NEONATAL INFECTIONS & SEPSIS

PRESENTED BY : VRUTI PATEL

PERINATAL INFECTIONS

• Infection is still one of the leading causes of neonatal death in developing countries.

• The neonates are more susceptible to infection as they are deficient in natural immunity and acquired immunity.

• Preterm infants are at high risk for perinatal infections.

• Neonates that survive from sepsis often suffer from severe neurological as well as severe parenchymal lung diseases.

RISK FACTORS FOR NEONATAL INFECTION

• Rupture of membrane > 18 hours• Maternal intrapartum fever > 100.4˚F• Low birth weight infant (< 2500 g)• Prematurity (< 37 weeks)• Chorioamnionitis• Male infant• Mother with Gr. B β haemolytic streptococcal

(GBS) infection• Repeated vaginal examination in labour• Invasive procedures of monitoring

MODE OF INFECTION

Antenatal• Transplacental : maternal infection that can

affect the fetus through transplacental route are predominantely the viruses, they are rubella, cytomegalovirus, herpes virus, HIV, chicken pox and hepatitis – B virus. Other infections are syphilis, toxoplasmosis and tuberculosis.

• Aminonitis : amnionitis following premature rupture of the membranes can affect the baby following aspiration or ingestion of infected amniotic fluid.

•  

Intranatal• - aspiration of infected liquor or

meconium following early rupture of the membranes or repeated internal examination. This may lead to neonatal sepsis, pneumonia and meningitis.

• - while the fetus is passing through the infected vagina – (a) eyes are infected – opthalmia neonatorum or (b) oral thrush with candid albicans.

• - Improper asepsis while caring the umbilical cord.

Postnatal – nosocomial infections• Transmission due to human

contact – infected mother, relative or staff of the nursery.

• Cross infection from an infected baby in the nursery.

• Infection through feeding, bathing, clothing or air-borne.

• Infection in environment of neonatal intensive care (NICU) or invasive monitoring.

The common pathogens are :• group B streptococcus (GBS),

Staphylococcus aureus, E. coli, klebsiella and pseudomonas, fungus (candida) and anaerobes.

• The infant is acquired during intrapartum period from the genital tract.

• The infant is colonised with the pathogens in the perinatal period.

• The primary sites of colonisation are : skin, nasopharynx, oropharynx, conjunctiva and umbilical cord.

COMMON SITES OF INFECTION

Trivial but may be serious : • Eyes – opthalmia neonatorum • Skin• Umbilicus• Oral thrush

Severe systematic :• Respiratory tract • Septicaemia• Meningitis• Intra – abdominal infections

TREATMENT

• Antibiotic therapy – broad spectrum are given to cover the germ positive and negative organisms as well as the anaerobes. Inj. Ampicillin 150 mg/kg/every 12 hours, gentamycin 3-4 mg/kg/every 24 hours, usually are started. In a severely ill patient, cefotaxime or ceftazidime is also added.

• Supportive therapy and management of complications as needed. E.g. mechanical ventilation for RDS, dopamine for hypotension, ant convulsion for seizure sodium bicarbonate for metabolic acidosis and Immunotherapy with hyper immune globulins.

CONGENITAL SYPHILIS

Congenital syphilis is caused by transplacental transmission of spirochetes; the transmission rate approaches 90% if the mother has untreated primary or secondary syphilis. Fetal infection can develop at any time during gestation. Manifestations are defined as early if they appear in the first 2 years of life and late if they develop after age 2 years.

DEFINITION

• Congenital syphilis is a severe, disabling, and often life-threatening infection seen in infants. A pregnant mother who has syphilis can spread the disease through the placenta to the unborn infant.

• Congenital syphilis is syphilis present in utero and at birth, and occurs when a child is born to a mother with secondary syphilis. Untreated syphilis results in a high risk of a poor outcome of pregnancy.

CAUSES

Congenital syphilis is caused by the bacterium Treponema pallidum, which is passed from mother to child during fetal development or at birth. Nearly half of all children infected with syphilis while they are in the womb die shortly before or after birth.• The risk of infecting the baby is greatest when the

mother is in the early stages of syphilis. But infection is possible any time during pregnancy.

SYMPTOMS

Early-onset congenital syphilis (diagnosed before or at age 2 y)• Symptoms in newborns may include:• Failure to gain weight or failure to thrive• Fever• Irritability• No bridge to nose (saddle nose)• Rash of the mouth, genitals, and anus• Rash -- starting as small blisters on the palms and soles,

and later changing to copper-colored, flat or bumpy rash on the face, palms, and soles

• Watery fluid released from the nose

LATE ONSET CONGENITAL SYPHILLIS

MOUTH• blunted upper incisor teeth known as Hutchinson's teeth• Abnormal notched and peg-shaped teeth, called

Hutchinson teeth• hard palate defect

EYE

Inflammation of the cornea known as interstitial keratitis• Blindness - • Clouding of the cornea

EAR & NOSE

• deafness from auditory nerve disease• saddle nose (collapse of the bony part of nose)• snuffles, aka "syphilitic rhinitis", which appears similar to

the rhinitis of the common cold, except it is more severe, lasts longer, often involves bloody rhinorrhea, and is often associated with laryngitis.

EXTRIMITIES

• Bone pain• Refusal to move a painful arm or leg• Joint swelling

SKIN

• Scarring of the skin around the mouth, genitals, and anus

• Gray, mucus-like patches on the anus and outer vagina• Saber shins (bone problem of the lower leg)

OPTHALMIA NEONATRUM

OPTHALMIA NEONATRUM/ CONJUNCTIVITIS

Opthalmia neonatorum is defined as inflammation of conjunctiva during first month of life.

Causes• Chlamydia trachomatis (oculogenitalis)• Other bacterial causes : gonococcus (rare),

staphylococcus, pseudomonas, etc.• Chemical – silver nitrate• Viral : herpes simplex (type II)

MODE OF INFECTION

• Infection occurs mostly during delivery by contaminated vaginal discharge.

• It is more likely ion face or breech delivery. • During neonatal period, there may be direct

contamination from other sites of infection or by chemical.

CLINICAL FEATURES

• It is varies • the discharge may be watery, mucopurulent to frank

purulent in one or both eyes. • The eyelids may be sticky or markedly swollen. • Cornea may be involved in severe cases.

PROGNOSIS & PREVENTION

Prognosis• It is favourable to most cases except in neglected

cases with rare gonococcal infection. Fortunately, effective methods of prophylaxis and treatment have almost eliminated the risk of blindness.

Prevention• Any suspicious vaginal discharge during the

antenatal period should be treated and the most meticulous obstetric asepsis is maintained at birth. The newborn baby’s closed lids should be thoroughly cleansed and dried.

INVESTIGATIONS

The discharge is taken for –

(a)gram stain smear

(b)culture and sensitivity

(c) scraping material from lower conjunctiva for Giemsa staining and also culture in suspected chlamydial infection (d) culture in special viral media for suspected herpes simplex infection.

TREATMENT

Prophylaxis : 1% silver nitrate solution (1-2 drops to each eye), 0.5% erythromycin opthalmic ointment, 2.5% povidone iodine solution is administered within 1 hour of birth and is continued for few days.

Treatment depend upon the specific aetiology.• Gonococcal – infant is isolated during the first 24 hours

of treatment. Eyes are irrigated with sterile isotonic saline evert 1-2 hours until clear. In severe and culture positive cases systemic ceftriaxone 50 mg/kg/q 12 h is given IM/IV. Single dose in infant without dissemination or for 7 days when there is dissemination, is usually given.

• Chlamydia – erythromycin suspension 40 mg/kg daily orally divided into 4 doses for 14 days is given to prevent systemic infection. Topical treatment alone is ineffective.

• Herpes simplex – the infant is isolated. Systemic t=herapy with acyclovir 20 mg/ kg every 8 hours for 2 weeks is given IV. Topical use of 0.1% iododoxyuridine ointment 5 times a day for 10 days is used.

NEONATAL SEPSIS

• Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days old. Early-onset sepsis is seen in the first week of life. Late-onset sepsis occurs between days 8 and 89.

• Neonatal sepsis specifically refers to the presence in a newborn baby ("neonate") of a bacterial blood stream infection(BSI) (such as meningitis, pneumonia, pyelonephritis, or gastroenteritis) in the setting of fever.

Neonatal sepsis is a bacterial infection in the blood. It is found in infants during the first month of life. This may become a serious condition. If you suspect your infant has this condition, contact your doctor right away.

CAUSES & RISK FACTORS SOURCE RISK FACTORS

Maternal Low socioeconomic status

Poor prenatal care

Poor nutrition

Substance abuse

Intrapartum Premature rupture of membranes

Maternal fever

Chorioamnionitis

Prolonged labor

Rupture of membranes >12 -18hr

Premature labor

Maternal urinary tract infection

Cont…SOURCE RISK FACTORS

Neonatal Twin or multiple gestation

Male

Birth asphyxia

Meconium aspiration

Congenital anomalies of skin or mucuos membranes

Galactosemia

Absence of spleen

Low birth weight or prematurity

Malnourishment

Prolonged hospitalization

Early-onset neonatal sepsis• The microorganisms most commonly associated with

early-onset neonatal sepsis include the following :• GBS• E coli• Coagulase-negative Staphylococcus• H influenzae• L monocytogenes

Late-onset neonatal sepsis

Organisms that have been implicated in causing late-onset neonatal sepsis include the following:

• Coagulase-negative staphylococci• S aureus• E coli• Klebsiella• Pseudomonas• Enterobacter• Candida• GBS• Serratia• Acinetobacter• Anaerobes

SYMPTOMS

SYSTEM SIGNS

Respiratory Apnea, bradycardia

Tachypnea

Grunting, nasal flaring

Retractions

Decreased oxygen saturation

Metabolic acidosis

Cardiovascular Decreased cardiac output

Tachycardia

Hypotension

Decreased perfusion

Central nervous Temperature instability

Lethargy

Cont..

SYSTEM SIGNS

Hypotonia

Instability, seizures

Gastrointestinal Feeding intolerance (decreased

Suck strength and intake; increasing residuals)

Abdominal distention

Vomiting, diarrhea

Integumentary Jaundice

Pallor

Petechiae

Mottling

DIAGNOSIS

• Blood tests such as complete blood count

Cultures of: Blood Urine Cerebrospinal fluid—through lumber puncture Skin lesions

 • X-rays of the chest or abdomen• Coagulation studies – DIC can occur in infected newborn• Chest radiography, CT Scan or MRI – in suspected

meningitis cases.

TREATMENT

• Treatment depends on how severe the condition is. If sepsis is suspected, your infant will be hospitalized while you wait for test results.

• Antibiotics  - Antibiotic medicine may have to be given directly into the vein (IV).

• Intravenous Fluids  - IV fluids will help support your infant until the infection clears. It may include fluids, glucose, and electrolytes.

• Oxygen  - infant may need oxygen therapy. In more severe cases, a ventilator may be used to support breathing.

Diet• Because of gastrointestinal (GI) symptoms, feeding

intolerance, or poor feeding, it may be necessary to give the neonate nothing by mouth (nil per os; NPO) during the first days of treatment. Consider parenteral nutrition to ensure that the patient’s intake of calories, protein, minerals, and electrolytes is adequate during this period.

• For the infant whose condition is seriously compromised, feeding may be restarted via a nasogastric tube For most infants, breast milk is the enteral diet recommended by the American Academy of Pediatrics (AAP).

Consultations• An infectious disease consultation is useful, especially if the

infant is not responding to treatment, is infected with an unusual organism, or has had a complicated clinical course. If neonatal meningitis is identified, consultation with a pediatric neurologist may be necessary for assistance with outpatient follow-up of neurologic sequelae. Inpatient consultation may be necessary if meningitis is complicated by seizures.

• Consultation with a pediatric pharmacologist may be helpful for obtaining advice on the most appropriate antibiotic or dosage to use if changes in the drug regimen prove necessary because of inadequate or toxic drug levels obtained with therapeutic monitoring. A pediatric surgical consultation may be necessary if sepsis is complicated by abscess, if the differential diagnosis includes necrotizing enterocolitis (NEC), or if central line placement is required.

Long-Term Monitoring• The primary care provider (PCP) should evaluate the

infant with neonatal sepsis within 1 week of discharge from the hospital. The infant can be evaluated for superinfection and bacterial colonization associated with antibiotic therapy, especially if the therapy was prolonged. The PCP should evaluate growth and determine whether the feeding regimen and activity have returned to normal.

• If neonatal sepsis was associated with meningitis, prolonged hypoxia, extracorporeal membrane oxygenation therapy, or brain abscess formation, the infant should be observed for several years to assess neurodevelopment. If problems are found, the child should receive appropriate early intervention services and therapies.

Medication• Antibiotics commonly used - ampicillin, gentamicin,

cefotaxime, vancomycin, metronidazole, erythromycin, and piperacillin. The choice of antibiotic agents should be based on the specific organisms associated with sepsis, the sensitivities of the bacterial pathogen, and the prevailing nosocomial infection trends in the nursery. Viral infections, such as herpes and fungal infections, can masquerade as bacterial infections.

PREVENTION

• Antibiotics can control dangerous bacteria in the mother. It will prevent the spread of bacteria during pregnancy or birth to the infant. Your doctor may recommend antibiotics if:

• The birth mother has previously given birth to an infant with neonatal sepsis.

• You have had a positive bacterial infection test before your due date.

• Breastfeeding may also help prevent sepsis in some infants.

• Follow steps to prevent premature labor or birth. This can include proper prenatal care, avoiding drugs and alcohol, and eating a healthy balanced diet.

NURSING DIAGNOSES

NEWBORN• Risk for in fection related to

• Maternal vaginal (or other) infection• Indwelling umbilical catheters, parenteral fluids

(invasive procedures)• Intrauterine electronic fetal monitoring• Dysmaturity, IUGR, gestational age

• Ineffective thermoregulation related to• systemic infection

• Impaired skin integrity related to• use of multiple supportive invasive measures (e.g,

physiologic monitoring, parenteral fluid therapy, inhalation therapy)

• Acute pain related to• Multiple supportive invasive measures

PARENTS AND FAMILY• Anxiety, fear, or anticipatory grieving related to

• Uncertainty about infant’s prognosis• Therapy (invasive)

• Risk for impaired parent-infant attachment related to• Separation of parent and newborn• Feelings of inadequacy in caring for infant

• Powerlessness or spiritual distress related to• Perinatal events or newborn’s condition beyond

parent’s control