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Neonatal Sepsis

Self-Learning Packet
2004

This self-learning packet is approved for 2 contact hours for the following professionals:
1. Registered Nurses
2. Licensed Practical Nurses

Orlando Regional Healthcare, Education & Development © Copyright 2004


Rev. 10/31/2004
Neonatal Sepsis

Table of Contents

Purpose.......................................................................................................................3

Objectives...................................................................................................................3

Instructions.................................................................................................................3

Introduction ................................................................................................................4

Immunity ....................................................................................................................4
Immune System Development ................................................................................................... 4
Immune System Physiology....................................................................................................... 5

Risk Factors................................................................................................................7

Trends in Neonatal Sepsis..........................................................................................8


Frequency................................................................................................................................... 8
Mortality/Morbidity ................................................................................................................... 8
Race, Sex, & Age ....................................................................................................................... 8

Early versus Late Onset Infections ............................................................................9

Clinical Signs of Sepsis ...........................................................................................10

Diagnostic Evaluations ............................................................................................10

Types of Pathogens ..................................................................................................12


Group B Strep .......................................................................................................................... 12
Staphylococcus......................................................................................................................... 13
Escherichia Coli ....................................................................................................................... 13

Management.............................................................................................................14

Nursing Considerations............................................................................................14

Family Implications .................................................................................................15

Summary ..................................................................................................................16

Post Test ...................................................................................................................17

References ................................................................................................................21

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Purpose
The purpose of this self-learning packet is to educate nurses who care for infants and to satisfy
the continuing education requirements of Orlando Regional Healthcare employees.
Orlando Regional Healthcare is an Approved Provider of continuing nursing education by
Florida Board of Nursing (Provider No. FBN 2459) and the North Carolina Nurses Association,
an accredited approver by the American Nurses Credentialing Center’s Commission on
Accreditation (AP 085).

Objectives
After completing this packet, the learner will be able to:
1. Match immune system development with appropriate week of gestation.
2. Identify the definition of neonatal sepsis.
3. Label the correct immunoglobulin with its definition.
4. Identify the cost of care related to neonatal sepsis.
5. Identify the risk factors for neonatal infections.
6. Describe trends in neonatal sepsis.
7. Differentiate between congenital and acquired infections.
8. Identify the signs and symptoms of a septic neonate.
9. Describe different types of neonatal infections.
10. Match treatment options with appropriate infection.
11. Identify nursing considerations when taking care of a sick infant.
12. Describe family implications when a newborn becomes ill.

Instructions
In order to receive 2.0 contact hours, you must:
• Complete the posttest at the end of this packet
• Submit the posttest to Education & Development with your payment
• Achieve an 84% on the posttest

Be sure to complete all the information at the top of the answer sheet. You will be notified if you
do not pass, and you will be asked to retake the posttest.

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Introduction
Newborn infants are at much higher risk for developing sepsis than children and adults because
of their immature immune system—especially premature infants, where 1 out of every 250 will
be diagnosed with sepsis. Sepsis is one of the major leading causes of death in the first few
months of a newborn’s life. Infections can contribute up to 13-15% of all deaths during the
neonatal period with the mortality rate reaching as high as 50% for infants who are not treated
timely. The combination of an immature and slow responding immune system increases the risk
of infection in the neonate. One reason for the increased risk is that antibodies, which help
protect mothers from infections, do not cross through the placenta to the fetus until
approximately 30 weeks of gestation. The antibodies present at birth take time to reach optimum
levels, which also affects the protection provided.

After reading this packet, the learner will have a better understanding of the physiology of the
neonatal immune system, current trends in the diagnosis and treatment of infections, risk factors,
signs and symptoms of sepsis, and implications for nurses who provide care for the septic
newborn.

Immunity
Immune System Development
The immune system begins very early in fetal development with the
origin of blood formation in the third week of gestation. In the
fourth week of gestation the thymus forms. The thymus helps to
mature and develop white blood cells so that they can play a key
role in fighting infections. By the eighth week of gestation, T cells,
B cells, and natural killer cells can all be found in the thymus.

T cells, which make an important component in cell-mediated


immunity, are formed solely in the thymus. B cells, which are the
precursors of antibody producing cells, are first produced in the
liver but by 12 weeks gestation move into the bone marrow where it
remains. Natural killer cells, which are cytotoxic cells that have the ability to attack viruses,
mature in the thymus. Interestingly, greater concentrations of natural killer cells are found in the
peripheral blood of newborns and the newborn usually has adult levels of these cells at birth, but
they diminish rapidly.

Neutrophils are relatively numerous in both the term and pre-term infant. A neutrophil is a type
of white blood cell that defends the body from organisms that cause infection. The stages of
neutrophil development, from immature to mature, are myeloblast, promyelocyte, myelocyte,
metamyelocte, band, and segmented neutrophil. When an infection is present, the neutrophils
migrate out of the capillaries and into the infected site, where they ingest and destroy the

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pathogens causing the infection.


The amount of circulating Differences in Immune Responses in Full and Preterm
neutrophils in the newborn peaks Infants
around 12 hours after birth and
then starts to decline to normal Immune System Full Term Infant Preterm Infant
levels. Even though a large Component
number of circulating
Immunoglobulin G Complete placental Incomplete placental
neutrophils can be found in the transfer, concentrations transfer, concentrations
newborn, the bone marrow comparable to mother decreased
storage pool of neutrophils at
birth is only 20% to 30% of the Lymphocytes Concentrations of T and Concentrations of T and
circulating pool in adults. B cells comparable to B cells comparable to
those in adults with those in adults with
normal response to normal response to
Immune System antigens antigens
Physiology Complement 50%-75% of Decreased concentration
concentration in adult
Despite the immune system and
immune system components, Neutrophils Elevated numbers at Elevated numbers at
early development during birth, with impaired birth, with impaired
gestation the newborn still functional ability functional ability
remains vulnerable to infections
Monocytes Normal number at birth Normal number at birth
after they are born because of the but have impaired but have impaired
immaturity of their immune chemotaxis chemotaxis
system.
Macrophages Normal number at birth Normal number at birth
A newborn has a poor response but decreased function but decreased function
to invading pathogens. This
Natural Killer Cells Concentration similar to Concentration similar to
immune response will gradually
adult level, but have adult level, but have
improve with age. During the diminished cytotoxic diminished cytotoxic
initial postpartum phase, the effects effects
infant relies on maternal
antibodies and the mother’s breast milk, which is rich with immunoglobulins. When a
pathogenic organism overcomes the infant’s defenses, infection and sepsis result. Sepsis is
defined as the presence of microorganisms or their toxins in blood or other tissues. Newborn
sepsis is still one of the most significant causes of neonatal disability and death today.

Reviewing the functions of the infant’s immune system will help provide a better understanding
of the interaction between the pathogenic organisms and the newborn’s susceptibility to
infection. Infections occur when the infant comes in contact with a pathogenic organism. The
organism, whether it is a virus, fungus, or bacteria, enters into the infant’s body system and
begins to multiply.

The infant’s immune system response to an organism is divided into three phases. The first
phase is the primary or nonspecific phase, which occurs immediately following the infant’s
inoculation with a pathogenic organism. During this phase, there is a migration of the neutrophils

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to the primary site of the infection. The neutrophils enter into the cells through membrane filters
and adhere to the pathogen. Ingestion and destruction of the invading organism then takes place.

The next phase in the immune response is called the secondary phase or the specific response
phase. During this phase, there is interaction of T and B cells to help develop immunoglobulins
or antibodies to protect the infant from the infection. There are three major types of
immunoglobulins: Immunoglobulin G (IgG), Immunoglobulin M (IgM), and Immunoglobulin A
(IgA).

Immunoglobulin G is the major immunoglobulin of the serum and interstitial fluid. It


provides immunity against both bacterial and viral pathogens. It starts to cross the
placenta and enter into fetal circulation around 30 weeks’ gestation and continues until
the 40th week. Term infants have IgG levels that are equal to or exceed maternal levels.
Since IgG is not transferred until around the 30th week of gestation, the preterm infant
does not have this protective barrier. Preterm infants are thus at higher risk for infections.
Research has shown that there are also decreased levels of IgG in post-term and small for
gestation age infants, which suggest that there may be some inhibition of transfer with
placental damage.

Immunoglobulin M does not cross the placenta thus, little or no IgM is transferred to the
fetus. This lack of IgM increases the infant’s susceptibility to gram negative infections.
The infant does however begin synthesis of this immunoglobulin very early in their fetal
life. Levels of IgM have been detected around 30 weeks’ gestation with higher levels
detected when there is an intrauterine infection present.

Immunoglobulin A is the most common immunoglobulin found in the gastrointestinal


tract, respiratory tract, human colostrum, and breast milk. IgA does not cross the
placenta, and intrauterine synthesis is minimal. Levels of IgA are usually not detected
until the infant is around 2 to 3 weeks old.

The last immune response is the tertiary phase. This phase provides long-term immunity against
the organism. During the second phase, the B cells produce memory cells that recognize the
invading pathogen on subsequent exposures. These memory cells recognize the invading
organism and cause them to be neutralized, preventing the infant from becoming sick again.
Although adequate numbers of B cells are present at birth, antibody production is diminished in
the neonate due to a lack of uterine exposure to foreign pathogens.

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Risk Factors
Causes of infections in newborns can
Source Risk Factors
be divided into three main groups:
intrauterine, intrapartum, and postnatal Maternal Poor prenatal care
infections. All three groups include Poor nutrition
factors that increase the infant’s risk of Substance abuse
coming in contact with an organism
that can cause an infection. Intrapartum Premature rupture of membranes
Maternal fever
Intrauterine or factors that increase the Prolonged labor
risk before birth include the following: Maternal UTI
poor prenatal care, poor nutrition,
recurrent abortions, and substance Neonatal Male
abuse. Intrauterine infections occur Birth asphyxia
when pathogenic organisms cross the Low birth weight
placenta into the fetal circulatory
system. The organisms, such as cytomegalovirus (CMV), can reside in the amniotic fluid,. Other
organisms ascend from the vaginal track, infecting the membranes and causing them to rupture.
This rupture of membranes can lead to infections of the respiratory and gastrointestinal tract of a
newborn.

Intrapartum or factors that increase the infants chance of becoming infected during the birthing
process include: prolonged rupture of membranes (>12 to 18 hours), urinary tract infections,
preterm labor, prolonged or difficult labor, maternal fever, colonization with Group B
Streptococcus (GBS), and maternal infections. Most infections during the birthing process are
related to the infant coming into unavoidable contact with an infected birth canal. The birth canal
can host bacteria that an infant’s immune system cannot defend against.

Postnatal infections may be contracted after delivery, as in the case with infections contracted
during resuscitation, or as a result of a nosocomial infection due to improper hand washing.
Infections in the postnatal period are more common in those infants who require foreign objects
be introduced into their systems. Items like endotracheal tubes or indwelling catheters increase
the risk of an infant becoming septic.

The single most important risk factor for infection in the neonate is prematurity. Neonatal factors
that increase the infant’s chance of becoming sick include: low birth weight, prematurity, birth
asphyxia, meconium staining, and resuscitation. There is a direct correlation between gestational
age and the infants risk for infection. Infants born at less then 32 weeks gestation have a 4 to 25
times higher risk of developing an early onset infection. Reasons for this include immature
immune system, thinner skin, and the frequent need for insertion of foreign objects. Also,
premature infants are likely to develop chronic lung disease requiring prolonged ventilator
support. Corticosteroids are often used to help treat their lung disease, but these drugs may leave
the infant at an increased risk of infection.

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It is important to note that in an otherwise healthy-appearing, term-gestation infant none of these


factors by themselves should lead to an assumption that the infant will suffer an infection.
However, a combination of these risk factors greatly increases the infant’s chance for infection
and therefore should heighten the suspicion of sepsis. Studies have shown that incidence of
infection increases to greater than 15% when two or more risk factors are present. An infant who
appears sick should heighten clinical suspicion of sepsis, and an evaluation for infection should
be performed immediately.

Trends in Neonatal Sepsis


Frequency
Sepsis identified by the results of cultures, such as blood, CSF, urine, occurs in approximately 2
out every 1000 live full term births. Of the 7-13% infants who undergo evaluation for sepsis only
3-8% have culture-proven sepsis. Since the early signs of sepsis are often nonspecific a high
percentage of newborns are subjected to a septic workup and administration of antibiotics before
the diagnosis has been made. The American Academy of Pediatrics (AAP), American Academy
of Obstetrics and Gynecology (AAOG) and the Centers for Disease Control and Prevention
(CDC) all have recommendations for sepsis screening and/or treatment for various risk factors,
thus a higher percentage of newborns are subjected to diagnostic tests. Since the mortality rate of
untreated sepsis is as high as 50%, most healthcare providers believe that the hazard of not
treating or delaying treatment to wait for positive cultures is too high, and therefore treatment is
initiated while awaiting the test results. As a result, the annual treatment cost for sepsis in
neonates here in the United States is approximately $800 million.

Mortality/Morbidity
Sepsis is a major cause of death during the first few months of life causing 13-15% of all
neonatal deaths. The mortality rate of neonatal sepsis can be as high as 50% for infants who are
not treated or when treatment is not begun quickly. A serious morbidity of neonatal sepsis is
neonatal meningitis. Research has shown that neonatal meningitis occurs in 2-4 per 10,000
infants and of those infants diagnosed with neonatal meningitis their chance of survival
significantly decreases. It is responsible for 4% of all neonatal deaths.

Race, Sex, & Age


Current research has shown that African-American infants have an increased incidence of Group
B Strep (GBS) disease as well as acquired or late sepsis. To help counter this many professional
healthcare groups have recommend guidelines for controlling risk factors in this race. Despite
these changes in screening and treatments, African-American infants still remain at the highest
risk for sepsis.

Male infants have a higher incidence of sepsis than their female counterparts. This higher rate of
sepsis is especially true for gram negative infections.

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Premature newborns also have a higher rate of infection than full term infants. The incidence of
sepsis is significantly higher in infants with very low birth weight. Infants weighing less than
1000g are at the highest risk for sepsis.

Early versus Late Onset Infections


Neonatal bacterial infections are classified into two different categories depending on the time of
their presentation. Congenital infections or early onset infections occur when an infant presents
with signs and symptoms of the illness within the first week of life. Acquired or late onset
infections occur after the infant is greater than a week old.

Congenital infections or early onset


sepsis occurs within the first few Characteristics of Congenital vs. Acquired Sepsis
days of life, and are typically
acquired during the intrapartum Characteristic Congenital Acquired
period, often from organisms in the
maternal genital tract. Eighty-five Time of Onset: Birth - 4 Days > 7 Days
percent of newborns with early
onset sepsis begin to show
symptoms within the first 24 hours OB Complications: Frequent Unusual
of life, 5% have symptoms between Source: Mother’s Postnatal
24 and 48 hours, a very small Genital Tract Environment
percentage of infants show
symptoms between 48 hours and 6 Clinical Multisystem Focal
days of life. Premature infants have Presentation:
the most rapid onset. A sudden Mortality Rate 5-50 2-6
onset and rapid progression to septic (%):
shock often characterize these Usual Group B Strep Staph Epi
infections. The main clinical feature Organisms: E. Coli Candida
of a newborn with early onset sepsis
is respiratory distress, which often presents as mild nasal flaring and tachypnea. The respiratory
distress can quickly progress to multisystem failure and shock if not caught early. With early
onset sepsis, there is a high mortality rate of 15% to 50%. The most common organism for early
onset bacterial infection is Group B Strep (GBS). In addition to GBS, Escherichia Coli,
Enterococcus, and Chlamydia are also common causes of congenital infections in the newborn.

Acquired or late onset infections can occur anywhere from 7 days to 2 months following birth.
These infections are normally seen after the first week of life and usually are contracted from
organisms in the postnatal environment. The clinical manifestations may be acute physiological
deterioration or manifestations of a more localized infection that has progressed to sepsis.
Acquired infections have slower onsets and have a decreased mortality rate of around 10% to
20%. Common pathogens responsible for late onset infections include Candida Albicans,
Coagulase Negative Staphylococci, Serratia, GBS, and Pseudomonas.

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Clinical Signs of Sepsis


Few neonatal infections are easy to recognize. Since infants are
unable to speak and vocalize when they are not feeling well, it Signs of Sepsis
is important for the staff caring for the infant to be observant of − Pallor
signs and symptoms of sepsis. These signs range from mild − Poor temperature control
symptoms to a rapidly deteriorating infant, who may need − Grunting
resuscitation. Early onset infections often present with − Flaring
nonspecific, vague symptoms because of neonate’s inability to − Apnea & Bradycardia
mount an inflammatory response. Often the only sign is that − Lethargy
the infant does not “look right”. See the box to the right for a − Hypoglycemia
list of the signs and symptoms. − Poor feeding
− Abdominal distention
Signs of infection may be exhibited even as early as the
mother’s labor. Often infants demonstrate profound
tachycardia before birth, or they may show decreased beat-to-beat variability on a fetal
monitoring strip. Newborns who have congenital infections may be depressed at delivery, have
low apgars, and/or require resuscitation.

Common nonspecific, early signs of infection seen most often include: hypothermia,
accompanied by a change in the infant’s color, tone, activity, and/or feeding behavior. During
this time, there may also be sudden episodes of apnea. Gastrointestinal symptoms include
feeding intolerance or a lack of interest in feeding. Because these nonspecific signs of sepsis
also characterize the onset of numerous noninfectious processes, it makes the diagnosis difficult.

Diagnostic Evaluations
Since sepsis can be easily confused with other neonatal conditions such
as hypoglycemia or CNS disorders, laboratory and radiographic tests are
performed. These tests can help confirm when an infant is truly septic.

Septic work-ups will usually be performed on those infants who are


displaying signs of sepsis. Work-ups may include a peripheral blood
culture, complete blood cell count (CBC) with differential, chest x-ray,
urine culture, and lumbar puncture with blood being the principle fluid
assessed for suspected sepsis. Ideally, all cultures should be obtained
before antibiotics are started. However, 20% to 30% of women in labor
receive antibiotics before delivery of the infant, and therefore the infant
may have already been exposed to the antimicrobials, which may affect
the results of the blood cultures.

Positive CSF, urine, and bacterial blood cultures are lab results that confirm the infant has an
infection. Other abnormal results to observe in an infant suspected of sepsis are hypoglycemia,

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hyperglycemia, metabolic acidosis, thrombocytopenia, or hyperbilirubinemia. The blood culture


and CBC are the most helpful tests to identify an infection and which pathogen is the causative
organism.

CBC findings that indicate an infection is present include: an elevated or decreased white blood
count (WBC), a low platelet count, and a high I:T ratio. The I:T ratio is a calculation which is
done to show the percentage of immature to total
white blood cells. When the I:T ratio is greater I:T Ratio Calculation
than 0.2, this indicates that there is a “left shift.”
This left shift means that there are more immature Immature cells
I:T ratio = Total (mature + immature)
neutrophils than mature neutrophils circulating
around in the bloodstream.

A neutrophil is a type of white blood cell that defends the body against organisms that cause
infection. When infection is present the neutrophils migrate out of the capillaries and into the
infected site, where they ingest and destroy the pathogens causing the infection. When the
demand for the neutrophils exceeds the supply in circulation, immature neutrophils are released
into the blood to help fight off the infection. This is labeled a “left shift” and indicates that an
infection may be present. As the infection diminishes and neutrophils are replenished, a “shift to
the right” occurs, indicating that everything is back to normal.

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Types of Pathogens
Over the past 70 years, there have been changes in the predominant bacteria that cause both early
onset and late onset infections. The fluctuating pattern is due to the development and use of new
drugs, the mobile population of families, and the prolonged survival of infants who would have
died previously. In the 1930’s most neonatal infections were the results of Group A Beta-
Hemolytic Streptococci. This pathogen continued to be the cause of most infections until the
1950’s when most infections were then caused by the pathogen Staphylococcus Aureus. From
1966 to 1978, either Escherichia Coli or Group B Strep caused the majority of infections. Group
B Strep remains one of the major causes of infections today.

Group B Strep (GBS)


Although any pathogenic organism can cause serious problems for the newborn,
GBS is by far the most serious cause of neonatal infection and mortality. GBS is
a normal flora found in the vagina and gastrointestinal tract of 15% to 20% of
women. It is not a sexually transmitted disease and normally does not cause any
problems for the women who are colonized with it. For infants though, GBS can
cause serious health problems and even death. Of the 20% of women colonized
with GBS, 50% of them give birth to infants colonized with GBS. 1% to 2% of
those infants become clinically ill with a GBS infection. One risk factor for
women who are colonized with GBS is that they have a higher chance for
premature labor because of the elevated amniotic fluid level of phospholipase
A2. This phospholipase produces prostaglandin, which is a potent labor
stimulatant. Other risk factors that increase the infant’s chance of becoming
infected with GBS include maternal temperature > 38 Celsius (100.4 F), prolonged rupture of
membranes, premature delivery, multiple births, and a previous sibling with a GBS infection.

Because of the severity of a GBS infection in the newborn, treatment guidelines have been
established by the governing bodies involved in newborn health. The main focus of the
guidelines is to promote GBS screening of all pregnant women late in their pregnancy. This is
partly due to the fact that upwards of 25% of GBS infections occur in term infants who are born
to mothers without any risk factors. When the pregnant woman is tested and is positive for
colonization of GBS, she should be treated with antibiotics during labor.

GBS infections can either be an early or late onset infection. The early onset infection is a result
of transmission of the GBS bacteria from the mother to the fetus, usually during delivery. The
infant will begin to present symptoms during the first 24-48 hours of life. At first, the symptoms
may be very subtle and nonspecific. The infant may present with pallor, tachypnea, tachycardia,
or decreased activity. If these first symptoms go undetected, the infant will progress to signs of
infection that are more obvious. These may include temperature instability and/or respiratory
distress, such as grunting, nasal flaring, retractions, and apnea. GBS infections are progressive
and the symptoms worsen if treatment is not initiated. Within hours, an infant can deteriorate
from grunting with slight retractions to septic shock and death. The mortality rate in infants less
then 36 weeks of gestation is 30% to 50%.

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Late onset GBS infections can occur anywhere after the first week of life up to 2 months of age.
Late onset infections seem to be caused by nosocomial transmission rather than maternal
transmission. This form of GBS infection can be less severe than the early onset form but still
carries a mortality rate of 25%. Infants with this late form will often present with meningitis as
their main symptom.

Treatment of GBS often begins when the mother is in labor. For women who test positive,
ampicillin is needed at least 4 hours before delivery for the treatment to be successful. If the
mother does not receive the ampicillin, the infant may have to undergo blood tests to rule out the
presence of the GBS bacteria. For those newborns who do acquire a GBS infection, treatment
starts with supportive care. This includes antibiotics, such as ampicillin and gentamicin, fluid and
volume support, and respiratory support, usually in the form of a ventilator. Treatment against
meningitis-induced seizure activity may also be required.

Long term outcomes for infants with GBS infections are dependent upon the type of infection,
whether it is early onset or late onset, and how soon treatment was started. Neonates who present
with early onset GBS and receive treatment quickly have a better prognosis then those who
acquire late onset GBS infections where 25% to 50% of those infants may have permanent
neurological damage.

Staphylococcus
Staphylococcal pathogens can cause mild to severe infections. Transmission may result in a
localized infection from a scalp electrode, to more widespread infections such as osteomyelitis
resulting in overwhelming sepsis. The major source of this infection from staphylococcus comes
from improper hand washing by the hospital staff. It is also associated with infections arising
from umbilical catheters, endotracheal tubes, and central lines. Other causes of nosocomial
infections are improper staffing, lack of space between infants, and lack of sterile technique
when caring for invasive catheters. Colonization of the pathogen occurs in 40% to 90% of
infants, usually by the fifth day of life. It is most often treated with vancomycin.

Escherichia Coli
E. Coli is the most common cause of gram negative neonatal
infection in the United States. This pathogen infects 1 to 2 out
of every 1,000 live births and is responsible for up to 45% of
neonatal infections. This bacterium is found in the mother’s
genital tract with a high incidence of colonization in the
neonate. The pathogen can cause severe infections that may
lead to respiratory distress, cardiovascular collapse, meningitis,
multiorgan failure, and even death. E. Coli is usually treated
with gentamicin.

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Management
To increase the infant’s chance of survival, early recognition of signs and symptoms of sepsis is
imperative. Often the diagnosis of sepsis is based upon suspicion of the presenting clinical signs
and symptoms. Antibiotic therapy is usually started before lab results confirm and identify the
pathogen causing the infection. In addition to antibiotic treatment, therapy consists of
circulatory, respiratory, nutritional, and developmental support.

Treatment begins with careful monitoring of the infant’s vital signs and regulation of the thermal
environment. Supportive therapy for a septic infant starts with the administration of oxygen
when respiratory distress or hypoxia becomes present. The infant may also need more invasive
respiratory support such as continuous positive airway pressure (CPAP) or to be placed on a
ventilator if they are suffering from apneic episodes. Infants who are sick may also develop
electrolyte abnormalities. These infants will need careful, ongoing monitoring and adjustment of
the fluid and electrolyte balance, especially when the infants are NPO.

Antibiotic therapy is continued for 7 to 21 days if the cultures


are positive, or it is discontinued in 3 days if cultures are
negative. The infant’s outcome is variable. Before the
availability of antibiotics, mortality rates for infected infants
were greater than 95%. In the 1970s and 1980s, the mortality
rate decreased to 20% to 40%. Today, with the use of
antibiotics along with early recognition and supportive care,
mortality has reduced to 13% to 45 %, depending on the
causative agent. However, approximately 1,500 neonates in
the United States still die annually from systemic infections.

Nursing Considerations
Nursing care for the infant with sepsis involves skilled observation and ongoing assessments.
Recognition of a problem is paramount in importance. It is most often the nurse who observes
and identifies that something “just isn’t right” with the infant. This is due to the fact that the
nurse maintains constant assessment and documentation of subtle changes in the infant’s vital
signs, physical assessments, feeding tolerance, responsiveness, and/or general behavior.
Awareness of the potential routes for transmission of infectious pathogens will also help identify
those infants at risk for developing sepsis.

Much of the care for infants with infections involves the medical treatment of the illness. Nurses
must be aware of the side effects of the specific antibiotics and the proper administration
guidelines. Prolonged antibiotic therapy poses additional hazards for affected infants.
Antibiotics predispose the infant to growth of resistant organisms and superinfections from
fungal agents such as candida. The nurse must be alert for signs of such complications.

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Another challenge in caring for a sick infant is starting and maintaining IV access for drug
therapy. Common sites in the infant include the hand and arm, as well as the veins found in the
scalp and foot. If the infant is going to require extensive antibiotic therapy, a peripherally
inserted central catheter (PICC) may be considered.

Total care of infants with sepsis involves decreasing any additional physiologic and/or
environmental stress. This includes providing an optimum thermoregulated environment and
anticipating potential problems, such as dehydration or hypoxia. Precautions need to be
implemented to prevent the spread of infections to other newborns. To be effective, precautions
must be carried out by all caregivers that come in contact with the sick infant. Proper
handwashing, use of disposable equipment, disposing of excretions, and adequate housekeeping
of the environment and equipment are essential. Since nurses are the most constant caregivers
involved with sick infants, it is usually their responsibility to oversee that everyone maintains all
phases of isolation.

Family Implications
Maternal attachment is a cumulative process
that begins before conception. It is strengthened
by significant events during pregnancy, and
matures through maternal-infant contact during
the neonatal period. When an infant becomes
sick, the necessary physical separation appears
to be accompanied by an emotional detachment
on the part of the parents, which may seriously
damage the capacity for parenting their infant.

During pregnancy, and sometimes even before


conception occurs, mothers develop an ideal or
fantasy image of their unborn child. To the
mother, the unborn child has an imagined appearance, pattern of behavior, and expected
accomplishments. Anything that alters this image can alter the bonding between the mother and
her new child. Therefore nursing care does not stop with providing medical care to a sick infant.
The nurse needs to encourage and facilitate parental involvement, rather than isolating the
parents from their infant and associated care.

Nurses should be cognitive of the fact that the parent’s worry associated with a sick infant can go
way beyond the infant’s actual state of illness. Often parents ask themselves, “Can I care for this
infant?” The nurse needs to provide constant teaching and supply the family with continual
updates on the infant’s condition to help them through this frightening time. It is important for
the nurse to use simple and basic vocabulary. When medical language is used, it increases the
parent’s anxiety level, and teaching if less effective. Some mothers feel guilty that they may
have done something to cause the infant’s condition. The nursing staff needs to provide constant
reassurance that this is a common feeling and that she did not cause the infant to become ill. The

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Neonatal Sepsis

nurse needs to remember the goals of his/her care. Goals cannot be only patient orientated, but
need to be family orientated as well. It is important to remember that it is the infant to who we
provide care, but it is the family who will take the baby home. The nurse needs to provide the
family with the knowledge and skills they need to take care of their infant once the baby is
discharged from the hospital.

Summary
Despite the major advances in neonatal medicine, many infants still develop life-threatening
infections during the first month of life. Identifying and caring for an infant with a possible
infection starts with a skilled nurse who is proficient in performing neonatal assessments. The
assessment begins with a nurse’s innate knowledge of the many different risk factors for
newborn infection. The nurse needs to be observant for any sign that may indicate sepsis. It
cannot be overemphasized that prompt recognition, early diagnosis, and immediate treatment of
sepsis can dramatically improve the infant’s outcome and limit any potential disability.

Once sepsis has been identified, treatment must be initiated promptly, and the infant reassessed
for their response to the therapy. Hours can make the difference of an infant surviving the
infection, or succumbing to its systemic devastation. Because of the nonspecific manifestations
of impending sepsis, any changes in the physical and/or behavioral state of an infant should raise
the suspicion of sepsis. Above all else, nursing assessment and interventions are the most
important tool in the prevention, prompt recognition, and effective management of newborn
infections.

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Neonatal Sepsis

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Please also complete the self-learning packet evaluation at the end of the packet.
In order to receive 2.0 contact hours, you must:
• Submit the answer sheet and payment ($5.00 for Orlando Regional Healthcare employees / $10.00 for
non-employees) to:
Orlando Regional Healthcare
Education & Development, MP 14
1414 Kuhl Ave.
Orlando, FL 32806
• Achieve an 84% on the posttest. (You will be notified if you do not pass and will be asked to retake the
posttest.)
Neonatal Sepsis

Post Test
Directions: Do NOT write on this test. Complete this test using the bubble sheet
provided.
1. All of the following define sepsis in the newborn EXCEPT:
A. The pathogen overcomes the infant’s defenses
B. The presence of microorganisms in the infant’s blood
C. The presence of the pathogen in the infant’s stool
D. The presence of microorganisms in the infant’s tissues

2. Which of the following are maternal risk factors for developing neonatal infections?
A. Regular wellness check ups
B. Poor nutrition
C. Multiple births
D. First pregnancy

3. T Cells are first found in the fetus at what week gestation?


A. 4 weeks
B. 6 weeks
C. 8 weeks
D. 10 weeks

4. The annual cost of treatment of neonatal sepsis in the United States is __________.
A. $600 million
B. $700 million
C. $800 million
D. $900 million

5. Infants that have a higher risk for developing infection are


A. Male infants
B. Female infants
C. Full term infants
D. Post term infants

6. An infant is 6 hours old and is starting to show signs of respiratory distress such as
grunting and retraction. Which of the following accurately describes the type of
infection the infant has?
A. Acquired
B. Congenital
C. Nosocomial
D. Periodic

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Neonatal Sepsis

7. A mother brings in her 2-week-old infant to the doctor and reports that the infant has
been lethargic and not eating very well. Which of the following accurately describes
the type of infection the infant has?
A. Acquired
B. Congenital
C. Intrapartum
D. Maternal

8. The most common type of organism that causes a congenital bacterial infection is:
A. Candida Albicans
B. Pseudomonas
C. Group beta strep
D. Serratia

9. All of the following are signs of infection in the newborn EXCEPT:


A. Pallor
B. Apnea
C. Hypoglycemia
D. Choking

10. Which statement best describes signs and symptoms of an infant with suspected
sepsis?
A. Infants with infections will have a fever.
B. The infant’s appetite is unaffected by sepsis.
C. Infants with infections are easy to recognize because of the obvious
symptoms.
D. Infants with infections are hard to recognize because of the vague symptoms.

11. When taking care of a sick infant the nurse should:


A. Decrease any physiologic or environmental stress
B. Have blood ordered and waiting
C. Perform frequent linen changes
D. Perform frequent lab draws

12. In general when assisting the family with coping with the hospitalized infant, the
nurse should recognize that:
A. Mothers often feel capable and ready to jump in and help with the care of the
sick infant.
B. Fathers often are ready to jump in and help with the care of the sick infant.
C. Mothers often feel guilty when their infant becomes sick, blaming themselves
for the infant’s illness.
D. Parental involvement is a low priority in the care of an infant.

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Neonatal Sepsis

Match the correct immunoglobulin with its description

13. Does not cross the placenta, levels are higher when
an infection is present. A. Immunoglobulin A
14. Most common immunoglobulin found in the B. Immunoglobulin G
gastrointestinal tract. Levels not detected until the
infant is 2-3 weeks old. C. Immunoglobulin M

15. Crosses the placenta and enters into fetal circulation


around 30 weeks of gestation.

Match the correct pathogen with its description

16. This pathogen is a major source of infection from


A. Escherichia Coli
hospital personnel with improper hand washing.
B. Group B Strep
17. Most common cause of gram negative infections.
C. Staphylococcus
18. Infection can be either early or late in its onset and
is one of the most serious causes of mortality in the
newborn.

Match the correct pathogen with its common treatment

19. Escherichia Coli A. Ampicillin

20. Group B Strep B. Gentamicin

21. Staphylococcus C. Vancomycin

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Neonatal Sepsis

References
Bellig, L. (2004, June 23). Neonatal sepsis. Emedicine. Retrieved July 12, 2004 from
http://www.emedicine.com/ped.topic2630.htm

CDC. Group B Strep. Retrieved July 23, 2004, from http://www.cdc.gov/ncidod/dbmd/gbs/

Deacon, J. & O’Neill, P. (1999). Core Curriculum for Neonatal Intensive Care Nursing (2nd ed.).
Philadelphia, PA: W.B. Saunders Company.

Gardner, S. & Merenstein, G. (2002). Handbook of Neonatal Intensive Care (5th ed.). St. Louis,
MI: Mosby.

Haw, P. (2003). Care of the Sick Neonate: A Quick Reference for Health Care Providers. New
York, NY: Lippincott Williams & Wilkins.

Huether, E. S. & McCance, L. K. (2000) Understanding Pathophysiology (2nd ed.). St. Louis,
MI: Mosby.

Ladewig, P., London, M., Moberly, S., & Olds, S. (2001). Contemporary Maternal-Newborn
Nursing Care (5th ed.). New York, NY: Prentice Hall.

Lowdermilk, L. D., Perry, E. S., & Bobak, M. (2000). Maternity & Women’s Health Care (7th
ed.). St. Louis, MI: Mosby.

McKenney, W. M. (2001, December). Neonatal nursing. Understanding the neonatal immune


system: high risk for infection. Critical Care Nurse, 21(6), 35-47.

Mullaney. D. (2001). Group B streptococcal infections in newborns. JOGNN, 30(6), 649-658.

Neonatology on the Web. Neonatal Infections. Retrieved July 14, 2004, from
http://www.neonatology.org/syllabus/sepsis/index.htm

Oddie, S. & Emblrton, N. (2002). Risk factors for early onset neonatal group B streptococcal
sepsis: case control study. British Medical Journal, 325(7539), 308-311.

Polinski, C. (1996, October). The value of the white blood cell count and differential in the
prediction of neonatal sepsis. Neonatal Network, 15 (7), 13-22.

Sater, J. K. (1998, September / October). Treatment of sepsis in the neonate. The Journal of
Intravenous Nursing, 21 (5), 275-281.

Sinha, A, Yokoe, D. & Platt R. (2003). Intrapartum antibiotics and neonatal invasive infections
caused by organisms other than group B streptococcus. The Journal of Pediatrics, 145
(5), 492-497.

Wong, J. D. (2003). Whaley & Wong’s Nursing Care of Infants and Children (7th ed.). St. Louis,
MI: Mosby.

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Neonatal Sepsis
Self-Learning Packet Evaluation

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Neonatal Behavioral Health Cardiology Oncology
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