NEONATAL

SEPSIS

Dr. L. Manglem Singh Paediatrician, J. N. Hospital, Porompat Imphal, Manipur.

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Neonatal Sepsis

Clinical syndrome of bacteraemia characterized by systemic signs and symptoms of infection in the first four weeks of life

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Early vs Late onset sepsis Early onset Age Risk factor <72 hours Prematurity Amnionitis, Maternal infection Source Maternal genital tract Presentation Fulminant Multisystem Pneumonia frequent Mortality 5-50%
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Late onset >72 hours Prematurity

Environmental (nosocomial) slowly progressive focal Meningitis frequent 10-15%

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Natural course of sepsis

Bacteria Focal infection sepsis Sepsis syndrome Bacteraemia

Early septic shock

Refractory septic shock

MODS DEATH
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Incidence In India - 3.9 % of all imtramural births - 20 30 % develop meningitis

In developed countries - 1 in 1000 live births - Term - 4 in 1000 live births - Preterm - 300 in 1000 VLBW babies

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Etiology

Escherichia coli Staphylococcus aureus Klebshiella pneumonae

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Risk Factors associated with Neonatal Sepsis

Maternal Risk Factors 1. Intrapartum Maternal Infection - Purulent / foul smelling liquor - Fever (>380C) - Leucytosis (WBC >18000 / mm3) 2. Premature rupture of membranes 3. Prolonged rupture of membranes > 12 hours 4. Premature onset of labour (<37 weeks 5. Maternal UTI
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Neonatal Risk factors 1. Low Birth Weight Baby 2. Perinatal asphyxia 3. Male gender

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Symptoms of Neonatal Sepsis CNS Lethargy, Refusal to suckle, Limp, Not arousable, poor or high pitch cry, Irritable, Seizures

CVS Pallor, Cyanosis, Cold and clammy skin Respiratory Tachypnoea, Apnoea, Grunt, Retractions
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Symptoms of Neonatal Sepsis GIT Vomiting, Diarrhoea, Abdominal distension Haematological Bleeding, Jaundice Skin Rashes, Purpura, Pustules

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Laboratory Diagnosis of Neonatal Sepsis 1. Direct methods - Blood culture - CSF culture - Urine culture 2. Indirect methods - Total leucocyte count - Absolute neutrophil count - Total immature neutrophils - Immature to total neutrophols - Neutrophil Morphology - Platelet count - Micro ESR - Acute phase reactants - Buffy coat examination - Smear of gastric aspirate / External ear canal fluid - C3d
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SEPSIS SCREEN
At Birth Major risk factors 1. Rupture of membranes > 24 hours 2. Maternal intrapartum fever > 100.40 F 3. Chorioamninitis Minor risk factors 1. Rupture of membrane > 12 hours 2. Maternal intrapartum fever > 99.50 F 3. Maternal WBC > 15000 / mm3 4. Low apgar score(< 5 at 1 min, < 7 at 5 min) 5. LBW ( < 1500 g ) 6. Preterm labour ( < 37 weeks)
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SEPSIS SCREEN
1. Leucopenia (TLC < 5000 / mm3) 2. Neutropenia (ANC <1800 / mm3) 3. Immature neutrophil to total neutrophil ( I / T) ratio ( > 0.2) 4. Micro ESR ( > 15 mm / 1st hour ) 5. CRP - positive
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Approach to Neonatal Sepsis

Antenatal Mothers with risk factors Symptomatic infants

Postnatal

Asymptomatic infant with risk factors

Term
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Preterm
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Evaluation of symptomatic infant for sepsis - Sepsis screen - Chest X-ray - Lumbar puncture - Blood culture Begin Antibiotics Culture positive Presence of focal infection Sepsis screen positive LP abnormal Symptoms persists 72 hrs Treat pneumonia 7-10 days Septicaemia 10-14 days Meningitis 14-21 days
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No risk factors for sepsis Culture negative Sepsis screen negative Symptoms resolve by 24 hrs

Treat for 48-72 hrs and discharge

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Evaluation of asymptomatic infant for sepsis

Sepsis screen Sepsis screen negative Sepsis screen positive Blood culture, LP

Begin Antibiotics
Observe for 48-72 hrs and discharge Culture positive LP abnormal Culture negative LP normal

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Treat septicaemia 10-14 days Treat for 48-72 hr Meningitis for 14-21 days and discharge 16

Supportive Care - Keep the neonate warm - Start IV Fluid, Infuse 10% Dextrose 2ml / Kg stat to maintain normoglycaemia - Maintain fluid and electrolyte balance and tissue perfusion If CRT > 3 sec infuse 10 ml / Kg normal saline
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Supportive Care - Avoid enteral feed, if sick - Start oxygen by hood, if cyanosed and support breathing - Consider exchange blood transfusion, if there is sclerema, DIC, Neutropenia

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Choice of Antibiotics
Pneumonia or Sepsis

Penicillin + Aminoglycoside (Ampicillin or Cloxacillin) (Gentamicin or Amikacin)

Meningitis Ampicillin + Gentamicin or
Cefotaxime + Gentamicin or Amikacin

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Superficial Infections

- Pustules

- After puncturing, clean with betadine and apply antimicrobial

- Conjunctivitis- Chloramphenicol eye drops

- Oral thrush - Local application of Nystatin or Clotrimazole

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Prevention of Infection
- Exclusive breastfeeding

- Keep cord dry

- Hand washing by care givers - Hygiene of Baby - No unnecessary intervention - Better management of IV Lines - Disinfection of Equipments
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Hand Washing

- Single most important means of preventing nosocomial infections

- Very Simple
- Cheap

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Hand Washing

- Two minutes, hand washing to be done before entering baby care area

- 10 seconds hand washing to be done before and after touching every baby, and after touching unsterile surfaces and fomites

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Steps of effective hand washing

- Roll sleeves above elbow - Remove wrist watch, bangles, ring etc - Using plain water and soap, wash parts of the hand in the following sequence

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Palm and fingers (web spaces) Back of hands Fingers and Knuckles Thumbs Finger tips Wrists and forearm up to elbow
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Steps of Effective Hand Washing - Keep elbow always dependent - Close the tap using elbow - Dry hands using single use sterile paper / napkin - Do not keep long or polished nails Rinsing hands with alcohol is NOT A SUBSTITUTE for PROPER HAND WASHING

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Medication preparation
( Prepare IV fluid under aseptic conditions ) - Never use stock solution for flushing - Do not use a single bottle for > 24 hrs - Label bottle with date / time

- After seal is removed, use betadine soaked sterile cotton to cover the stopper of bottle
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- Use disposable needle each time

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Better management of IV Lines

- Thorough hand washing

- Wear gloves
- Use disposable IV cannula - Thorough skin preparation - All IV ports should be wiped with alcohol - Early identification of extravasation - Avoid unnecessary IV infusion
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Conclusion
- High index of clinical suspicion - Look for Lab evidence of sepsis - Start parenteral antibiotics (intravenous) - Provide supportive care

- Review culture reports

- Practise barrier nursing to prevent Crossinfection

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Thank you

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