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