neonatal sepsis - university of babylonneonatal sepsis: definition: a clinical syndrome of systemic...
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NEONATAL SEPSIS:Definition:
A clinical syndrome of systemic illness accompanied by bacteremia occurring in the first month of life, especially among premature & V.L.B.W. - It usually presents as septicemia, pneumonia, meningitis, arthritis, osteomyelitis & U.T.I., and it is the commonest cause of neonatal mortality.
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SOURCE OF INFECTIONS:
- Intra-amniotic infection
(CHORIOAMNIONITIS) is a major risk
factor for neonatal sepsis.
The primary sites of infection are: skin,
nasopharynx, oropharynx, conjunctiva, &
umbilicus.
- Some infections are transmitted
transplacentally (CONGENITAL or
TORCH INFECTIONS).
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Neonates are more liable to get
infection because :
1- Immaturity of the immune system.
2- They have low level of complement.
3- Impaired function of neutrophils, monocytes, & macrophages.
4- K.cells (killer cells) have diminished cytotoxic effect.
5- IgM & IgA do not cross the placenta.
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TYPES OF SEPSIS:
1.Early Onset Sepsis(EOS):- Usually occurs in the first wk. of life,
characterised by multisystem, fulminant illness with prominent respiratory symptoms caused by group B streptococci (G.B.S.), listeria monocytogenes, & viruses e.g. CMV.
- 90% of cases presents in the first 24 hr. as respiratory distress which proceeds to respiratory failure.
- Pneumonia is commonest disease.
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2.Late Onset Sepsis:
- It usually presents after the first wk.
- Commonly presents as meningitis.
- G.B.S. is the commonest organism
but Listeria monocytogenes accounts
for up to 20%.
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3.Nosocomial Infection:
- Usually occurs in the N.I.C.U. & in ill
infants.
- It depends on N.I.C.U. environment,
invasive monitoring and technique.
- Common organisms are staphylococcus
epidermidis, Gram –ve bacteria(e.g.E.coli,
(pseudomonas,klebsiella,proteus) & fungi.
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Risk factors for neonatal sepsis:
1. Prematurity.
2. Prolonged rupture of membranes (> 24 hr.).
3. Maternal fever (> 38c).
4. Maternal U.T.I. or genital infection.
5. Meconium stained or foul smelling amniotic fluid.
6. Multiple gestation.
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7. Resuscitation at birth with low
APGAR ( < 6 at 1,5 minutes).
8. Invasive procedures.
9. Artificial feeding.
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CLINICAL PRESENTATION :
1- Reluctance to feed.
2- Respiratory distress, grunting & apnea.
3- Lethargy, decreased or no movements &
neonatal reflexes.
4- Hypo or hyperthermia (only 50% of
infected neonates have high temp.).
5- Vomiting, diarrhea, abdominal distension.
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6- skin rash, petechiae, purpura, skin mottling (cutis murmorata), ecthymagangrenosum (deep ulcers with ecchymotic margins commonly seen in klebsiella infection), impetigo, cellulitis, omphalitis.
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7- Poor peripheral perfusion & delayed capillary refill ( > 2 seconds).
8- Hypoglycemia.
9- Sclerema, Edema.10- Hepatosplenomegaly, jaundice.
11- Convulsions, bulging anterior fontanel.
30% of women have asymptomatic G.B.S. colonization.
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Differential Diagnosis:1. R.D.S.
2. Metabolic disorders.
3. Perinatal asphyxia.
4. Intracranial hemorrhage.
5. Hypoplastic left heart syndrome.
6.Inbornerrorsofmetabolism.So a high index of suspicion is the corner stone for diagnosis of sepsis because clinical symptoms are non-specific.
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LAB STUDIES:
1.Complete Blood Picture:
a) Low platelet count(
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5. Increased procalcitonin level ( produced
by hepatocytes & monocytes). 6.
P.C.R. 7.
Imaging studies ( CXR, ultrasound, CT,
MRI). 8.
Cord Interleukin 6&8 measurements
are predictive of sepsis.
9.Elevated IgM level (in congenital
infections).
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Indications of Lumbar Puncture :
1- Infants with +ve blood culture.
2- Clinical & Lab.data suggestive of
bacteremia.
3- No response or deterioration while on
antimicrobial tratment.
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TREATMENT:
-Early treatment is very
important.
No delay is made
waiting for Lab. results.
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BUT REMEMBER THAT:
prolonged empirical Rx (≥5 days) with broad-
spectrum antibiotics for preterm neonates is
associated with higher risks of late onset
sepsis, N.E.C., & death, so
antimicrobial therapy should be discontinued at
48 hr. if clinical probability of sepsis is low &
CRP remains normal.
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TREATMENT :1- Antibiotics should be given by
I.V. route.
Duration of Rx:
.clinical sepsis (based on clinical
suspicion) : 7-10 days.
.meningitis: 14-21 days.
.Osteomyelitis: 4-6 weeks.
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CHOICE OF ANTIBIOTICS:
A combination of ampicillin & an
aminoglycoside (e.g. gentamicin) or
3rd. generation cephalosporin
(e.g.cephotaxime) is generally used as
initial therapy.
-Ceftriaxone is contraindicated in neonates
because it is highly protein bound and may
displace bilirubin, leading to a risk of
kernicterus. -Metronidazole for
anaerobic infections (for 7-10days).
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2- Granulocyte transfusion. 3- Granulocyte macrophage colony stimulating factor (GM-CSF) and Granulocyte colony stimulating factor (G-CSF):are glycoproteins that stimulate proliferation & differentiation of neutrophil precursors & activate mature neutrophils.
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4- Supportive care (incubator, O2, i.v.fluid
& electrolytes, dopamine,TPN, IPPV,
vit.K).
5- Pentoxiphylline: a xanthine derivative
which inhibits TNF production &
reduces tissue
injury. 6-
I.V.Immunoglobulin: which promote host
defences by multiple mechanisms.
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Prevention of Neonatal Sepsis:
1- Breast feeding.
2- Hand washing by care givers.
3- Tetanus immunization of mothers.
4- Umbilical stump should be kept
clean.
5- Keep interventions as low as
possible.
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•6- Intrapartum Rx of infected mothers with i.v. antibiotics (4hr.before delivery) for prevention of GBS infections.
7- Avoid overcrowding in NICU.
8- Good ventilation. 10- No prophylactic antibiotics for
nosocomial infections.
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Complications:1.Septic emboli.
2.Abscesses.
3.Septic arthritis.
4.Osteomyelitis.
5.Septic shock.
6.DIC.
7.Meningitis( in 1/3 rd of cases).
8.Mortality is about 50% .