High-Risk related to Infectious Processes

Neonatal Sepsis

Objectives

At the end of this discussion, YOU will be able to:

• Define neonatal sepsis

• Differentiate between the types of sepsis

• Out line the main diagnostic measures for sepsis

• Discuss therapeutic management of sepsis

• Discuss nursing care management for child with sepsis

• Sepsis or septicemia: refers to a generalized bacterial infection in the bloodstream

• Neonates are highly susceptible to infection as a result of:

▪Diminished nonspecific (inflammatory).

▪ Specific (humoral) immunity

• Delayed chemotactic response.

• Minimal or absent immunoglobulin-A IgA, and IgM.

• Decrease complement levels

Sepsis

• Sepsis or septicemia: refers to a generalized bacterial infection in the bloodstream

• Neonates are highly susceptible to infection as a result of:

▪Diminished nonspecific (inflammatory).

✓There is usually no local inflammatory reaction at the portal of entry to

signal an infection so diagnosis may be delayed.

Sepsis

▪ Specific (humoral) immunity such as:

✓Impaired phagocytosis

✓Delayed chemotactic response (the movement of a microorganism or cell in response to a chemical stimulus)

✓Minimal or absent immunoglobulin-A IgA, and IgM.

✓Decrease complement levels.

Sepsis

Sepsis

• Infant has poor response to pathogenic agent , no local

inflammatory reaction, so, symptoms tend to be vague and non

specific that may delay treatment

Sepsis

Risk factors:

• High risk infant

• Male gender

• Prematurity

• Congenital anomalies

• Invasive procedures, nosocomial exposure in NICU

Neonatal sepsis is common in infant at risk:

- Preterm infant

- Infant born after a difficult or traumatic labor and delivery

Sepsis

• Sepsis can be acquired from:

- Prenatally across the placenta from the maternal bloodstream e.g. viruses as cytomegalovirus (CMV) , toxoplasmosis, treponema pallidum (syphilis)

- During labor from ingestion or aspiration of infected amniotic fluid

- Postnatal

Sepsis

• Sepsis that acquired prenatal period across the placenta from the

maternal bloodstream or during labor from ingestion or aspiration of

infected amniotic fluid.

• Prolonged rupture of the membranes .

Types of Sepsis

1. Early - onset sepsis (EOS): less than 3 days:EOS: a positive blood culture in an infant who is less than 72 hours of age Important cause of serious illness and death

▪ Acquired in the perinatal period

▪ Microorganisms across the placenta from the maternal bloodstream

or during labor from ingestion or aspiration of infected amniotic fluid

▪ Prolonged rupture of the membranes

Types of Sepsis

• Transplacental transfer can occur with organisms and viruses such as

cytomegalovirus, toxoplasmosis, and Treponema pallidum (syphilis), during

the latter half of pregnancy

• Infection can occur from direct contact with organisms from the maternal

GI and genitourinary tracts.

Types of Sepsis

▪ The most common organisms are group B streptococcus (GBS) and E-coli

(GBS) cause of death to (50%) infants.

▪ Haemophilus influenzae and Candida albicans are common seen in early

onset sepsis in VLBW infants

Types of Sepsis

2. late sepsis: 1-3 weeks after birth

▪ Primarily nosocomial

▪ The common organisms are staphylococci, klebsiella, enterococci,and

pseudomonas

▪ Contaminated older children and adult most common cause of late sepsis

in VLBW and ELBW infants

Types of Sepsis

2. late sepsis: 1-3 weeks after birth

▪ Bacterial invasion can occur through sits as umbilical stump, skin, mucous

membranes of the eye, nose, pharynx and ear, and body systems(

respiratory, nervous, urinary and GI system)

Types of Sepsis

3. Postnatal infection:

▪ Acquired by cross-contamination from other infants, personal. Or

objects in the environment

▪ Bacterial that are commonly called “water bugs” are found in water

supplies, humidifying apparatus, suction machines

Types of Sepsis

3. Postnatal infection:

▪ Coagulase - negative staphylococcus usually colonize the skin may

infect indwelling venous and arterial catheters used for infusion, blood

sampling.

Types of Sepsis

• Diagnostic Evaluation is based on clinical S&S: box 9-9, p: 312

• Isolation of the specific organism is always attempted through cultures of

blood, urine, and CSF

• Blood studies: anemia, leucopenia, and leukocytosis

• Leukopenia is usually an threatening sign because of its frequent

association with high mortality

Diagnostic Evaluation

• Elevated of immature Neutrophils, increase or decrease of total

Neutrophils and change morphology also suggest an infectious process in

the neonate.

• C-reactive protein serial measurements and interleukin- 6 may have a

significant role in establishing or excluding the diagnosis of sepsis

Diagnostic Evaluation

Diagnostic Evaluation

• Interleukins (ILs) are group of cytokines (secreted proteins and signal

molecules) that are first seen to be expressed by white blood cells

(leukocytes)

• They promote the development and differentiation of T and B

lymphocytes, and hematopoietic cells

• Based on clinical S&S: box 9 -11, p:283

General signs: infant not doing well, poor temperature control

(hypothermia, hyperthermia)

Circulatory system: pallor, cyanosis, mottling. Cold, clammy skin.

Hypotension, edema, irregular heart beat_ bradycardia, tachycardia

Respiratory system: irregular respirations, apnea, or tachypnea, grunting

,dyspnea, and retractions

Clinical Manifestations

Bulging fontanel

Central nervous system: diminished activity_ lethargy, hyporeflexia,

coma. Increase activity_ irritability, tremors, and seizures

Increased or decreased tone

Abnormal eye movements

Clinical Manifestations

Gastrointestinal system: poor feeding, vomiting, diarrhea or decreased

stooling, abdominal distention, and hepatomegaly

Hemoccult-positive stools

Hematopoietic system: jaundice, pallor, petechiae, ecchymosis,

splenomegaly

Clinical Manifestations

• Breastfeeding has a protective benefits against infection

• It should be promoted in all newborns

• Colostrum contains immunoglobulin's against gram-negative bacteria and

E.coli

• Human milk contains microphage and lymphocyte that promote local

inflammatory reaction

Prevention

• Programs to screen pregnant women for GBS colonization and treatments

of those women in labor.

• Screening programs for other maternal infections including hepatitis B

and HIV

• In developed countries, breastfeeding mothers with HIV is not

recommended because the virus may be transmitted by breast milk

Prevention

Nursery procedures aimed at minimizing the risk of nosocomial infections include:

▪ Proper hand washing techniques

▪ Appropriate isolation precautions when indicated

▪ The adoption of recommendation standards for spacing of infant beds

▪ Early introduction of enteral feeding to reduce the need for indwelling of central lines is recommended

Prevention

• Early recognition and diagnosis are essential to increase the infant's chance for

survival and reduce the likelihood of permanent neurologic damage

Antibiotic therapy:

• Is initiated before laboratory result are available, it is continued for 7-10 days if

cultures are positive

• Discontinued in 3 days if cultures are negative and the infant is asymptomatic

Therapeutic Management

• Antifungal and/or antiviral therapies are implemented as appropriate, depending on

causative agents

Supportive therapy usually involves:

▪ Administration of oxygen if need for it

▪ Regulation of fluid.

▪ Correction of electrolyte or acid-base balance.

▪ Temporary discontinuation of oral feedings.

▪ Blood transfusions may be needed to correct anemia .

Therapeutic Management

• Sever neurologic and respiratory problems may occur in ELBW and VLBW

infants as a result of early-onset sepsis.

• Late-onset sepsis and meningitis may also result in poor outcomes for

immunocompromised neonates

Prognosis

• Recognition of the problem is very important, it is usually the nurse who

observes and assesses infants and identifies that "something is wrong"

with them

• Awareness of the potential modes of infection transmission

• Knowledge of the side effects of the specific antibiotic and proper

regulation and administration of the drug are vital

Nursing Care Management

• Antibiotics predispose the infant to growth of resistant organisms and

superinfection from fungal or mycotic agents, such as Candida albicans

• Destroy normal flora that needed for synthesis of vit k

• Continuous cardiorespiratory and pulse oximetry monitoring provides an

ongoing assessment of the infant's condition

Nursing Care Management

• Observe for complications, Nystatin oral suspension is swabbed on the

buccal mucosa for prophylaxis against oral candidiasis

• Decrease any additional physiologic or environmental stress, this includes

providing an optimum thermoregulated environment and anticipating

potential problems such as dehydration or hypoxia

Nursing Care Management

• Precautions are implemented to prevent the spread of infection to other

newborns including:

• Proper hand washing

• The use of disposable equipment (e.g., linens, catheters, feeding supplies,

IV equipment)

Nursing Care Management

• Precautions are implemented to prevent the spread of infection to other

newborns including:

• Disposing of excretions (e.g., vomitus, stool)

• Adequate housekeeping of the environment and equipment are essential

Observation for signs of complications, including meningitis and septic

shock

Nursing Care Management

• Hand hygiene to decrease the ventilator associated

pneumonia in neonatal ICU (Hockenberry et al., 2017).

Evidence Based Practice (EBP)

References

Hockenberry, M. J.,Wilson, D. & Rodgers, C., (2017). Wong's Essentials of

Pediatric Nursing (10th ed.). St. Louis, MO: Elsevier Mosby

Thank You

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