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NEONATAL SEPSIS Prevention and

ManagementManoj sharma

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Neonatal Sepsis

Clinical syndrome of bacteremia with systemic signs and symptoms of infection in the first four weeks of life.

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Care• Incidence:India: 9-60/1000 live births (average:38/1000)

• Almost 5 times higher than in developed countries

• Causes 20% of neonatal deaths• Incidence is 5-10 times higher in LBW and

preterms than normal weight term babies

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Early Late

Onset <72 hrs >72 hrs

Source Maternal Environmentalgenital tract (nosocomial)

Risk factor Prematurity Prematurity Amnionitis, Maternal infection Presentation Fulminant slowly progressive Multisystem focal Pneumonia frequent Meningitis frequent Mortality 5-50% 10-15%

Early vs Late onset sepsis

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• Gram – ve : LPS / endotoxin• Gram +ve :lipoteichoic acid – peptidoglycan

• Activation of – Coagulation pathway– Complement System – Cytokines

• Multiorgan dysfunction

Mechanism of injury

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Care• Immunological response to infection• Release of a cascade of cytokines

– both pro and anti inflammatory– secondary to bacterial endotoxins or exotoxins

• Cytokines SIRS septic shock +

MSOFSepsis is a very rapidly progressive condition which

can kill even before diagnosis

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ETIOLOGY

• E coli• Klebsiella • CONS• Staphylococcus aureus• GBS• Pseudomonas• Acinetobacter• Citrobacter• Candida albicans and non albicans candida

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MATERNAL RISK FACTORS

• Chorioamnionitis• Fever>38C• Foul smelling liquor• Fetal tachycardia• PROM> 18 hrs• Multiple examinations, prolonged labour

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NEONATAL RISK FACTORS

• LBW• ELBW• Asphyxia• Twins• Male sex• Disruption of skin barrier• Prematurity• Lack of breast feeds

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RISK FACTORS Late onset sepsis

• Prolonged intensive care• Long lines• Ventilation• prolonged antibiotic use• TPN• Steroids

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clinical features of neonatal sepsis

• CNS– Lethargy, refusal to suckle, limp, not arousable, poor or

high pitched cry, irritable, seizures

• CVS– Pallor, cyanosis, cold clammy skin

• Respiratory– Tachypnea, apnea, grunt, retractions

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Symptoms of neonatal sepsis

• GIT

– Vomiting, diarrhea, abdominal distension

• Hematological

– Bleeding, jaundice

• Skin

– Rashes, purpura, pustules

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Signs of neonatal sepsis

• Cold to touch ( hypothermia )

• Poor perfusion ( CRT )

• Hypotension

• Renal failure

• Sclerema

• Bulging fontanels.

• Poor weight gain** Indicates low grade sepsis

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Care1. Feeding ability reduced

2. No spontaneous movement

3. Temperature >380 C

4. Prolonged capillary refill time

5. Lower chest wall indrawing

6. Resp. rate > 60/minute

7. Grunting

8. Cyanosis

9. H/o of convulsions

ClinicalClinical featuresfeatures of severe of severe infectionsinfections

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Diagnosis of neonatal sepsis

Direct- Isolation of organisms from blood, CSF, urine

is diagnostic Indirect

-Screening tests

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Sepsis screen

Leukopenia (TLC < 5000mm3)

Neutropenia (ANC < 1800/mm3)

Immature neutrophil to total neutrophil

(I/T) ratio (> 0.2)

Micro-ESR (> 15mm 1st hour)

CRP +ve*If two or more tests are positive treat infant as neonatal sepsis

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Mature neutrophil Band cell

Neutrophils

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Meningitis

10-15 percent cases of sepsis have meningitis

Meningitis can be often missed clinically

LP must be done in all cases of late onset & symptomatic early onset sepsis

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Management

• Mainstays of therapy:– Early recognition – ABC’s - supportive care– Appropriate and adequate antimicrobials

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Management: Supportive care

Keep the neonate warm

If sick, avoid enteral feed

Start IV fluids, infuse 10% dextrose to maintain normoglycemia

Maintain fluid and electrolyte balance and tissue perfusion

If CRT >3 sec, infuse 10 ml/kg normal saline bolus.

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Supportive care

• cyanosed / RR >60/min / severe chest retractions– Start oxygen by hood

• sclerema– Consider exchange blood transfusion/IVIG.

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Suspected neonatal sepsis Start parenteral antibiotics Send cultures (report in 72 hrs)

Culture -ve Culture +ve

Clinically no sepsis (Stop Ab)

Clinically ill (Cont Abx7-10D)

Pneumonia, Sepsis (Cont Ab X 7-10D)

Meningitis, Osteomyelitis (Cont Ab X 3-6 wks)

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Choice of antibiotics• Pneumonia or Sepsis

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

• Meningitis Ampicillin + Gentamicin

OrGentamicin or Amikacin + Cefotaxime or Ceftriaxone

+

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Care• Change to Third gen CP in case of gm-ve enteric bacilli like E.coli.

• L.monocytogen: resistant to cp treat with ampicillin and gentamycin.

• Add Vancomycin if MRSA and enterococci.• VRE add linezolid/quinipristin.• Pseudomonas: combination of two agents like

ceftazidime,piperacillin/tazobactem,genta/amikacin.

Which Antibiotics

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Care• ESBLs: many strains of E.

coli,klebsiella,pseudomonas serratia etc found with these resistant enzymes. Carbapenems,cefepime and pipera/tazobactem are most effective.

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Other measures in LOS

• IVIG• G-CSF• PROBIOTICS• LACTOFERRIN• EARLY ENTERAL FEEDING.

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Superficial infections

Pustules - After puncturing, clean with betadine and apply

local antimicrobial Conjunctivitis - Ciprofloxacin eye

drops

Oral thrush - Local application of nystatin or Clotrimazole

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Prevention of Infections

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Five ‘cleans’ to prevent infection

• Clean hands• Clean cord tie• Clean cord• Clean surface• Clean blade

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Cleans• Surfaces : housekeeping

• Hands– 2 minutes wash : first time– Use of disinfectant between any outer object and baby– Rolled up sleeves– Nails– Rings , watches– Nail polish

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A scanned picture of steps of hand washing

Six steps of hand washing

Step 1Wash palms with fingers

Step 2Wash back of hands

Step 3Wash fingers & knuckles

Step 5Wash finger tips

Step 6Wash wrists

Step 4Wash thumbs

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Hand washingSimplest, most effective measure for preventing

hospital acquired infections

2 minutes hand washing prior to entering nursery

15 seconds of hand washing before touching baby

Alcohol based hand rub effective but costly

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The birth of a baby

• Are we able to maintain asepsis in the delivery room?– Mother– Birth attendant for the mother– Birth attendant for the baby– Objects in the resuscitation of the baby– Hygiene of practices at the time of birth

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Prevention of Infections

• Exclusive breast feeding• Keep cord dry• Hand washing by care givers• Hygiene of baby• No unnecessary interventions

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Intravenous lines: Peripheral

• Skin preparation• Maintenance after insertion• Extravasation/thrombophlebitis• Flushing solutions• Change IV infusion sets daily• Replace IV tubings used to give blood / blood

products at end of infusion• Barrier precautions during line change

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Disposal of waste and soiled linen

• Safe disposal• Colour coding• Sharps• Infected wastes

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Work culture

Sterile gowns and linen for babies Hand washing by all Regular cleaning of unit No sharing of baby belongings Dispose waste-products in separate bins

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Control of hospital infections

Hand washing by all staff

Isolation of infectious patient

Use plenty of disposable items

Avoid overcrowding

Aseptic work culture

Infection surveillance

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Control of hospital outbreak of infections

Epidemiological investigation

Increased emphasis on hand washing

Reinforce all preventive measures

Review of protocols of nursery

Screen all personnel

Review of antibiotic policy

Cohorting of infants

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Fumigation

Use Potassium permanganate 70 gm with 170 ml of 40% formalin for 1000 cubic feet area for 8-24 hours

alternatively

Bacillocid spray for 1-2 hours may be equally effective

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Conclusions

• High index of clinical suspicion• Look for lab evidence of sepsis• Start parenteral antibiotics (I.V.)• Provide supportive care• Review culture report• Practise barrier nursing to prevent cross-

infection

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Care• Neonatal sepsis is a serious disease• Suspect early and admit to NICU/Ward• Start AB in preterms for suspected sepsis

(maternal risk factors )even if asymptomatic• Treat all cases of probable or proven sepsis

with antibiotics• Give supportive and adjunctive treatment• Prognosticate cautiously

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Thank you