1. -C.S.N.Vittal
Vijayawada

2. Bacterial Sepsis in Neonate
Definition :
Clinical syndrome of
infection with bacterimia in
first month of life.
• May get predominantly localized to lung (Pneumonia)
• May be localized to meninges (meningitis)

3. Bacterial Sepsis in Neonate
Incidence :
24 / 1000 live births
Single most important cause of neonatal deaths in the
community (>50%)

4. Bacterial Sepsis in Neonate
Patterns
Late Onset
Early Onset
•Within 72 hrs of birth
• Complicated pregnancy +
• Maternal Genital tract
• Symptoms beyond 72 hrs
of birth
• Complicated pregnancy +
• Fulminant course
• Maternal Genital tract /
Environmental
• Pneumonia
• Slower progression
• 5-50 % mortality
• Meningitis
• 2-6 % mortality

5. Neonatal Sepsis
Major Risk Factors
• Ruptured membranes > 24 hrs.
• Maternal Fever (100.4oF(38oC)
• Chorionamnionitis
• Sustained fetal heart rate
>160/min
• Multiple obstetric procedures
Minor Risk Factors
• Ruptured membranes > 12 hrs.
• Foul smelling liquor
• Maternal Fever > 99.5oF (37.5oC)
• Low APGAR < 5 at 1 min,
< 7 at 5 min
• Prematurity
• Multiple gestation
Presence of 1 major or 2 minor risk factors ->
High Risk of Sepsis

6. NNF CRITERIA
SUSPECT SEPSIS
1 out of 3 parameters is an indication for antibiotic therapy
• PREDISPOSING FACTORS like PROM, Foul
smelling liquor, amnionitis, gastric aspirate
showing polymorphs 5 / HPF
• POSITIVE SEPSIS SCREEN (2/4 parameters)
– TLC <5000 per cubic ml
– Bandemia 20%
– CRP >10 ng per ml
– Micro ESR >10mm fall in 1hr
• CXR showing Pneumonia

7. Neonatal Sepsis
Pathogenesis
• Infection in the birth canal
• Colonization of skin, umbilical stump,
nasopharynx, conjunctiva, etc.
• Transient bacteremia
• Invasion of blood stream
• Metastatic foci
• Meningitis, etc.

8. Neonatal Sepsis
Risk factors for Late onset sepsis (LOS)
• Prolonged hospitalization
• Prematurity
• LBW
• Previous antibiotic use
• Invasive procedures
• Presence of foreign material (ET Tubes/
catheters)
• Lack of disposables
• Over crowding / understaffing

9. Neonatal Sepsis
Risk factors for Community acquired sepsis
• Bottle feeding
• Poor hygiene
• Poor cord care
• Over crowding

10. Pathogenesis ...
• SIRS
• CARS
• MARS

11. Infection
Systemic Inflammatory Response Syndrome (SIRS)
Resp:
Tachypnoea
Hypoxia PaO2
> 2 SD
< 70 mm Hg
CVS :
Tachycardia
> 2 SD
Hypothermia
< 2 SD or hyperthermia
Peripheral Perfusion:
Delayed Capillary Filling
> 3 Sec.
Oliguria
< 0.5 ml / kg / hr
Lactic acidosis
Altered mental status
Increased or decreased white blood count:

12. Infection > SIRS
Sepsis –
• Systemic response to infection with bacteria :
SIRS with hypotension
Severe Sepsis –
• Sepsis with organ dysfunction, hypoperfusion or hypotension
• Changes in mental status, oliguria, hypoxemia or lactic acidosis

13. Septic shock –
Severe Sepsis with persistent hypotension
despite adequate fluid resuscitation
Multiple Organ Dysfunction Syndrome
(MODS) –
Presence of altered organ function such that
homeostasis
can not be maintained without intervention
Death

14. Local
Initial insult
pro-inflammatory (bacterial, viral
response
thermal, traumatic)
Systemic spillover of proInflammatory mediators
Systemic Reaction
Local
anti-inflammatory
response
Systemic spillover of antiInflammatory mediators
SIRS : Pro
CARS : Anti
MARS : Mixed
C
H
CV Compromise Homeostasis
A
Aptosis
O
MODS
S
Suppression of immunity

15. Clinical Features
• General :
• Skin:
– Lethargy, jaundice
– Temperature instability
• Respiratory
– Distress after a period of
normalcy
– Apnea
• GI:
– Poor feeding, vomiting,
abdominal distention, bilious
aspirates
– Temperature labiality
– Petechial rashes, bleeding from
puncture sites
– Sclerema
• CNS:
•
– Lethargy, irritability, seizures
Metabolic:
– Unexplained metabolic acidosis
– Hyperglycemia
– Hypoglycemia
• Features to system
involvement

16. Sepsis Screen
• Total neutrophil count :
• Immature to total ratio :
•Acute Phase Reactions
• Micro ESR
• C Reactive Protein
• Hepatoglobin
:
:
Laboratory Studies
< 5000 / mm3
> 0.2
> 15 mm in 1st hour
> 10 mg/L
• Cultures
• Chest X-Ray
• Grams Stain of gastric aspirate
• Antigen detection methods
• Lumbar Puncture

17. Neonatal Sepsis
Total neutrophil count & Immature to total ratio:
• TWBC
• Tot. neutrophil count
: < 5000 / micro liter or >24000
: < 1000 / micro liter
( Normal= 1,750 /µL)
• Band / Total Neutrophil
: > 0.2
( Normal = 0.16 in 1st Day,
0.12 after 24 Hrs.)
• Platelet Count
: < 1 Lakh/mm3
(Normal = 1.5 to 4 Lakhs /mm3)
- Increased risk of infection
Repeat TWBC & DC at 8 - 12 hrs in a symptomatic neonate
may have more predictable value than single record.

18. Neonatal Sepsis
Cultures
• Blood
• Urine
• CSF ( For Late Onset type)]
Two positive cultures are more significant

19. Neonatal Sepsis
Chest X-Ray
• Persistent focal changes with
infiltrative process
• Findings similar to RDS in GBS
infection

20. Neonatal Sepsis
Acute Phase Reactants - Sepsis Screen
Positive CRP ( > 6 mg/ L or 10 times normal)
Elevated hepatoglobin level
Micro ESR After 14 days of age 15 mm or
more for the first hour is abnormal.
(Normal ESR = Age in days + 2)
If all results are -ve : Probability that infection absent = 99%
If all results are +ve : Probability of infection = 90%

21. Neonatal Sepsis
Grams Stain of gastric aspirate
Positive Result :
If > 5 neutrophils / hpf
or
Large number of bacteria (esp. Gram+ve cocci) in
large clumps and chains
Predictive value less

22. Neonatal Sepsis
Antigen detection methods
• Latex particle aggulutination assays
for GBS and ECK1
• Counter immuno electrophoresis

23. Neonatal Sepsis
Lumbar Puncture
• Valuable in symptomatic infants
who have risk factors for sepsis.
• CSF studies prior to antibiotic
therapy is preferable
LP in RDS is difficult
Interpretation is difficult if LP is traumatic
Sometimes meningitis may be present with normal
CSF picture

24. Normal Neonatal CSF
TEST
TERM
PRETERM
WBCs (per cm)
Polymorphs
Up to 30
60%
Up to 90
60%
Protein (mg/dL)
Up to 150
Up to 150
Glucose (mg/dL)
35-120
25-65

25. Neonatal Sepsis
Miscellaneous Investigations
• DIC Profile
• Culture of catheters/ ET Tubes
• Maternal vaginal swab cultures, etc.

27. Supportive therapy
•
•
•
•
•
•
•
•
•
Thermoneutral environment
IV Fluids
Electrolyte and acid base balance
Maintain oxygen saturation
Circulatory support
Glucose homeostasis
Treat anemia with packet
Rbc
Treat bleeding diathesis with FFP / platelets

29. Antibiotic Therapy
Indications:
•
•
•
•
•
PROM > 12 hrs.
Evidence of Chorioannionitis
Delivery outside labour room
Infants with 1 major or 2 minor risk factors
Positive Sepsis Screen

30. •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Sulfa Drugs
Folic Acid Analogs
The Beta-Lactams
Aminoglycosides
Tetracyclines
Macrolides
Lincosamides
Streptogramins
Fluoroquinolones
Polypeptides
Rifampin
Mupirocin
Cycloserine
Aminocyclitol
Glycopeptides
Oxazolidinones
Arm
a
me
nt
ariu
m
… and the list is
incomplete …

31. Which
one
would
you
choose ?

32. Factors to be considered in the choice of
Antibiotic
Gram + ve
Gram _ ve
Anaerobes

33. Antibiotic Selection
Presumptive therapy directed to most commonly
encountered pathogens.
1st Line :
Ampi/Sulbactum+Aminoglycoside
2nd Line
2nd gen. Cephalosporins + Aminoglycosides
3rd Line
Vancomycin + Cephalosporins
Newer antibiotics

34. er
ew
fN
le o
Ro
s?
r ug
d

35. Antibiotic Evolution

36. When you can’t decide , you tend to …
Resort to “Shotgun Therapy”

37. Bauer-Kirby Method
(Agar gel diffusion method)

38. Duration of Antibiotic Therapy
Culture Positive Sepsis
Pyogenic Meningitis
- 14 Days
- 21 Days /
2 weeks after CSF sterile
Culture – ve/ clinically probable sepsis screen +ve:7-10 d.
Culture – ve/ clinically probable sepsis screen -ve:5-7 d.
Septic Arthritis
- 6 Weeks

39. Immunotherapy
• Immunoglobulin : IVIG 500-1000 mg/kg/dose
• Specific Immunoglobulins : Anti GBS Ig.
• Oral administration of IgA and IgG in NEC
• Granulocyte infusions
• G – CSF 10 µg/kg/d for 3 days
• GM – CSF 10 µg/kg/d for 5 days
• Double volume exchange transfusions

40. Supportive Therapy
• Continued Breast Feeding
• Nutrition : TPN / Aminoplasma
• Fluid / Electrolyte balance
• Treatment of acidosis

41. Preventive Aspects of Neonatal Sepsis
• Obstetric Management strategies
• Screening based approach
• Risk factor approach
• Exclusive breast feeding
• No prelacteals
• Keeping the cord dry
• Hand washing by care givers before and after handling the baby
(Single most effective measure)
• Hygiene of the baby
• Avoid unnecessary intravenous fluids, needle pricks etc.

42. Algorithm for early prevention of GBS
Risk Factors
Give intrapartum
Previous GBS
penicillin
Preterm delivery
Bacteremia
Rectal & Vaginal swab
c/s. at 35-37 wks.
Risk Factors
Intrapartum Temp.
PROM > 18 hrs
No intrapartum prophylaxis needed
Give intrapartum
penicillin
Give intrapartum
penicillin