Neonatal Sepsis and Necrotizing Enterocolitis

Neonatal Sepsis, Necrotizing Enterocolitis

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Dr. Kalpana MallaMD Pediatrics

Manipal Teaching Hospital

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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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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Common - E.coli, Klebsiella, Pseudomonas, Proteus,

Others- Staph. aureus, streptococcus ssp, acintobactor, H. inlfluenzae, Anaerobes, L monocytogens, GBS, Enterococcus,Citrobacter

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Etiology

Maternal Risk Factors1. 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 liquor7.Chorioamnionitis

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Neonatal Risk factors 1. Low Birth Weight Baby/Preterm 2. Perinatal asphyxia 3. Male gender

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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,

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, Catheters, Infusion sets, Face masks.

Organisms• Staph aureus . epidermidis, E.coli, Klebsiella,

pseudomonas, proteus (2/3 are by gram –ve bacilli), Enterobacteriae

CLASSIFICATION

ⓑ Community infection • After discharge from hospital Source - mother, family, contacts, baby care

units,Organisms: • Strepto pneumoniae • Tuberculosis • Viruses

CLASSIFICATION

3. Late-late onset• After 30 days of ageOrganisms- saph. epidermidis, E.coli, candida,

Tuberculosis Viruses

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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Symptoms of Neonatal Sepsis1. 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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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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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/minMinor 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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Minor risk factorsMinor 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

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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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

Lab diagnostic criteria

• Septic screen- if 3 are abnormal chance of infection 90%

A) TLC>20,000 or <5000B) Bands >20% or band: neutro>0.2C) abnormal neutrophils-toxic granulesD) micro ESR>15mm/1st hr E) CRP >8mcg/mlOthers-elevated haptoglobin,alpha-1antitrypsin

fibrinogen

Management of Neonatal Septicemia

1. Antibiotic Therapy2. Supportive Therapy3. Immunotherapy

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

Supportive care:

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

Immunotherapy

• IVIG• Exchange blood transfusion - if there is

sclerema, DIC, Neutropenia

• Granulocyte transfusion - Colony Stimulating Factors

• Prognosis-upto 50% mortality

Natural course of sepsis Bacteria Focal infection Bacteraemia

sepsis

Sepsis syndrome

Early septic shock

Refractory septic shock

MODS Multiple organ dysfunction syndrome

DEATH

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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

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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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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Hand Washing

- Single most important means of preventing nosocomial infections

- Very Simple

- Cheap

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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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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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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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• An idiopathic coagulation necrosis and inflammation of the intestine in a neonate.

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Definition

NECROTIZING ENTEROCOLITIS

• 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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Incidence

• 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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Age of Onset

• 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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Risk Factors

• Bell’s staging criteriaStage I (suspected NEC)

Stage II (definite NEC)

Stage III (advanced NEC, severely ill) IIIA (without perforation) IIIB (with perforation)

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Clinical Manifestations

• Stage I• Systemic signs

• Intestinal Signs

• Radiological signs

• Temp instability

• Mild abdominal distention, emesis

• Normal or mild dilatation or ileus

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Clinical manifestations

Stage II• Systemic signs

• Intestinal signs

• Radiologic signs

• Same as Stage I with metabolic acidosis and mild thrombocytopenia

• Same as Stage I with decreased bowel sounds and abdominal tenderness

• Intestinal dilatation, ileus and pneumatosis intestinalis

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Clinical Manifestations

Stage III (A & B)• Systemic signs

• Intestinal signs

• Radiologic signs

• Same as II plus hypotension, severe apnea, DIC, neutropenia, anuria

• Same as II with generalized peritonitis, marked tenderness and distention, and abdominal wall erythema

• Same as II with portal vein gas, definite ascites pneumoperitoneum

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Clinical Manifestations

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• 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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Radiologic findings

• 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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Complications

• Suspected NEC (Bell’s stage I)Hold enteral feedsObtain an x-ray to view bowel gas patternGastric decompression with an NG tube to

suctionRule out Sepsis with initiation of IV antibiotics

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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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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

supportSurgery as indicated

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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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Treatment Strategies

• Antenatal steroids decreased the incidence of NEC • Use of human milk • GI priming with cautious advancement of enteral

feeding.

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Prevention

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