1. Neonatal Sepsis, Necrotizing
Enterocolitis
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. Neonatal Sepsis
Clinical syndrome of bacteraemia
characterized by systemic signs and
symptoms of infection in the first four
weeks of life
Bacterial invasion and multiplication in the
blood
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3. 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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4. Etiology
Common -
E.coli, Klebsiella, Pseudomonas, Proteu
s,
Others- Staph. aureus, streptococcus
ssp, acintobactor, H.
inlfluenzae, Anaerobes, L
monocytogens, GBS, Enterococcus,Citr
obacter
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5. 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
6.Meconium stained liquor
7.Chorioamnionitis
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6. Neonatal Risk factors
1. Low Birth Weight Baby/Preterm
2. Perinatal asphyxia
3. Male gender
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7. CLASSIFICATION
1. Early onset –
• < 72hrs of age - Before or during delivery
ⓐ PROM →Ascending Chorioamninitis
ⓑ During passage through birth canal
ⓒ Resuscitation at birth – added risk in the OT & LR
• Organisms from - maternal genital tract, LR,OT
Organisms :
• E coli., Klebsiella, GBS,

8. CLASSIFICATION
2. Late-onset
• >72hrs-30 days of age mostly end of 1st week.
ⓐ Nosocomial infection/Hospital inf.
Source: Organisms from NICU, postnatal
ward.
Incubators, Resuscitators, Ventilators, Cathe
ters, Infusion sets, Face masks.
Organisms
• Staph aureus .
epidermidis, E.coli, Klebsiella, pseudomonas, prot
eus (2/3 are by gram –ve
bacilli), Enterobacteriae

9. CLASSIFICATION
ⓑ Community infection
• After discharge from hospital
Source - mother, family, contacts, baby care
units,
Organisms:
• Strepto pneumoniae
• Tuberculosis
• Viruses

10. CLASSIFICATION
3. Late-late onset
• After 30 days of age
Organisms-
saph.
epidermidis, E.coli, candida, Tuberculosis
Viruses

11. Early vs Late onset sepsis
Early onset Late onset
Age <72 hours >72 hours
Risk factor Prematurity Prematurity
Amnionitis,
Maternal infection
Source Maternal genital Environmental
tract (nosocomial)
Presentation Fulminant slowly progressive
Multisystem focal
Pneumonia frequent Meningitis frequent
Mortality 5-50% 10-15%
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13. Symptoms of Neonatal Sepsis
1. CNS
Lethargy, Refusal to suck, Limp, Meningitis seen in 1/3 of all cases-
bulging fontanelle. High pitched cry, excessive
crying, convulsions, Not arousable, Irritable, Hypothermia in
preterm, fever in older babies
2. CVS
Shock-pallor, Cyanosis, Cold and clammy skin cap filling>2 sec
3.Respiratory
Tachypnoea, Apnoea, Grunt, Retractions
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14. Symptoms of Neonatal Sepsis
4.GIT
Vomiting, Diarrhoea, Abdominal distension, NEC,blood in stool
5.Haematological
Bleeding manifestations-DIC, pulmonary Hge, IVH , NNJ
6.Skin
Rashes, Purpura, Pustules, Sclerema (skin thick, unpinchable,
involves face ,chest, legs)
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15. SEPSIS SCREEN
At Birth
Major risk factors
1. Rupture of membranes > 24 hrs
2. Maternal intrapartum fever > 100.40 F (>38oC)
3. Chorioamninitis
4. Sustained fetal heart rate >160/min
Minor risk factors
1. Rupture of membrane > 12 hours
2. Maternal intrapartum fever > 99.50 F , ≥37.5oC
3. Maternal WBC > 15000 / mm3
4. Low apgar score(< 5 at 1 min, < 7 at 5min)
5. LBW ( < 1500 g )
6. Preterm labour ( < 37 weeks)
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16. Minor risk factors
Minor risk factors
7.Foul smelling liquor/ meconium stained
8.Maternal WBC Count >15,000
9.Maternal GBS colonization
10.Low APGAR score(<5 at 1min)
11.Multiple gestation
12. > 3 vaginal exam
**1 major or 2 minor risk factors

17. Laboratory Diagnosis of NNS
1. Direct methods
- Blood culture
- CSF culture
- Urine culture
2. Indirect methods / Screening tests
- TLC < 5000 / mm3)
- ANC <1800 / mm3)
- Total immature neutrophils (Band neutrophil count >20%
- Immature neutrophil (Band N) to total neutrophil
ratio ( > 0.2)
- Micro ESR( > 15 mm / 1st hour )
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18. 2. Indirect methods / Screening tests
- Acute phase reactants- CRP - positive
- Buffy coat examination
- Smear of gastric aspirate- >5 neutrophil /HPF
- C3d
- Toxic granules, cytoplasmic vaculation, dhole
bodies in PS

19. Lab diagnostic criteria
• Septic screen- if 3 are abnormal chance of
infection 90%
A) TLC>20,000 or <5000
B) Bands >20% or band: neutro>0.2
C) abnormal neutrophils-toxic granules
D) micro ESR>15mm/1st hr
E) CRP >8mcg/ml
Others-elevated haptoglobin,alpha-1antitrypsin
fibrinogen

20. Management of Neonatal Septicemia
1. Antibiotic Therapy
2. Supportive Therapy
3. Immunotherapy

21. Antibiotic Therapy
• Antibiotic started on clinical grounds tillC/S
reports: Initial choice
**EOS – Aminoglycoside + Ampicillin or
Crystallin Pencillin + Gentamycin / Amikacin
**LOS – Aminoglycoside + Cloxacillin
• Pseudomonas: Ceftazidime
• Staph. Aureus: Vancomycin
++Meningitis – aminoglycoside +Cefotaxime
• Duration: Septicemia- 10 to 14 days
• Pneumonia- 14 days
• Meningits- 21 days

22. Supportive care:
• IV fluids, glucose,
• Vit K, anticonvulsants
• Blood transfusion,
• Shock-Dopamine, Dobutamine,Steroids
• Phototherapy, Oxygen
• Hypoglycemia: 10% dextrose
• FFP
• Ventilatory support

23. Immunotherapy
• IVIG
• Exchange blood transfusion - if there is
sclerema, DIC, Neutropenia
• Granulocyte transfusion - Colony
Stimulating Factors
• Prognosis-upto 50% mortality

24. Natural course of sepsis
Bacteria
Focal infection Bacteraemia
sepsis
Sepsis syndrome
Early septic shock
Refractory septic shock
MODS Multiple organ dysfunction
syndrome
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DEATH

25. Evaluation of symptomatic infant for sepsis
- Sepsis screen
- Chest X-ray
- Lumbar puncture
- Blood culture
Begin Antibiotics
Culture positive No risk factors for sepsis
Presence of focal infection Culture negative
Sepsis screen positive Sepsis screen negative
LP abnormal Symptoms resolve by 24 hrs
Symptoms persists 72 hrs
Treat pneumonia 7-10 days Treat for 48-72 hrs
Septicaemia 10-14 days and discharge
Meningitis 14-21 days

26. 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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27. Prevention of Infection
- Exclusive breastfeeding
- Keep cord dry
- Hand washing by care givers
- No unnecessary intervention
- Better management of IV Lines
- Disinfection of Equipments
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28. Hand Washing
- Single most important means of
preventing nosocomial infections
- Very Simple
- Cheap
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29. 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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30. 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
- Palm and fingers (web spaces)
- Back of hands
- Fingers and Knuckles
- Thumbs
- Finger tips
- Wrists and forearm up to elbow
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31. 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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32. NECROTIZING ENTEROCOLITIS
Definition
• An idiopathic coagulation
necrosis and inflammation of the
intestine in a neonate.
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33. Incidence
• 0.5 - 3.5/1000 live births
• Affects mostly premature infants (10% occur in FT)
• Increased incidence with decreasing BW and GA
• Hypothesis - the risk of NEC is determined by maturity of the
GI tract
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34. Age of Onset
• The age of onset is highly variable but rarely occurs in the
first three days of life
• The lowest GA (24-28 weeks) tend to develop NEC after the
second week of life
• Intermediate GA (29-32 weeks) develop it within 1-3 weeks
• Term infants or >32 weeks tend to develop it in the first
week of life
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35. Risk Factors
• low APGARS,
• UAC
• severe RDS,
• PDA’s (ie gut ischemia),
• Aggressive and early enteral feeding in a premature
infant
• Prematurity (with immature GI tract and host
defenses) is the primary risk factor
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36. Clinical Manifestations
• Bell’s staging criteria
Stage I (suspected NEC)
Stage II (definite NEC)
Stage III (advanced NEC, severely ill)
IIIA (without perforation)
IIIB (with perforation)
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37. Clinical manifestations
• Stage I
• Systemic signs • Temp instability
• Intestinal Signs • Mild abdominal
distention, emesis
• Radiological signs
• Normal or mild
dilatation or ileus
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38. Clinical Manifestations
Stage II
• Systemic signs • Same as Stage I with
metabolic acidosis and
mild thrombocytopenia
• Same as Stage I with
decreased bowel sounds
• Intestinal signs and abdominal tenderness
• Intestinal dilatation, ileus
and pneumatosis
• Radiologic signs intestinalis
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39. Clinical Manifestations
Stage III (A & B)
• Systemic signs • Same as II plus
hypotension, severe
apnea, DIC, neutropenia, anuria
• Intestinal signs
• Same as II with generalized
peritonitis, marked tenderness
and distention, and abdominal
wall erythema
• Radiologic signs
• Same as II with portal vein
gas, definite ascites
pneumoperitoneum
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43. Radiologic findings
• Generalized bowel distention (earliest sign)
• Pneumatosis Intestinalis
• Pneumoperitoneum
• Large distended immobile loop on repeated x-rays
(persistant loop sign-may indicate a gangrenous loop of bowel)
• Gasless abdomen (perforation and peritonitis)
• Portal venous air
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44. Complications
• Mortality is 30-60%
• Stricture formation is 25-35%
• Bowel obstruction in 5%
• Enterocutaneous fistulas
• FTT secondary to short bowel syndrome and malabsorption
• Central line sepsis
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45. Treatment strategies
• Suspected NEC (Bell’s stage I)
Hold enteral feeds
Obtain an x-ray to view bowel gas pattern
Gastric decompression with an NG tube to
suction
Rule out Sepsis with initiation of IV
antibiotics
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46. Treatment Strategies
• Definite NEC (Bell’s stage II)
Follow serial exams and serial x-ray's with left lateral decubitus
films to screen for perforation
correction of metabolic disturbances(acidosis, hyperkalemia,
hyperglycemia etc), hypovolemia, thrombocytopenia, and DIC
Intubation if needed
Consider surgical consult
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47. Treatment Strategies
• Advanced NEC (Bell’s Stage III)
Same management as Stage II with increased
monitoring of BP, other vitals)
Vigorous fluid resuscitation, inotropes, ventilator
support
Surgery as indicated
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48. Treatment Strategies
• Surgery indication :-
Absolute indications
1) pneumoperitoneum
2) intestinal gangrene
 Relative indications
1) progressive clinical deterioration
2) fixed abdominal mass, portal vein gas, abdominal
wall erythema
3) persistently dilated bowel loop
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49. Prevention
• Antenatal steroids decreased the incidence of NEC
• Use of human milk
• GI priming with cautious advancement of enteral
feeding.
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50. Thank you
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Medical Post [ www.themedicalpost.net ]