3. DEFINITION
• Clinical syndrome of Systemic illness resulting from metabolic and
circulatory collapse
• Bacterial infection of a neonate
• Incidence varies from 1-10/1000 live births and up to 22/1000 live births in
developing countries.
• 40% neonatal deaths in Pakistan are due to this
• Case fatality rate : 20-50%
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4. AETIOLOGY
• E coli
• Group b streptococcus
• Klebsialla
• Pseudomonas
• Staphylococcus
• Proteus
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6. PREDISPOSING
FACTORS
• HOST FACTORS
• Impaired cellular response
• Impaired humeral response
• MATERNAL FACTORS
• Poor socioeconomic status (LBW)
• Maternal illness at the time of labour and delivery
(TLC>18000)
• Intrapartum maternal fever of >37 C
• PROM (more than 18 hours)
• Maternal chorioaminionitis
• Prolonged labour (>18 hrs)
• Maternal colonisation with infectious agents
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• Environmental factors
• Home delivery
• Low birth weight
• Birth asphyxia
• Bacterial contamination at the time of labor and
delivery
• Unclean hospital as well as nursery
environment and practices
• Prematurity
• Bottle feeding
• Indwelling of venous or catheters, endotracheal
intubations, TPN, prolonged use of antibiotics.
7. CLINICAL FEATURES
• Early signs and symptoms are subtle/non specific
• Generally the following should be sought :
• Refusal to feed
• Off colour
• Poor temperature control
• Tachycardia or Bradycardia
• Inactivity, lethargy , irritability
• Seizures,coma
• Respiratory distress or apnea
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8. INVESTIGATIONS
• Adjunctive test
• WBC count (reliable indicator)
• >30,000 or <4000
• Neutropenia (<2000) ; poor prognosis
• Immature neutrophils > 25%
• Band-neutrophil ratio of 0.2 or higher
• Low platelet count (<150,000)
• Raised CRP or procalcitonin
• Chest X-ray
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9. 9
• Specific diagnostic tests
• Blood culture: 1 ml/kg
• Cerebrospinal fluid culture
• Urine culture (significance for late onset sepsis)
• Tracheal aspirate culture and gram stain (VAP)
10. Management
• Preferable to get specimen for investigation before antimicrobial
therapy initiation but the therapy shouldn’t be delayed for this
purpose.
• Supportive treatment
• Early onset sepsis
• Late onset sepsis
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11. 11
EARLY ONSET SEPSIS
• Treatment according to C/S report
• Ampicillin+ amino glycoside (gentamicin) or cefotaxime.
• Ampicillin: 100-300 mg/kg/day - I/V x 8 hourly doses
(listeria monocytogenes)
• Gentamicin: 5 mg/kg/day - I/v x 8-12 hourly dose
• Anaerobic infection - Clindamycin/ metronidazole
• Group b streptococcus — penicillin (for 14 days)
• Bacteraemia - 10 days
• Complicated infections by gram negative bacteria extends the treatment to 21-28 days
• Meningitis - third Gen. cephalosporin (cefotaxime; 100 mg/kg/days 8-12 hourly dose) or cabapenem
(nosocomial) x 14 days
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LATE ONSET
SEPSIS
• Vancomycin + amino-glycosides (esp. cases with long line)
• Vancomycin - 15 mg/kg/dose given 8 hourly
• Amikacin - 15 mg/kg/day 12 hourly dose
• Meningitis suspicion - Cephalosporin
• Carbapanem if 3 Gen. cephalosporin recently received
• Pseudomonas - Ceftazidime or carbapenem
• Fungal infection - Amphotericin B
13. SUPPORTIVE
• Thermo-neutral environment
• Monitor vital signs
• Strict intake and output record
• Fluid and electrolyte balance { 5% dextrose 1/2 normal saline then 1/5 saline)
• Good respiratory support with oxygen and artificial ventilation.
• Monitor and manage metabolic disturbances (esp. serum electrolytes, hypoglycaemia, hypocalcemia, and metabolic acidosis)
• Metabolic acidosis : Sodium bicarbonate (0.5-1 ml/kg made up of 8.4% preparation)
• Hyperbilirubinemia : antibiotics / exchange transfusion as it can lead to kernicterus
• Seizures : anticonvulsants (phenobarbitone)
• Anaemia (Hb<12) : blood transfusion
• Bleeding (DIC) : fresh-frozen plasma, platelet transfusions, or whole blood
• Immunoglobulins such as Pentaglobin (highly enriched immunoglobulins IgM and IgG) or fresh frozen plasma can be given.
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14. Prevention
• Maternal vaccination against preventable diseases
(rubella, tetanus, varicella zoster virus, hepatitis B)
• Antenatal care
• Early onset sepsis — maternal intrapartum antibiotic prophylaxis
• Cord care
• Suspected Maternal chorioamnionitis aggressive treatment
• Hand washing and breast feeding (late onset sepsis)
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15. 15
COMPLICATIONS OF
SEPSIS
• Endocarditis
• Septic emboli
• Abscess formation
• Septic joints with residual disability
• Osteomyelitis
• Bone destruction
• Recurrent bacteraemia (rare:<5% of pts)
• Candidemia
• Septic shock
• DIC
• Organ failure
• Neonatal Meningitis
