Close this window to return to IVIS

www.ivis.org

Proceedings of the 16th

Italian Association of Equine Veterinarians
Congress

Carrara, Italy
January 29-31, 2010

Next SIVE Meeting:

Feb. 4-6, 2011 – Montesilvano, Pescara, Italy

Reprinted in the IVIS website with the permission of the

Italian Association of Equine Veterinarians – SIVE

http://www.ivis.org
Published in IVIS with the permission of SIVE
Interactive foal cases: septicaemia
Kevin Corley
BVM&S PhD DACVIM DECEIM DACVECC MRCVS
Anglesey Lodge Equine Hospital
Co. Kildare, Ireland
SEPTICAEMIA
Causes
Septicaemia is by definition a bacterial infec-
tion. It is not known how the bacteria gain en-
try to the foal in most cases. In utero infection
and entry via the gastrointestinal tract are
thought to be the major routes of infection.
The most common bacteria isolated from
foals with septicaemia are Escherichia coli
and Actinobacillus species. However, the pro-
portion of Gram-positive organisms appears
to be increasing and Streptococcus and Ente-
rococcus isolates are also frequently isolated.
Some USA and Australian hospitals and farms
have recently experienced high isolation rates
of multi-drug resistant bacteria, including Me-
thicillin Resistant Staphylococcus aureus
(MRSA) and highly resistant Enterobacter
and Enterococcus species.
Typical history
Often these foals are vigorous at birth. They
are reported as standing and nursing normally.
They then are noted to become progressively
weaker, duller, depressed and ultimately un-
able to rise. About 25% of foals that are ad-
mitted to referral centres with septicaemia are
still standing. These foals have a better prog-
nosis. The proportion of foals that are still
standing when admitted to hospital increases
with improved skill of the farm staff and re-
ferring veterinary surgeons.
Foals may be also born septic (in these cases
the placenta often shows signs of infection), in
which case they may never get up.
Clinical signs
Typical physical examination: Most foals ini-
54
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
Close window to return to IVIS
tially appear to become progressively less in-
terested in nursing. They may then become
dull and depressed. As the disease progresses,
they will become recumbent and ultimately
will die. The speed of progression of these
signs depends on the age of the foal, and the
virulence of the infecting bacteria. Some foals
will show injected mucous membranes (a very
inconsistent sign – mucous membranes can be
normal, congested or injected). Petechiation is
often quoted as a sign of sepsis. It was present
in 35% of blood culture positive foals and
22% of blood culture negative foals in our
practice. Foals may demonstrate fever, hy-
pothermia or a normal rectal temperature. The
rectal temperature often undulates markedly
during the day, and may only spike above the
normal range once or twice a day.
Hypotension (mean arterial blood pressure
less than 60 mmHg) is common in referred
septic foals. Capillary leak, hypopyon, hy-
phaema, erythema around the coronary bands,
seizures and coma can occur in severely af-
fected foals.
The sepsis score has been published as a
means of identifying septic foals. However,
the low negative predictive value (55%) limits
the clinical usefulness of the test. The most
frequent false positive results for the sepsis
score are foals with perinatal asphyxia syn-
drome. The cytokine activation with septi-
caemia and asphyxia is similar, resulting in
similar clinical signs between the two disease
processes. Often the final diagnosis of septi-
caemia or perinatal asphyxia syndrome is
made based on ancillary diagnostics (such as
blood culture results) that are not immediately
available and on clinical course, and the initial
management of the two diseases is similar.
Published in IVIS with the permission of SIVE
The internal umbilical remnants are a com-
mon site for infection. Umbilical ultrasonog-
raphy can demonstrate increases in the size or
changes in the echo-density of the umbilical
structures, suggestive of infection. The umbil-
ical arteries pass caudally from the external
umbilical stump, travel with the remnant of
the urachus to the bladder, and then split to
other side of the bladder to run caudally. After
they have regressed, they become the round
ligaments of the bladder. The normal size of
the internal umbilical arteries is up to 1 cm in
diameter in the first week of life. The umbili-
cal vein runs cranially and midline from the
external umbilical stump, initially directly
over the linea alba. As it courses cranially, it
moves dorsally away from the body wall and
into the liver. The umbilical vein is enveloped
by the falciform ligament. The vein has an
ovoid appearance on ultrasound. The maxi-
mum diameter in the normal foal in the first
week of life is 0.4 cm.
Synovial structures are also common sites of
infection. In my practice, all foals with sus-
pected sepsis are checked for heat or effusion
in all joints multiple times a day. This allows
us to detect joint infection early, whilst the
prognosis is still good. Ultrasonography can
be helpful to demonstrate changes in the syn-
ovial echogenicity, synovial effusion and os-
teomyelitic lesions. Radiography can be ex-
tremely useful to detect osteomyelitic lesions,
but interpretation can be difficult due to open
growth plates and ongoing endochondrial os-
sification in the neonate.
The lungs are also a common site of infection.
They are best imaged with ultrasonography or
radiography. Ultrasonography is readily avail-
able (a scanner used normally for equine re-
productive work will provide a good diagnos-
tic image). However, only the surface of the
lung is imaged with ultrasonography and this
may not be representative of the pathology
deeper in the lungs.
Generally in foals, a few ventral narrow
“comet-tail” artefacts are not considered sig-
nificant. Surface changes resulting in broad
“comet-tails” or hyperechoic “curtains” can
indicate significant underlying pathology.
Surface consolidation and pleural effusions
55
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
Close window to return to IVIS
can occur in foals, but are rare. In older foals,
surface abscesses may be imaged with ultra-
sound in cases of Rhodococcus equi infection.
Radiography usually demonstrates a diffuse
increase in radiodensity (mixed pattern) in
foals with septic pneumonia.
Laboratory signs
The laboratory signs of septicaemia are some-
what non-specific. Both low and high periph-
eral white cell counts are seen in foals with
sepsis. Immature (‘band’) neutrophils are of-
ten seen, and appear to have some association
with severity of illness. Neutrophils with ‘ring
nuclei’ are typically seen in the more severe
cases. Plasma fibrinogen concentrations may
be increased or decreased in sepsis. If they are
increased in the first 24 hours of life, this sug-
gests in utero infection.
Decreased plasma fibrinogen concentrations
are associated with the onset of disseminated
intravascular coagulation, which can be a se-
quel of severe sepsis. Serum amyloid A is an
acute phase protein that increases and de-
creases much faster than fibrinogen. Several
studies have shown that increased concentra-
tions are a reasonably reliable indicator of
sepsis in the foal.
Treatment
Antibiotics are the mainstay of treatment for
septicaemia. However, they are not sufficient,
and many other treatments are required in
more severely affected foals to ensure success.
Antibiotics are the second priority, after en-
suring an adequate circulation. Fluid resusci-
tation is discussed in the lecture on emergency
treatment.
The choice of antibiotic to use depends on a
number of different factors, including avail-
ability, clinical signs and expense.
Generally, broad-spectrum antibiotics are
used. Foals with low blood white cell counts
are more likely to have Gram-negative infec-
tions, and it is important to ensure that they re-
ceive antibiotics with good Gram-negative ac-
tivity. One thing to remember is that the doses
of drugs are not necessarily the same in foals
as adult horses, particularly for water-soluble
drugs.
Published in IVIS with the permission of SIVE
Typical drugs or drug combinations used are:
Penicillin (20,000 iu/kg i.v. q6h) and gentam-
icin (11 mg/kg i.v. q24h)
Cefquinome (2.5 mg/kg IV q6-8h)
Ceftiofur (5-10 mg/kg i.v. q6-12h)
Timentin (Ticarcillin and Clavulanic acid) (50
mg/kg i.v. q6h)
Doxycycline 10 mg/kg p.o. q12h (this drug is
toxic i.v.)
Other antimicrobials are used for specific pur-
poses, often guided by results of culture
and sensitivity testing. These include:
Metronidazole (15 mg/kg i.v. loading dose,
followed by 7.5 mg/kg i.v. q6h) – for
Clostridial infections suspected on the ba-
sis of haemorrhagic diarrhoea.
Ceftriaxone (25 mg/kg i.v. q12h) for suspect-
ed meningitis
Imipenem (10 mg/kg i.m. q8-12h) for highly
resistant bacteria
Fluconazole (14 mg/kg p.o. loading dose then
5 mg/kg p.o. q24h) for fungal infections
Cefpodoxime protexil (10 mg/kg p.o. q6-12h)
as an alternative oral antibiotic for foals
Some drugs that are commonly used in adult
horses are not suitable for foals. One ex-
ample is enrofloxacin, which can cause
cartilage damage in young animals.
If joint sepsis is suspected, it is vital to treat
this aggressively and early, so that the future
athletic potential of the foal is not compro-
mised. Treatments include needle flushes,
arthroscopic lavage, local instillation of an-
timicrobials (e.g. Gentamicin 0.5-1.0 ml of
10% solution) and regional perfusion of an-
56
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
Close window to return to IVIS
timicrobials. The prognosis for athletic func-
tion decreases when more than one joint is in-
volved, and with each additional joint.
In the hospital, in addition to antimicrobial
treatment, we also institute treatments aimed
at maintaining homeostasis whilst giving time
for the antimicrobials to work. These include
fluid therapy (crystalloids and colloids), nutri-
tional therapy (total parenteral nutrition
and/or nasogastric nutritional supplementa-
tion, insulin), blood pressure support (dobuta-
mine, norepinephrine, vasopressin), nursing
care (maintaining in sternal recumbency, pre-
venting decubitus ulcer formation) and occa-
sionally mechanical ventilation. When provid-
ing this advanced support, it is necessary to
closely monitor the patient and adjust the ther-
apies accordingly. We routinely measure elec-
trolytes, haematology and blood biochemistry
in our patients. In recumbent patients, we
monitor blood pressure and arterial blood gas-
es. We have the ability to monitor end-tidal
gases and cardiac output (lithium dilution) in
the most severely affected patients.
Prognosis
The prognosis for septic animals undergoing
intensive care at referral institutes is reason-
ably good – my current survival rate is 71%
(66/93 foals). The survival rate of septic foals
managed in the field is probably much lower
than this. In a report from the University of
Leipzig, they had a survival rate for foals that
were considered to have early sepsis (still
standing, suckle response) of 30%, and an
overall survival rate of septic foals of 13%.