try again!
Miss: Kamlah Olaimat 34
Treatments for Neonatal Sepsis
It is of vital importance that treatment is initiated as soon as sepsis is suspected, especially for those
infants at risk.
Broad Spectrum Antibiotics (Ampicillin & Gentamycin) are the first line of defense against neonatal sepsis
[2].
Why????
What are other recommendations/options?
Miss: Kamlah Olaimat 35
Why is it so important to start antibiotic treatment?
If not treated as soon as sepsis is suspected a neonate is more likely to die from sepsis and its complications.
For this reason it is of vital importance that healthcare workers (nurses and physicians) notice and act upon even the most subtle changes in a neonates assessment, particularly those infants at
risk (GBS+).
Miss: Kamlah Olaimat 36
Treatment Recommendations
Antibiotics should be initiated after all cultures and lab work is completed to ensure proper diagnosis.
All neonates will remain on IV antibiotics until blood/urine culture results
come back in approximately 2-3 days. Further therapy will depend on
lab work results and the neonates response to treatment.* Every hospital/organization has an antibiotic protocol specific to their site.
Although antibiotic therapy is vital, it is just as important to continue the overall support of the neonate (i.e. respiratory &
cardiac).
Miss: Kamlah Olaimat 37
Infection control in NICU
Its an important part of every copmonant of care of a neonate baby .
The most important factors contributing to nasocomial infection are :-
o Noncompliance to infection control policy (hand washing )
o Invasive procedure which interrupt normal body barriers as intubations
o Overcrowding and understanding in NICU
o Immaturity of immune system
o Antibiotic abuse
Miss: Kamlah Olaimat 38
General principle of infection control in NICU
1) Appropriate physical setup of NICU environment ( isolated , no windows open to outside , avoid overcrowding , adequately ventilated)
2) Provide routine care for the newborn baby
3) Consider every person as potentially infectious ( including member of staff )
4) Wash hand or use alcohol based hand scrub
Miss: Kamlah Olaimat 39
General principle of infection control in NICU
1) Wear protective clothing and gloves
2) Sterilize or disinfect instrument and equipment
3) Routinely clean the NICU and dispose of waste
4) Isolated the infectious baby
5) Surveillance for nasocomial infection
Miss: Kamlah Olaimat 40
Neonate
Neonate should be bath 3 time/week using baby soap
Electrodes should be changed every third day
Umbilical stump should be treated with alcohol / shift
Prophylactic eye drop at first day
Neonate admitted from out side of hospital isolated or 72 hours
Miss: Kamlah Olaimat 41
Staff health
Health care should be immune to rubella, measles, chicken pox
Health care yearly receive influinza vaccination
Any person with any disease (common cold) not have direct contact with neonate
Limited the number of person handle the baby
Miss: Kamlah Olaimat 42
Had washing
Mother should wash hand after and before handle baby
Remove accessory before inter NICU
Finger nails trimmed short , no false nail use
Antiseptic preparation
At least 10 second washing
Hand wash even when use gloves
Hand washing is the single most important procedure for infection control
Miss: Kamlah Olaimat 43
Protective clothes and gloves
Sterile gowns must be worn by all person in direct contact with baby
Use gloves when handle the baby
Miss: Kamlah Olaimat 44
General housekeeping and waste disposable
Clean NICU as order :-
Patient area , accessory , adjacent halls
From top to bottom
Counter , work surface , horizontal area cleaned once daily
Clean up spill of blood or bodily fluid immediately by using disinfectant solution
Separate contaminated waste from non contaminated
Use a puncture proof container for sharps
Destroy container when it is two third full
Miss: Kamlah Olaimat 45
General housekeeping and waste disposable
Change breathing material and CPAP / 3 day
Change suction apparatus daily
Change suction tube after use by each infant
Incubator changed for cleaning with 10% hypochlorite
Every 5 day for infant 1000gm
Linen changed every day in incubator
Miss: Kamlah Olaimat 46
Feeding and nutrition equipment
Sterilization of feeding bottles
Sterile water for formula preparation
Feeding tube changed \ 2-3 days
Hand washing before and after feeding
Miss: Kamlah Olaimat 47
Isolated infectious baby
Isolated room or area should be available
Keep door closed
When entering the room
wear a clean gown
wear gloves
Before leaving room:-
remove gown and gloves
wash hand with alcohol
The nurse work with infectious baby should give few assignment
Miss: Kamlah Olaimat 48
Surveillance for nasocomial infection
Routine surveillance of the incidence of acquired infections in nursery should be mandatory
Perform culture by swabbing for bacteria on likely surface area
Perform blood culture of infected neonate
Identify bacterial isolated
Bacterial culture from person and equipment are necessary
Miss: Kamlah Olaimat 49
I hope you have enjoyed your experience and have learned some new information
about neonatal sepsis.
mailto:[email protected]
Miss: Kamlah Olaimat 50
References1. Amaxa Biosystems. (n.d.). Mission #3: Transfect human monocytes. [Online image]. Retrieved March 22,
2006 from www.amaxa.com/mission3.html
2. Bellig, L.L. & Ohning, B.L. (2004). Neonatal Sepsis. Retrieved February 8, 2006, from emedicine:http://wwwemedicine.com/ped/topic2630.htm
3. Dahmer, M.K., Randolph, A., Vitali, S., & Quasney, M.W. (2005). Genetic polymorphisms in sepsis. Pediatric Critical Care Medicine, 6(3), 61-73. Retrieved February 23, 2006 from PubMed database.
4. Farlex Inc. (n.d.). The Free Dictionary. Retrieved March 30, 2006, from www.thefreedictionary.com
5. LaRosa, S.P. (2002). Sepsis. Retrieved February 14,2006, from The Cleveland ClinicWebsite: http://www.clevelandclinicmeded.com/diseasemanagement/infectiousdisease/sepsis.htm
6. McKenney, W.M. (2001). Neonatal nursing: Understanding the neonatal immune system: High risk for infection. Crtitical Care Nurse, 21(6), 35-58. Retrieved February 14, 2006, from ProQuest database.
7. Microsoft Corp. (2006). Microsoft Clip Art. Retrieved March 30, 2006, from www.microsoftclipart.com
8. Mrozek, J.D., Georgieff, M.K., Blazer, B.R., Mammel, M.C., & Schwarzenburg, S.J. (2000). Effect of sepsis syndrome on neonatal protein and energy metabolism. [Electronic version] Journal of Perinatology, 2, 96-100.
Miss: Kamlah Olaimat 51
References9. Neonatal Handbook:Sepsis. (n.d.). Retrieved February 14, 2006, from
http://www.netsvic.org.au/nets/handbook/index.cfm?doc_id=898
10. Oostdyk, R. (2005). Neutrophil. [Online image]. Retrieved April 20, 2006, fromhttp://en.wikipedia.org/wiki/Image:Segmented_neutrophils.jpg
11. Orr, P.A., Case, K.O., & Stevenson, J.J. (2002). Metabolic response and parenteral nutrition in trauma sepsis and burns. Journal of Infusion Nursing, 25(1), 45-53. Retrieved March 7, 2006 from Ovid database.
12. Sharma, S. & Mink, S. (2004). Septic shock. Retrieved February 14, 2006, from emedicine: http://www.emedicine.com/MED/topic2101.htm
13. St. Elizabeth Hospital. (n.d.). The newborn center at St. Elizabeths. [Online image]. Retrieved March 22, 2006 from www.steliz.org/newborn_center.htm
14. Villar, J., Maca-Meyer, N., Perez-Mendez, L., & Flores, C. (2204). Bench to bedside review: Understanding genetic predisposition to sepsis. Critical Care, 8(3), 180-189. Retrieved February 23, 2006, from PubMed
database.
End Show