Objectives

1
Neonatal sepsis

• Objectives
• Definition
• Classification
• Risk factors
• Causative organism
• Clinical presentation of early and late onset
  sepsis
• Differential diagnosis
• Management (including investigations and
  treatment)

• causative organisms
• Nosocomial infection
• Varies by nursery
• Staphylococcus epidermidis
• Pseudomonas, Klebsiella, Serratia Proteus
• Fungi (candida .)

• Clinical presentation
• nonspecific
• Temperature instability
• Hypo/hyperthermia
• Change in behavior
• Lethargy, irritability, changes in tone
• Skin changes
• Poor perfusion, mottling, cyanosis, pallor,
• petechiae, rashes, jaundice

• Neonatal Sepsis
• What is it?
• Clinical syndrome of systemic illness
• accompanied by bacteremia occurring in the
• first month of life

• Incidence
• 1-8/1000 live births
• Mortality
• 15-30/1000 live births for infants lt 1500g

• Feeding problems
• - Intolerance, vomiting, diarrhea, abdominal
• distension
• Cardiorespirarory
• - Tachypnea, grunting, flaring, retractions,
• apnea, tachycardia, hypotension
• Metabolic
• - Hypo or hyperglycemia, metabolic acidosis

• Neonatal sepsis
• 1- Prenatally acquired
• 2- Early sepsis (1-7 days of age)
• 3- Late sepsis (1-3 weeks of age)

• Risk factors
• Early onset sepsis
• Prematurity and low birth weight
• PROM
• Group B streptcoccal carrier mother
• Maternal peripartum fever
• Chorioamnionitis
• Resuscitation at birth
• Multiple gestation
• Invasive procedures

• Early Onset
• First 5-7 days of life
• Usually multisystem
• fulminant illness
• prominent respiratory symptoms

• High mortality rate
• 5-20
• Typically acquired during intrapartum
• period from maternal genital tract
• Associated with maternal chorioamnionitis

• Late onset sepsis
• Prematurity
• Invasive procedures (central lines, ETT )
• Poor infection control measures in the NICU
• overcrowding
• TPN

• Late Onset
• May occur as early as 5 days but is most
• common after the first week of life
• Less association with obstetric
• complications

• Usually have an identifiable focus
• Most often sepsis or meningitis
• Acquired from
• - maternal genital tract or
• - human contact

• Causative organisms
• Early Onset
• Group B streptococcus
• Gram-negative enterics (esp. E. coli)
• Listeria monocytogenes, Staphylococcus,
• other streptococci (entercocci), anaerobes

2

• Differential diagnosis of neonatal sepsis
• It depends on the clinical presentation
• RDS
• Metabolic disease
• Hematologic disease
• CNS disease
• Cardiac disease
• Other infectious processes (i.e. TORCH)

• Radiology
• CXR
• Obtain in infants with respiratory
• symptoms
• Difficult to distinguish GBS or Listeria
• pneumonia from uncomplicated RDS

• Management
• Antibiotics
• Early onset sepsis
• ampicillin and gentamicin
• Nosocomial sepsis
• differs from NICU to other
• cloxacillin and gentamicin or cefotaxime
• Change based on culture sensitivities
• Dont forget to check drugs levels

• Nosocomial sepsis
• Occurs in high-risk newborns
• Pathogenesis is related to
• the underlying illness of the infant
• the flora in the NICU environment
• invasive monitoring
• Breaks in the barrier function of the skin
• and intestine allow for opportunistic
• infection

• Supportive therapy
• Respiratory
• Oxygen and ventilation as necessary
• Cardiovascular
• Support blood pressure with volume
• expanders and/or pressors
• Hematologic
• Treat DIC with FFP
• Platelets transfusion
• PRBC transfusion

• Diagnosis
• Cultures
• Blood
• Confirms sepsis
• 94 grow by 48 hours of age

• Urine
• Dont need in infants lt24 hours old
• because
• UTIs are exceedingly rare in this age
• group
• CSF

• CNS
• - Treat seizures with phenobarbital
• - Watch for signs of SIADH (decreased
• UOP, hyponatremia) and treat with fluid
• restriction
• Metabolic
• - Treat hypoglycemia/hyperglycemia and
• metabolic acidosis

• Adjunctive lab tests
• White blood cell count and differential
• Neutropenia can be an ominous sign
• IT ratio gt 0.2 is of good predictive value
• Serial values can establish a trend
• Platelet count
• thrombocytopenia

• Acute phase reactants
• CRP rises early, monitor serial values
• ESR rises late
• Other tests
• - bilirubin, glucose, sodium