Neonatal Infections

May 2005

Dr Patricia Fenton

Sheffield Children’s Hospital

Neonatal Infections

Hazard analysis at critical control point

A baby production line

Uterus to push chair

The Bad News Is…..

No

Pictures

The Good News Is….

994 out of every 1000 infants born in the

UK survive

Some Definitions

Infant - <1 year

Neonate - < I month

“early onset” - < 7 days

Infant Deaths 93-97 (Number)

0

1000

2000

3000

4000

5000

6000

7000

8000

Congen Infection

E and W figures Neonates account

for 67% of deaths Infection is NOT a

major cause of neonatal death.

A Hazardous Journey

The uterus: Listeria monocytogenes The birth canal: group B streptococcus The unit: Acinetobacter baumanii Devices: CNS The attendants: Staph aureus

Three Barriers to Infection

NORMALFLORA

SKIN ANDMUCOUS

MEMBRANES

IMMUNITY

Impaired Barriers

Thin skin

Raw umbilicus

Invasive devices

Small/premature =

Poor antibody response Poor neutrophil response Poor complement activation Impaired macrophage activity Poor T cell function Reduced placental IgG

Clinical Presentations

Not breathing well Not feeding well Not looking well

lethargic irritable mottled Fever and tachycardia Seizures

AND NOT A BLOOD TEST OR XRAY!

Listeria monocytogenes

1-3 cases per million per year E&W 17 pregnancy associated cases 2001 >300 pregnancy assoc. 87-89

Soft cheese, paté and chilled meals All animals 5% humans in bowel

Listeria - an interesting organism

G + rod Flagellae-RT not BT Tumbling motility Haemolytic BA Invasin (IC) Actin tails Listerioloysin O

Log10 bacteria per ml

0

1

2

3

4

5

6

7

8

9

1 week 2 weeks 3 weeks 4 weeks

4 degreesminus 20

Disease Spectrum

Influenza like illness (maternal) Sepsis with stillbirth

Neonatal sepsis/meningitis

Sepsis/meningitis in impaired immunity (at any age)

Treatment, Outcome and Control

Ampicillin or amoxycillin Plus gentamicin

One third fatal

Avoidance, food quality measures, high level of suspicion, early treatment

Early Onset GBS Disease

376 cases in 2001 39 died

Important because: Identified risk factors Preventable

Risk Factors

Previous baby affected by GBS GBS in urine at any time this pregnancy Preterm labour Prolonged ROM Fever in labour

(RCOG guidelines 2003)

Screening Based Strategy

27% carry it (rectal plus vaginal swabs)

Antibiotic prophylaxis 86% reduction

Treat 1000, prevent 1.4

Risk Factor Strategy

25% women have one or more risk

Antibiotic prophylaxis 69% reduction

Treat 1000, prevent 2

The Disease

Early onset Low apgar Sepsis Pneumonia

GBS causes 70% early onset sepsis Low birth weight

Prevention

Choose your mother carefully (IgG)

Be big (mortality 6% vs. 18%)

Penicillin AT ONSET OF LABOUR

Christmas Day HH

Premature 35/40 No ANC Septic, ventilated Extubated day 11 Home “to die”

BUT….

The Unit

24 cots (2x6 bedded 1x12 bedded) Zero to two cases per year for 5 years 4 month period 11 cases clinical sepsis All cases in one 6 bedded ward area

The Bug

Acinetobacter baumannii Gram negative cocco-bacillus Water-dwelling saprophyte Long survival on dry surfaces Mattresses, air con, ventilators Up to 25% normal human skin flora Dissemination via hands?

What Happened Next?

Cultured everything.

Results?

Nothing

Followed each baby and everything that happened to them

And they found

Hydrocolloid dressings-large sheets Cut and stored Used on skin

CULTURE POSITIVE OUTBREAK STRAIN

What happened next?

Practice stopped Outbreak ended

3 babies died

Lessons Learnt

A knowledge of background infection rates useful (none to 11)

Susceptible patients are just that

Plastic wallets make good incubators

Devices

Initial response Getting worse

Central line in situ ?CNS

Coagulase negative staphylococci

Gram positive cocci Normal skin flora Low grade pathogen in normal host Hydrophobic cell surface (adheres) Polysaccharide production - biofilm Neonatal infections

Neonatal Unit B/C

CNS 234 Stau 17 E.coli 19 GNB’s 32 GBS 18

Attendants

6 week period 4 blistered babies Early discharge 14 more identified

Staph aureus Phage type 3A/3C Exfoliative toxin A

Outbreak Control

Swabs of all staff handling newborns Check all hands

One individual handled 17/18 affected Epidemic strain from nose, axilla, peri All other staff negative Treatment of carrier ended outbreak

Staphylococcus aureus

Looks like CNS and.. Normal flora (30% adults) but.. Highly pathogenic Exfoliative toxin A - SSSS Potential for cross infection

Treated with flucloxacillin

Control Measures

Wash hands

and

check hands

Conclusions

Infection: significant hazard to neonate Journey womb to push chair Bacteria for every occasion

Smaller is frailer Never give up on a neonate

Our Aim at SCH

Family focused service

Putting the needs and welfare

of children first