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Miss: Kamlah Olaimat 1
Neonatal Sepsis
Presented by
Kamlah olaimat
Miss: Kamlah Olaimat 2
Welcome !!
Causes
Symptoms
Diagnosis
Treatments
Summary
What is Neonatal Sepsis?
Objectives
Miss: Kamlah Olaimat 3
Tutorial Objectives
Completing this tutorial will provide the learner with a better
understanding of Neonatal Sepsis:
* Pathology
* Causes
* Symptoms
* Diagnosis
* Treatments
What will I learn?
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What is Neonatal Sepsis?
Neonatal Sepsis is a term
used for a severe infection
in newly born infants.
Clinical syndrome of systemic illness accompanied by bacteremia occurring in the first month of life
Image used with permission and provided by www.steliz.org/newborn_center.htm
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More facts about Neonatal Sepsis
Neonatal Sepsis affects approximately 2 infants per 1000 births with a higher incidence in premature & low birth weight infants [2].
• Mortality rate is 13-25%– Higher rates in premature infants and those with early disease
There are two types of Neonatal Sepsis: Early OnsetLate Onset
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Causes of Neonatal Sepsis
The primary causes of Neonatal Sepsis are bacteria, such
as Staphylococcus and Group Beta Strep (GBS).
Bacteria may be the cause of neonatal sepsis, but neonates are more susceptible to these bacteria for two reasons [3&6]:
Immature immune response
Genetic predisposition
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What makes a neonate’s immune system immature?
Normally an immune system
responds to a pathogen in a specific manner, but if there are problems with any
element the immune system is unable to function properly
Pathogen enters body
Neutrophils move in
Chemotaxis occurs
Opsonization causes
phagocytosis
Monocytes kill pathogen
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pathogens can enter a neonate’s body in many ways !
Pathogens can enter through the prenatal, perinatal, and postnatalperiods [6].
Prenatal Maternal Substance Abuse
Premature Rupture of Membranes (>18 Hours)
Maternal Infection
Perinatal Microbial Colonization at Birth
Maternal Infection
Vaginal Exam of Mother
Postnatal Invasive Catheters
Endotracheal Intubation
Exposure to Nosocomial Microorganisms
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Neutrophils: An important cell in immunity against pathogens
Neonatal neutrophils are deficient in
their ability to adhere to vessel walls at site of infection [2&6].
Further release of neutrophils
depletes a neonatal storage
pool because the bone marrow
storage of a neonate is only 20-30%
of the pool in an adult [2&6].
Neonatal neutrophils have a
decreased ability to “deform” &
migrate into tissues [2&6].Neutrophils
Red Blood Cells
Image provided with permission from
http://en.wikipedia.org/wiki/Image:Segmented_neutrophils.jpg
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Chemotaxis
Imagine: Being in a dark tunnel without any direction or a way out. Finally you see light. You move towards the light and get out of the tunnel. Well this is like chemotaxis. The sun is the chemoattractant attracting you out to the world!!
Neonatal neutrophils have
decreased chemotaxis due to
decreased chemoattractant
Production [2&6].
Chemoattractants attract
neutrophils to the site of infection
[2&6].
Neonatal neutrophils therefore
cannot reach the site of infection
because of the chemotaxis
deficiency caused by decreased
chemoattractant production.
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Opsonization
Opsonization is the coating of a pathogen with antibodies that makes it susceptible to phagocytosis [2&6].
Phagocytosis is the process of cells (phagocytes) engulfing, ingesting, &
destroying pathogens [2&6].
Neonates have a decreased amount of opsonins (antibodies that promote
opsonization) [2&6].
Opsonization
Pathogen
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Monocytes: Another important cell in the fight against pathogens
Monocytes are a type of White Blood Cell that ingests
pathogens.
Neonates have a sufficient amount of
monocytes and full capability to kill organisms [2], but because of a neonates deficiencies previously
discussed very few monocytes get to
the site of infection.
Image provided with permission and copyrighted by amaxa GmbH at
www.amaxa.com/mission3.html
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What makes a neonate’s immune system susceptible to sepsis?
OR
Maturity
Immaturity
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You’re Right!!!!
The immaturity of a neonate’s immune system makes them MORE SUSCEPTIBLE to sepsis.
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Not Quite! Try Again
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Genetic Predisposition to Sepsis
Multiple factors play into a neonate’s response to infection and the
possible development of sepsis. One of these factors is genetics. As
science has moved into recognizing the human genome there have
also been advances with finding genetic contributions to sepsis.
The body’s first response to infection requires recognition of the presence of a pathogen. After recognition has occurred the body responds appropriately to resolve the problem [3&14]. Many polymorphisms have been recognized within both of these phases and they have been implicated in
influencing the susceptibility to and/or outcome from sepsis [3&14].
Let’s look further into these two phases to see the effect
polymorphisms have on neonatal sepsis:
Recognition Phase Response Phase
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Recognition Phase
The body’s initial response to infection requires recognition of the
presence of a pathogen [3].
Polymorphisms in genes coding for proteins involved in the recognition
of pathogens can influence the susceptibility to and/or outcome of
neonatal sepsis [3].
Let’s look into two of these:
Mannose-Binding Lectine (MBL)
Lipopolysaccharide (LPS)
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Response PhaseAfter the initial recognition of a pathogen occurs the body responds by releasing elevated levels of proinflammatory cytokines followed by a release of anti-inflammatory cytokines [3]. This dual release of opposite cytokines helps the cytokines return to a baseline level and that enables the start of tissue repair to start [3].
It is generally accepted that an imbalance between proinflammatory and anti-inflammatory cytokines result in clinical manifestations of sepsis [3]. This Imbalance is due to polymorphisms in various proteins involved in the response to pathogens.
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Not quite! Try again.
Miss: Kamlah Olaimat 20
Great answer! You’re correct!
Polymorphisms cause either an over expression or under expression of
proteins and/or genes that have significant roles in the immune
response to infection. This alters their ability to properly function
which makes a neonate more susceptible to sepsis.
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Early Onset
• First 5-7 days of life • Usually multisystem fulminant illness with
prominent respiratory symptoms (probably due to aspiration of infected amniotic fluid)
• High mortality rate– 5-20%
• Typically acquired during intrapartum period from maternal genital tract– Associated with maternal chorioamnionitis
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Late Onset
• May occur as early as 5 days but is most common after the first week of life
• Less association with obstetric complications
• Usually have an identifiable focus– Most often meningitis or sepsis
• Acquired from maternal genital tract or human contact
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Nosocomial sepsis
• Occurs in high-risk newborns
• Pathogenesis is related to – the underlying illness of the infant
– the flora in the NICU environment
– invasive monitoring
• Breaks in the barrier function of the skin and intestine allow for opportunistic infection
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Risk factors
• Prematurity and low birth weight• Premature and prolonged rupture of
membranes• Maternal peripartum fever• Amniotic fluid problems (i.e. mec, chorio)• Resuscitation at birth, fetal distress• Multiple gestation• Invasive procedures• Galactosemia• Other factors: sex, race, variations in immune
function, hand washing in the NICU
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Symptoms of Neonatal Sepsis
The symptoms of neonatal sepsis are not concrete and vary widely [9].
TachpneaHeart Rate Changes
Feeding difficulties
Difficulty Breathing Temperature Instability
Jaundice Irritability
Why are symptoms so broad?
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Clinical presentation• Temperature irregularity (high or low)• Change in behavior
• Lethargy, irritability, changes in tone
• Skin changes• Poor perfusion, mottling, cyanosis, pallor, petechiae,
rashes, jaundice
• Feeding problems• Intolerance, vomiting, diarrhea, abdominal distension
• Cardiopulmonary• Tachypnea, grunting, flaring, retractions, apnea,
tachycardia, hypotension
• Metabolic• Hypo or hyperglycemia, metabolic acidosis
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Inflammation in Neonatal Sepsis
It is widely known that sepsis occurs
because of an exaggerated
systemic inflammatory response (SIR) [12].
Let’s find out how this is true Inflammatory Process
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Inflammatory Process
[12]
Pathogen enters body
Inflammatory mediators released (cytokines)
Injury to endothelium
Tissue factors released
Production of thrombin
Coagulation promotes clot formation
Increased activity of fibrinolysis inhibitors
Decreased fibrinolysis
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Inflammation
Overall, the imbalance among inflammation, over coagulation, and decreased fibrinolysis are the cause for the majority of deaths
in sepsis [12].
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How is Neonatal Sepsis Diagnosed?
There is no definite marker in neonatal sepsis, but there are determinants of infection.
When a neonate presents with sepsis symptoms a septic work-up
is completed [2]. What is included in a septic work up?
* Complete Blood Count (CBC)
* Blood & Urine cultures
* Lumbar Puncture (LP)
* Chest X-Ray
* Line cultures
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Is there a diagnostic marker for neonatal sepsis?
True
False
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Yeah!!! You are correct!
There is NOT a specific diagnostic marker, only determinants of infection (labs, x-rays).
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Are you sure? Try again!
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Treatments for Neonatal Sepsis
It is of vital importance that treatment is initiated as soon as sepsis is suspected, especially for those
infants at risk.
Broad Spectrum Antibiotics (Ampicillin & Gentamycin) are the first line of defense against neonatal sepsis
[2].
Why????
What are other recommendations/options?
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Why is it so important to start antibiotic treatment?
If not treated as soon as sepsis is suspected a neonate is more likely to die from sepsis and it’s complications.
For this reason it is of vital importance that healthcare workers (nurses and physicians) notice and act upon even the most subtle changes in a neonates assessment, particularly those infants at
risk (GBS+).
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Treatment Recommendations
Antibiotics should be initiated after all cultures and lab work is completed to ensure proper diagnosis.
All neonates will remain on IV antibiotics until blood/urine culture results
come back in approximately 2-3 days. Further therapy will depend on
lab work results and the neonate’s response to treatment.* Every hospital/organization has an antibiotic protocol specific to their site.
Although antibiotic therapy is vital, it is just as important to continue the overall support of the neonate (i.e. respiratory &
cardiac).
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Infection control in NICU
• Its an important part of every copmonant of care of a neonate baby .
• The most important factors contributing to nasocomial infection are :-
o Noncompliance to infection control policy (hand washing )
o Invasive procedure which interrupt normal body barriers as intubations
o Overcrowding and understanding in NICU
o Immaturity of immune system
o Antibiotic abuse
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General principle of infection control in NICU
1) Appropriate physical setup of NICU environment ( isolated , no windows open to outside , avoid overcrowding , adequately ventilated)
2) Provide routine care for the newborn baby
3) Consider every person as potentially infectious ( including member of staff )
4) Wash hand or use alcohol – based hand scrub
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General principle of infection control in NICU
1) Wear protective clothing and gloves
2) Sterilize or disinfect instrument and equipment
3) Routinely clean the NICU and dispose of waste
4) Isolated the infectious baby
5) Surveillance for nasocomial infection
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Neonate
• Neonate should be bath 3 time/week using baby soap
• Electrodes should be changed every third day
• Umbilical stump should be treated with alcohol / shift
• Prophylactic eye drop at first day
• Neonate admitted from out side of hospital isolated or 72 hours
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Staff health
• Health care should be immune to rubella, measles, chicken pox
• Health care yearly receive influinza vaccination
• Any person with any disease (common cold) not have direct contact with neonate
• Limited the number of person handle the baby
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Had washing
• Mother should wash hand after and before handle baby
• Remove accessory before inter NICU
• Finger nails trimmed short , no false nail use
• Antiseptic preparation
• At least 10 second washing
• Hand wash even when use gloves
Hand washing is the single most important procedure for infection control
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Protective clothes and gloves
• Sterile gowns must be worn by all person in direct contact with baby
• Use gloves when handle the baby
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General housekeeping and waste disposable
• Clean NICU as order :-
Patient area , accessory , adjacent halls
• From top to bottom
• Counter , work surface , horizontal area cleaned once daily
• Clean up spill of blood or bodily fluid immediately by using disinfectant solution
• Separate contaminated waste from non contaminated
• Use a puncture – proof container for sharps
• Destroy container when it is two – third full
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General housekeeping and waste disposable
• Change breathing material and CPAP / 3 day
• Change suction apparatus daily
• Change suction tube after use by each infant
• Incubator changed for cleaning with 10% hypochlorite
Every 5 day for infant <1000gm
Every 7 day for infant >1000gm
• Linen changed every day in incubator
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Feeding and nutrition equipment
• Sterilization of feeding bottles
• Sterile water for formula preparation
• Feeding tube changed \ 2-3 days
• Hand washing before and after feeding
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Isolated infectious baby
• Isolated room or area should be available
• Keep door closed
• When entering the room
wear a clean gown
wear gloves
• Before leaving room:-
remove gown and gloves
wash hand with alcohol
• The nurse work with infectious baby should give few assignment
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Surveillance for nasocomial infection
• Routine surveillance of the incidence of acquired infections in nursery should be mandatory
• Perform culture by swabbing for bacteria on likely surface area
• Perform blood culture of infected neonate
• Identify bacterial isolated
• Bacterial culture from person and equipment are necessary
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I hope you have enjoyed your experience and have learned some new information
about neonatal sepsis.
Miss: Kamlah Olaimat 50
References1. Amaxa Biosystems. (n.d.). “Mission #3: Transfect human monocytes”. [Online image]. Retrieved March 22,
2006 from www.amaxa.com/mission3.html
2. Bellig, L.L. & Ohning, B.L. (2004). Neonatal Sepsis. Retrieved February 8, 2006, from emedicine:http://wwwemedicine.com/ped/topic2630.htm
3. Dahmer, M.K., Randolph, A., Vitali, S., & Quasney, M.W. (2005). Genetic polymorphisms in sepsis. Pediatric Critical Care Medicine, 6(3), 61-73. Retrieved February 23, 2006 from PubMed database.
4. Farlex Inc. (n.d.). The Free Dictionary. Retrieved March 30, 2006, from www.thefreedictionary.com
5. LaRosa, S.P. (2002). Sepsis. Retrieved February 14,2006, from The Cleveland ClinicWebsite: http://www.clevelandclinicmeded.com/diseasemanagement/infectiousdisease/sepsis.htm
6. McKenney, W.M. (2001). Neonatal nursing: Understanding the neonatal immune system: High risk for infection. Crtitical Care Nurse, 21(6), 35-58. Retrieved February 14, 2006, from ProQuest database.
7. Microsoft Corp. (2006). Microsoft Clip Art. Retrieved March 30, 2006, from www.microsoftclipart.com
8. Mrozek, J.D., Georgieff, M.K., Blazer, B.R., Mammel, M.C., & Schwarzenburg, S.J. (2000). Effect of sepsis syndrome on neonatal protein and energy metabolism. [Electronic version] Journal of Perinatology, 2, 96-100.
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References9. Neonatal Handbook:Sepsis. (n.d.). Retrieved February 14, 2006, from
http://www.netsvic.org.au/nets/handbook/index.cfm?doc_id=898
10. Oostdyk, R. (2005). “Neutrophil”. [Online image]. Retrieved April 20, 2006, fromhttp://en.wikipedia.org/wiki/Image:Segmented_neutrophils.jpg
11. Orr, P.A., Case, K.O., & Stevenson, J.J. (2002). Metabolic response and parenteral nutrition in trauma sepsis and burns. Journal of Infusion Nursing, 25(1), 45-53. Retrieved March 7, 2006 from Ovid database.
12. Sharma, S. & Mink, S. (2004). Septic shock. Retrieved February 14, 2006, from emedicine: http://www.emedicine.com/MED/topic2101.htm
13. St. Elizabeth Hospital. (n.d.). “The newborn center at St. Elizabeth’s”. [Online image]. Retrieved March 22, 2006 from www.steliz.org/newborn_center.htm
14. Villar, J., Maca-Meyer, N., Perez-Mendez, L., & Flores, C. (2204). Bench to bedside review: Understanding genetic predisposition to sepsis. Critical Care, 8(3), 180-189. Retrieved February 23, 2006, from PubMed
database.
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