2. Bacterial Sepsis in Neonate
Definition :
Clinical syndrome of
infection with bacterimia in
first month of life.
• May get predominantly localized to lung (Pneumonia)
• May be localized to meninges (meningitis)
3. Bacterial Sepsis in Neonate
Incidence :
24 / 1000 live births
Single most important cause of neonatal deaths in the
community (>50%)
5. Neonatal Sepsis
Major Risk Factors
• Ruptured membranes > 24 hrs.
• Maternal Fever (100.4oF(38oC)
• Chorionamnionitis
• Sustained fetal heart rate
>160/min
• Multiple obstetric procedures
Minor Risk Factors
• Ruptured membranes > 12 hrs.
• Foul smelling liquor
• Maternal Fever > 99.5oF (37.5oC)
• Low APGAR < 5 at 1 min,
< 7 at 5 min
• Prematurity
• Multiple gestation
Presence of 1 major or 2 minor risk factors ->
High Risk of Sepsis
6. NNF CRITERIA
SUSPECT SEPSIS
1 out of 3 parameters is an indication for antibiotic therapy
• PREDISPOSING FACTORS like PROM, Foul
smelling liquor, amnionitis, gastric aspirate
showing polymorphs 5 / HPF
• POSITIVE SEPSIS SCREEN (2/4 parameters)
– TLC <5000 per cubic ml
– Bandemia 20%
– CRP >10 ng per ml
– Micro ESR >10mm fall in 1hr
• CXR showing Pneumonia
7. Neonatal Sepsis
Pathogenesis
• Infection in the birth canal
• Colonization of skin, umbilical stump,
nasopharynx, conjunctiva, etc.
• Transient bacteremia
• Invasion of blood stream
• Metastatic foci
• Meningitis, etc.
8. Neonatal Sepsis
Risk factors for Late onset sepsis (LOS)
• Prolonged hospitalization
• Prematurity
• LBW
• Previous antibiotic use
• Invasive procedures
• Presence of foreign material (ET Tubes/
catheters)
• Lack of disposables
• Over crowding / understaffing
9. Neonatal Sepsis
Risk factors for Community acquired sepsis
• Bottle feeding
• Poor hygiene
• Poor cord care
• Over crowding
11. Infection
Systemic Inflammatory Response Syndrome (SIRS)
Resp:
Tachypnoea
Hypoxia PaO2
> 2 SD
< 70 mm Hg
CVS :
Tachycardia
> 2 SD
Hypothermia
< 2 SD or hyperthermia
Peripheral Perfusion:
Delayed Capillary Filling
> 3 Sec.
Oliguria
< 0.5 ml / kg / hr
Lactic acidosis
Altered mental status
Increased or decreased white blood count:
12. Infection > SIRS
Sepsis –
• Systemic response to infection with bacteria :
SIRS with hypotension
Severe Sepsis –
• Sepsis with organ dysfunction, hypoperfusion or hypotension
• Changes in mental status, oliguria, hypoxemia or lactic acidosis
13. Septic shock –
Severe Sepsis with persistent hypotension
despite adequate fluid resuscitation
Multiple Organ Dysfunction Syndrome
(MODS) –
Presence of altered organ function such that
homeostasis
can not be maintained without intervention
Death
14. Local
Initial insult
pro-inflammatory (bacterial, viral
response
thermal, traumatic)
Systemic spillover of proInflammatory mediators
Systemic Reaction
Local
anti-inflammatory
response
Systemic spillover of antiInflammatory mediators
SIRS : Pro
CARS : Anti
MARS : Mixed
C
H
CV Compromise Homeostasis
A
Aptosis
O
MODS
S
Suppression of immunity
15. Clinical Features
• General :
• Skin:
– Lethargy, jaundice
– Temperature instability
• Respiratory
– Distress after a period of
normalcy
– Apnea
• GI:
– Poor feeding, vomiting,
abdominal distention, bilious
aspirates
– Temperature labiality
– Petechial rashes, bleeding from
puncture sites
– Sclerema
• CNS:
•
– Lethargy, irritability, seizures
Metabolic:
– Unexplained metabolic acidosis
– Hyperglycemia
– Hypoglycemia
• Features to system
involvement
16. Sepsis Screen
• Total neutrophil count :
• Immature to total ratio :
•Acute Phase Reactions
• Micro ESR
• C Reactive Protein
• Hepatoglobin
:
:
Laboratory Studies
< 5000 / mm3
> 0.2
> 15 mm in 1st hour
> 10 mg/L
• Cultures
• Chest X-Ray
• Grams Stain of gastric aspirate
• Antigen detection methods
• Lumbar Puncture
17. Neonatal Sepsis
Total neutrophil count & Immature to total ratio:
• TWBC
• Tot. neutrophil count
: < 5000 / micro liter or >24000
: < 1000 / micro liter
( Normal= 1,750 /µL)
• Band / Total Neutrophil
: > 0.2
( Normal = 0.16 in 1st Day,
0.12 after 24 Hrs.)
• Platelet Count
: < 1 Lakh/mm3
(Normal = 1.5 to 4 Lakhs /mm3)
- Increased risk of infection
Repeat TWBC & DC at 8 - 12 hrs in a symptomatic neonate
may have more predictable value than single record.
19. Neonatal Sepsis
Chest X-Ray
• Persistent focal changes with
infiltrative process
• Findings similar to RDS in GBS
infection
20. Neonatal Sepsis
Acute Phase Reactants - Sepsis Screen
Positive CRP ( > 6 mg/ L or 10 times normal)
Elevated hepatoglobin level
Micro ESR After 14 days of age 15 mm or
more for the first hour is abnormal.
(Normal ESR = Age in days + 2)
If all results are -ve : Probability that infection absent = 99%
If all results are +ve : Probability of infection = 90%
21. Neonatal Sepsis
Grams Stain of gastric aspirate
Positive Result :
If > 5 neutrophils / hpf
or
Large number of bacteria (esp. Gram+ve cocci) in
large clumps and chains
Predictive value less
23. Neonatal Sepsis
Lumbar Puncture
• Valuable in symptomatic infants
who have risk factors for sepsis.
• CSF studies prior to antibiotic
therapy is preferable
LP in RDS is difficult
Interpretation is difficult if LP is traumatic
Sometimes meningitis may be present with normal
CSF picture
30. •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Sulfa Drugs
Folic Acid Analogs
The Beta-Lactams
Aminoglycosides
Tetracyclines
Macrolides
Lincosamides
Streptogramins
Fluoroquinolones
Polypeptides
Rifampin
Mupirocin
Cycloserine
Aminocyclitol
Glycopeptides
Oxazolidinones
Arm
a
me
nt
ariu
m
… and the list is
incomplete …
32. Factors to be considered in the choice of
Antibiotic
Gram + ve
Gram _ ve
Anaerobes
33. Antibiotic Selection
Presumptive therapy directed to most commonly
encountered pathogens.
1st Line :
Ampi/Sulbactum+Aminoglycoside
2nd Line
2nd gen. Cephalosporins + Aminoglycosides
3rd Line
Vancomycin + Cephalosporins
Newer antibiotics
38. Duration of Antibiotic Therapy
Culture Positive Sepsis
Pyogenic Meningitis
- 14 Days
- 21 Days /
2 weeks after CSF sterile
Culture – ve/ clinically probable sepsis screen +ve:7-10 d.
Culture – ve/ clinically probable sepsis screen -ve:5-7 d.
Septic Arthritis
- 6 Weeks
39. Immunotherapy
• Immunoglobulin : IVIG 500-1000 mg/kg/dose
• Specific Immunoglobulins : Anti GBS Ig.
• Oral administration of IgA and IgG in NEC
• Granulocyte infusions
• G – CSF 10 µg/kg/d for 3 days
• GM – CSF 10 µg/kg/d for 5 days
• Double volume exchange transfusions
40. Supportive Therapy
• Continued Breast Feeding
• Nutrition : TPN / Aminoplasma
• Fluid / Electrolyte balance
• Treatment of acidosis
41. Preventive Aspects of Neonatal Sepsis
• Obstetric Management strategies
• Screening based approach
• Risk factor approach
• Exclusive breast feeding
• No prelacteals
• Keeping the cord dry
• Hand washing by care givers before and after handling the baby
(Single most effective measure)
• Hygiene of the baby
• Avoid unnecessary intravenous fluids, needle pricks etc.
42. Algorithm for early prevention of GBS
Risk Factors
Give intrapartum
Previous GBS
penicillin
Preterm delivery
Bacteremia
Rectal & Vaginal swab
c/s. at 35-37 wks.
Risk Factors
Intrapartum Temp.
PROM > 18 hrs
No intrapartum prophylaxis needed
Give intrapartum
penicillin
Give intrapartum
penicillin
