NEONATAL SEPSIS

Ekawaty Lutfia HaksariPerinatology, Department of Child Health Gadjah Mada

University

Trends in child mortality among those younger than 5 years and in first 28days of life 1965-2015(Lawn et al. 4 million neonatal deaths:When?Where?Why?Lancet 2005;365:891-900)

Worldwide causes of neonatal mortality Save the Children. Saving Newborn Lives. Washington, 2000

32%

24%10%

5%

29%

AsphyxiaLBW+prematurityI nf ectionsCongenital anomalyOthers

NEONATAL SEPSIS• Systemic infection

important cause morbidity & mortality

• Laboratory, clinical diagnose – difficult leading to delayed treatment

ONSET OF NEONATAL SEPSIS•Early onset sepsis - Onset 0-72 hours of age - Acquired around birth - Usually vertical transmission - mother •Late onset sepsis - Onset >72 hours age - Acquired environtment - Hospital acquired or nosocomial infection

Risk factors – Late onset neonatal sepsis

• Prematurity/ low birth weight• In hospital• Invasive procedures: ventolator, iv lines,

central lines, urine catheter, chest tube• Contact with infectious disease- doctors,

nurses, babies with with infections, siblings

• Not fed maternal breast milk

CLINICAL DIAGNOSISoEarly sign very subtle, non specific very quickly to late sign death

oAnticipate possible severe infection carefull examine observe them – slight changes early diagnosis, T/

•Algorithms - symptoms/signs health workers to identify neonatal sepsis referral/ home treatment (WHO, 2002)

• Newborn has not been well since birth

• Well infant 1 or > signs neonatal sepsis poor feeding + sucking

SIGNS OF INFECTION (WHO, 2002)

Early signs Late signs Local/specific sign

Not able to feed /suck, after fedding normallyLethargyAbnormal body temp

Breathing difficulties

Severe lethargyUnconciousnessSeizureApneaJaundiceScleremaBleeding

DiarrhoeaAbdominal distensionUmbilical rednessPus draining-eyesmovement of limbCrying-limb is touch/movedSwelling,warmth, redness- limb/jointBulging fontanelleOpisthotonus

Possible infection (Kosim, 2004)

A BBreathing difficultiesSeizureUnconciousnessAbnormal body temperature (sepsis)Delivery problem (sepsis)Condition (sepsis)

Tremor Lethargy Weak Irritability Onzet day 4 (sepsis) Poor feeding (sepsis)

Risk factors of early onset•Maternal history-uterine

infection PROM > 18 hours• Birth weight <2000g or

gestation age < 35 weeks • Signs of infection possible severe infection

Kosim, 2004

Perinasia 1991 POSSIBLE SEPSIS

•Clinically sepsis at least 1 sign is found in 4 out of 6 group categories

•Risk factors

Surjono, 2004

Perinasia konsensus 1991

Clinically sepsisat least 1 sign is found in 4 out of 6 group categories: (1) General condition (2) Gastrointestinal system (3) Respiratory system (4) cardiovascular system (5) central nervous system (6) hematologic system

(1) General condition not doing well, poor feeding, temperature instability, sclerema

(2) Gastrointestinal system abdominal distention, vomiting,

diarrhea, hepatomegaly

(3) Respiratory system apnea, dyspnea, tachypnea, retraction,

flaring, grunting, cyanosis

(4) Cardiovascular system tachycardia, bradycardia, poor perfussion

(5) Central nervous system irritability, lethargy, tremor, seizure

(6) Hematologic system jaundice, splenomegaly, pallor, petechiae, bleeding, leucopenia, ratio immature/mature neutrophil (I/T>0,2), thrombocytopenia, toxic granulation

CLINICALLY SEPSIS (cont)

Not doing well Poor feeding Lethargy Respiratory problem Hypothermia > hyperthermia

(Yu & Monintja, 1997)

• C-reactive protein (CRP)• Chest X-Ray• Gold standard• Culture – body fluid: blood, urine, stools,

endotracheal aspirates, cerebrospinal fluid (CSF), pleural or pus

Diagnosis (cont)

TREATMENT•Specific: Antibiotics - Ampicillin and Gentamicin - Cephalosporin•Supportive care - Temperature - Cardiorespiratory - Hematological - Gastrointestinal - Immunological ?

Antibiotic resistance pattern in developing countries

(from Vergnano S, et al. Arch Dis Child Fetal Neonatal Ed 2005)

Klebsiella spp E.coli

Ampicillin 65 – 100% 69 – 100%

Gentamicin 16 – 85% 30- 93%

Amikacin 0 – 74% 0 – 67%

Cefotaxime 0 – 86% 0 – 75%

Imipenem 0 – 6% 0%

Supportive Care • Temperature support- hypothermia • GI support - vomiting, ileus• Cardiorespiratory support - hypoxia, apnea,

ARDS, hypotension, shock• Hematological support: anemia,

thrombocytopenia, DIC• Neurological support- seizures

SUGGESTIONS TO PREVENT NEONATAL SEPSIS

• Treat mother’s infections - pregnancy• Use clean delivery practices -labor and birth• Use infection prevention steps – labor,birth and post natal care• Treat a mother with antibiotics -labor - she has the sign of infection / prolonged rupture membrane >18hours

suggestions

• Wash the hands before and after handling each newborn • Rooming in – normal newborn • Do not bring the baby into contact

with sick people• Isolate a sick newborn from healthy ones

suggestions

• Teach the mother & family - to keep the baby away from sick people

- to use infection prevention steps, especially hand washing

Human milk• Enteral feeding - human milk is generally regarded as beneficial

• Breastfeed the newborn exclusively

(Kramer, 2002; Beck, 2004)

HUMAN MILK (cont)• NICU: incidence of neonatal infection (el-Mohandes, 1997; Tysson, 1997; Xanthou,1998; Hanson, 2002)

• Early full enteral feeding significantly the risk of late onset of septichaemia - extremely premature infant

(Ronnestad, 2005)

LOCALIZED INFECTIONS• Umbilical cord: uncovered, clean and dry• Skin infection• Eye infection• Oral trush (WHO 2002, Kosim 2004, Beck 2004)

PREVENTION OF NOSOCOMIAL INFECTION

• The lay out & organisation - the neonatal unit may have an important effect on infection control practices• Hand washing is a cornerstone of

infection control