Neonatal sepsis
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Neonatal sepsis is a clinical syndrome of infection in the first four weeks of life that can cause multi-organ dysfunction and death if not recognized and treated early. It is a significant problem in India, causing 20% of neonatal deaths. The presentation and risk factors differ between early onset sepsis (<72 hours) which is usually caused by maternal pathogens and late onset sepsis (>72 hours) which is usually nosocomial. Treatment involves supportive care, administration of antibiotics, and recognition/prevention of risk factors like prematurity and invasive procedures. Handwashing and maintaining sterile techniques are essential to prevent hospital-acquired infections.
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Neonatal sepsis
- 1. 7We Care NEONATAL SEPSIS Prevention and Management Manoj sharma
- 2. 7We Care Neonatal Sepsis Clinical syndrome of bacteremia with systemic signs and symptoms of infection in the first four weeks of life.
- 3. 7We 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
- 4. 7We CareEarly Late Onset <72 hrs >72 hrs Source Maternal Environmental genital 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
- 5. 7We Care • Gram – ve : LPS / endotoxin • Gram +ve :lipoteichoic acid – peptidoglycan • Activation of – Coagulation pathway – Complement System – Cytokines • Multiorgan dysfunction Mechanism of injury
- 6. 7We 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 + MSOF Sepsis is a very rapidly progressive condition which can kill even before diagnosis
- 7. 7We Care ETIOLOGY • E coli • Klebsiella • CONS • Staphylococcus aureus • GBS • Pseudomonas • Acinetobacter • Citrobacter • Candida albicans and non albicans candida
- 8. 7We Care MATERNAL RISK FACTORS • Chorioamnionitis • Fever>38C • Foul smelling liquor • Fetal tachycardia • PROM> 18 hrs • Multiple examinations, prolonged labour
- 9. 7We Care NEONATAL RISK FACTORS • LBW • ELBW • Asphyxia • Twins • Male sex • Disruption of skin barrier • Prematurity • Lack of breast feeds
- 10. 7We Care RISK FACTORS Late onset sepsis • Prolonged intensive care • Long lines • Ventilation • prolonged antibiotic use • TPN • Steroids
- 11. 7We Care 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
- 12. 7We Care Symptoms of neonatal sepsis • GIT – Vomiting, diarrhea, abdominal distension • Hematological – Bleeding, jaundice • Skin – Rashes, purpura, pustules
- 13. 7We Care Signs of neonatal sepsis • Cold to touch ( hypothermia ) • Poor perfusion ( CRT ) • Hypotension • Renal failure • Sclerema • Bulging fontanels. • Poor weight gain** Indicates low grade sepsis
- 14. 7We Care 1. 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 severeof severe infectionsinfections
- 15. 7We Care Diagnosis of neonatal sepsis Direct - Isolation of organisms from blood, CSF, urine is diagnostic Indirect -Screening tests
- 16. 7We Care 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
- 17. 7We Care Mature neutrophil Band cell Neutrophils
- 18. 7We Care 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
- 19. 7We Care Management • Mainstays of therapy: – Early recognition – ABC’s - supportive care – Appropriate and adequate antimicrobials
- 20. 7We Care 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.
- 21. 7We Care Supportive care • cyanosed / RR >60/min / severe chest retractions – Start oxygen by hood • sclerema – Consider exchange blood transfusion/IVIG.
- 22. 7We Care 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)
- 23. 7We Care
- 24. 7We Care Choice of antibiotics • Pneumonia or Sepsis Penicillin Aminoglycoside (Ampicillin or Cloxacillin) (Gentamicin or Amikacin) • Meningitis Ampicillin + Gentamicin Or Gentamicin or Amikacin + Cefotaxime or Ceftriaxone +
- 25. 7We 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/am ikacin. Which Antibiotics
- 26. 7We Care • ESBLs: many strains of E. coli,klebsiella,pseudomonas serratia etc found with these resistant enzymes. Carbapenems,cefepime and pipera/tazobactem are most effective.
- 27. 7We Care Other measures in LOS • IVIG • G-CSF • PROBIOTICS • LACTOFERRIN • EARLY ENTERAL FEEDING.
- 28. 7We Care Superficial infections Pustules - After puncturing, clean with betadine and apply local antimicrobial Conjunctivitis - Ciprofloxacin eye drops Oral thrush - Local application of nystatin or Clotrimazole
- 29. 7We Care Prevention of Infections
- 30. 7We Care Five ‘cleans’ to prevent infection • Clean hands • Clean cord tie • Clean cord • Clean surface • Clean blade
- 31. 7We Care 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
- 32. 7We Care A scanned picture of steps of hand washing Six steps of hand washing Step 1 Wash palms with fingers Step 2 Wash back of hands Step 3 Wash fingers & knuckles Step 5 Wash finger tips Step 6 Wash wrists Step 4 Wash thumbs
- 33. 7We Care
- 34. 7We Care Hand washing Simplest, 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
- 35. 7We Care 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
- 36. 7We Care Prevention of Infections • Exclusive breast feeding • Keep cord dry • Hand washing by care givers • Hygiene of baby • No unnecessary interventions
- 37. 7We Care 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
- 38. 7We Care Disposal of waste and soiled linen • Safe disposal • Colour coding • Sharps • Infected wastes
- 39. 7We Care
- 40. 7We Care 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
- 41. 7We Care 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
- 42. 7We Care 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
- 43. 7We Care 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
- 44. 7We Care 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
- 45. 7We 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