Neonatal Sepsis3

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NEONATAL SEPSIS Dr. L. Manglem Singh Paediatrician, J. N. Hospital, Porompat Imphal, Manipur.


Neonatal Sepsis Clinical syndrome of bacteraemia characterized by systemic signs and symptoms of infection in the first four weeks of life


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%


Natural course of sepsis Bacteria Focal infection Bacteraemia sepsis Sepsis syndrome Early septic shock Refractory septic shock MODS DEATH


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

Etiology : 

Etiology Escherichia coli Staphylococcus aureus Klebshiella pneumonae


Risk Factors associated with Neonatal Sepsis Maternal Risk Factors 1. 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


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


Symptoms of Neonatal Sepsis CNS Lethargy, Refusal to suckle, Limp, Not arousable, poor or high pitch cry, Irritable, Seizures CVS Pallor, Cyanosis, Cold and clammy skin Respiratory Tachypnoea, Apnoea, Grunt, Retractions


Symptoms of Neonatal Sepsis GIT Vomiting, Diarrhoea, Abdominal distension Haematological Bleeding, Jaundice Skin Rashes, Purpura, Pustules


Laboratory Diagnosis of Neonatal Sepsis 1. Direct methods - Blood culture - CSF culture - Urine culture 2. Indirect methods - Total leucocyte count - Absolute neutrophil count - Total immature neutrophils - Immature to total neutrophols - Neutrophil Morphology - Platelet count - Micro ESR - Acute phase reactants - Buffy coat examination - Smear of gastric aspirate / External ear canal fluid - C3d


SEPSIS SCREEN At Birth Major risk factors 1. Rupture of membranes > 24 hours 2. Maternal intrapartum fever > 100.40 F 3. Chorioamninitis Minor risk factors 1. Rupture of membrane > 12 hours 2. Maternal intrapartum fever > 99.50 F 3. Maternal WBC > 15000 / mm3 4. Low apgar score(< 5 at 1 min, < 7 at 5 min) 5. LBW ( < 1500 g ) 6. Preterm labour ( < 37 weeks)


SEPSIS SCREEN 1. Leucopenia (TLC < 5000 / mm3) 2. Neutropenia (ANC <1800 / mm3) 3. Immature neutrophil to total neutrophil ( I / T) ratio ( > 0.2) 4. Micro – ESR ( > 15 mm / 1st hour ) 5. CRP - positive


Approach to Neonatal Sepsis Antenatal Postnatal Mothers with risk factors Symptomatic Asymptomatic infants infant with risk factors Term Preterm


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


Evaluation of asymptomatic infant for sepsis Sepsis screen Sepsis screen Sepsis screen Blood culture, LP negative positive Begin Antibiotics Observe for 48-72 hrs Culture positive Culture negative and discharge LP abnormal LP normal Treat septicaemia 10-14 days Treat for 48-72 hr Meningitis for 14-21 days and discharge


Supportive Care - Keep the neonate warm - Start IV Fluid, Infuse 10% Dextrose 2ml / Kg stat to maintain normoglycaemia - Maintain fluid and electrolyte balance and tissue perfusion If CRT > 3 sec infuse 10 ml / Kg normal saline


Supportive Care - Avoid enteral feed, if sick - Start oxygen by hood, if cyanosed and support breathing - Consider exchange blood transfusion, if there is sclerema, DIC, Neutropenia


Choice of Antibiotics Pneumonia or Sepsis Penicillin + Aminoglycoside (Ampicillin or Cloxacillin) (Gentamicin or Amikacin) Meningitis Ampicillin + Gentamicin or Cefotaxime + Gentamicin or Amikacin


Superficial Infections - Pustules - After puncturing, clean with betadine and apply antimicrobial - Conjunctivitis- Chloramphenicol eye drops - Oral thrush - Local application of Nystatin or Clotrimazole


Prevention of Infection - Exclusive breastfeeding - Keep cord dry - Hand washing by care givers - Hygiene of Baby - No unnecessary intervention - Better management of IV Lines - Disinfection of Equipments


Hand Washing - Single most important means of preventing nosocomial infections - Very Simple - Cheap


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


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


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


Medication preparation ( Prepare IV fluid under aseptic conditions ) - Never use stock solution for flushing - Do not use a single bottle for > 24 hrs - Label bottle with date / time - After seal is removed, use betadine soaked sterile cotton to cover the stopper of bottle - Use disposable needle each time


Better management of IV Lines - Thorough hand washing - Wear gloves - Use disposable IV cannula - Thorough skin preparation - All IV ports should be wiped with alcohol - Early identification of extravasation - Avoid unnecessary IV infusion


Conclusion - High index of clinical suspicion - Look for Lab evidence of sepsis - Start parenteral antibiotics (intravenous) - Provide supportive care - Review culture reports - Practise barrier nursing to prevent Cross–infection


Thank you

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