Neonatal SepticemiaNeonatal Septicemia

Li Yijuan

First Affiliated Hospital

SUMS

Will They Have Good Future ???

Objectives

What will I learn?

Etiologies and risk factors

Symptoms

Diagnosis

Treatment

Introduction

Common -20% of VLBW has sepsis

-In term 0.1%-Inter-institution difference 11-32% (NICHD net work)

Serious-mortality is 3-5 times more for infant with sepsis in NICU

What is Neonatal Sepsis?

Neonatal Septicemia is a generalized

infection characterized by the proliferation

of organisms in the blood circulation during

the first month of life.

Some basic definitions

• SIRS(systemic inflammatory response syndrome ) - fever, tachypnoea, tachycardia, abnormal WBC

• Sepsis- systemic response to infection

• Severe sepsis- sepsis with organ dysfunction, hypotension

• Septic shock- severe sepsis with multiorgan

dysfunction

difficult to apply these definitions and a staging

system to the newborn

Pathogen

• Staphylococcus • Escherichia coli• Conditional pathogen • Group B streptococcus

Staphylococcus

E. Coli

• Staphylococcus epidermidis

• Pseudomonas aeruginosa

Klebsiella

• Clostridium perfringens

Group B -hemolytic streptococcus

Route of Infection

• Prenatal infection

• infection during delivery

• postnatal infection

Sepsis Risk Factors

• Prematurity

• Birth weight

– Term 0.1%

– 1,000 -1,500 g 10%

– <1,000 g 35%

– <750 g. 50%

• Delay enteral feeding and Prolonged TPN

I.Risk Factors (maternal and neonatal)A.Major

1.Maternal prolonged Rupture of Membranes >24 hours 2.Intrapartum maternal fever >38 C (>100.4 F) 3.Chorioamnionitis 4.Sustained Fetal Tachycardia >160 beats per minute

B.Minor 1.Intrapartum maternal fever >37.5 C (>99.5 F) 2.Twin Gestation 3.Premature infant (<37 weeks) 4.Maternal Leukocytosis (White Blood Cell count >15000) 5.Rupture of Membranes > 12 hours 6.Tachypnea (<1 hour) 7.Maternal Group B Streptococcus Colonization 8.Low APGAR (<5 at 1 minute) 9.Low birth weight (<1500 grams) 10.Foul lochia

What makes a neonate’s immune system susceptible to sepsis?

Maturity

Immaturity

or

You’re Right!!!!

The immaturity of a neonate’s immune system makes them MORE SUSCEPTIBLE to sepsis.

Why are newborns so vulnerable to infection?

Non-specific immunity

Specific immunity

IMMUNE SYSTEM

Neutrophils –Qualitative

and quantitative

Complement andimmunoglobulinlevels decreased

T cells- antigenically naïve

limited cytokineproduction

Why are newborns so vulnerable to infection?

• Poor skin barrier

• Umbilical stump

• Poor blood-brain barrier

Classification

• Early onset sepsis (EOS):– bacteria acquired before and during delivery– 5-7/1000 live birth– 1.5% of VLBW infants had EOS (intrapartum

antibiotics)

• Late onset sepsis (LOS): – bacteria acquired after delivery (Nosocomial

or community)– 20% of VLBW infants

Clinical menifestationsClinical menifestationsClinical menifestationsClinical menifestations

EOS LOS

Onset Within 7 days >7 days

Source Prenatal

During delivery

During delivery

Postnatal(nosocomial )

Pathogens G-bacili Staphylococcus;

Opportunitic

Presentation

Mortality

Pneumonia

High

Bacteremia and / or meningitis

Low

Symptoms of Neonatal Sepsis

The symptoms are not concrete and vary widely

Tachypnea Heart Rate Changes

Feeding difficulties

Difficulty Breathing Temperature Instability

Jaundice Irritability

Omphalitis

Bleeding tendencyPoor perfusion

Enlargement of liver and spleen

toxical paralytic ileus

NEC

NEC

dyspnea

Clinical presentation

Early warning signs are often non-specific and subtle

easily confused with non-infective causes (e.g. apnea of prematurity, variation in environmental temperature or

acute exacerbation of chronic lung disease)

clinical course alarmingly fulminant

septic shock + DIC

death

Non-specific, multi- systems/organs involved

Clinical manifestationClinical manifestation

The symptoms are so broad , non-specific,

and acute deterioration,

How to make a diagnosis as early as possible ?

Laboratory studies

• Evidence for inflammation

• Evidence for infection

• Evidence for multiorgan system disease

Laboratory Examination: CBC

• WBC<5×109/L or WBC>20× 109/L

• I/T≥0.2 ， toxic granules

• thrombocytopenia <100×109/L

Reference values for neutrophilic cells

Manroe BL, J Pediatr 1979;95:89-98.

Total neutrophils

Immature neutrophil

I/T ratio

Lab examination:CRP

• CRP

• α1-AG

• α1-AT

Lab Exam: Organism detection

blood culture

culture of body fluid and secretion

plasma brown layer smear

--Detection of antigen: usually for antibody

of GBS or E coli in CSF, blood and urine

--Molecular biochemical method PCR

Summary

Is there a diagnostic marker

for neonatal sepsis?

Great answer! You’re correct!

• There is NOT a specific diagnostic marker, only determinants of infection

Summary

The best approach for diagnosis of systemic bacterial infection:

• use of multiple markers (e.g. CRP, IL-6, TNF, CD64), and

• serial measurements

Diagnosis • history

–high risk factors• clinical manifestation

--nonspecific S/S• lab results

- abnormal blood routine,

CRP, positive culture

or detection of organisms

Therapy

• Infection should be the first thought

when an infant has symptoms

• Aggressive treatment should begin before

the diagnosis is confirmed.

• Therapy can be discontinued if sepsis is

excluded

Treatment

Antibiotics therapy

management of complications

supporting therapy

Clearance of infectious focus

Immunotherapy

Antibiotic therapy

• using antibiotics as early as possible

• choose antibiotics according to drug sensitivity

• giving drugs intravenously

• combine effective drugs to make synergism

• enough therapeutic course

• consider the possible side effects

Dosages of antibiotics for newborns

Supporting therapy

• Nursing care

--warm environment

--oxygen supply

• correction of acidosis and electrolyte

disturbance

• fluid , glucose and nutrition balance

Management of complications

• Shock

• DIC

• Cerebral edema

• Pulmonary hemorrhage

Immunotherapy

• IVIG

• Exchange transfusion

• Granulocyte transfusion ， G-CSF

• Platelet transfusion

Questions

• Could prophylatic IVIG reduce the

morbidity and mortality of neonatal

sepsis?

• Might prophylatic IVIG interfere the

development of the neonatal IM

system?

Thank you for your attentionThank you for your attention