‫بسم هللا الرحمن الرحیم‬

‫‪Neonatal sepsis‬‬
‫ت ر ت ی ب ک ن ن د ه ‪ :‬د ا ک ت ر ح ف ی ظ هللا " ف ر ز ی ن “ ت ر ی ن ی س ا ل س و م‬
‫ت ح ت ن ظ ـــــر ‪ :‬ر ن ح و ر ی ا ر د و ک ت و ر ا ح م د ح ا م د “ پ ی م ا ن "‬
 CONTENTS
1. Definition
2. Etiology
3. Pathophysiology
4. Clinical features
5. Diagnosis
6. D/Diagnosis
7. Complications
8. Management
9. Prognosis
Definition
1. Neonatal sepsis is a clinical syndrome characterized by signs and
symptoms of infection with or without accompanying bacteremia in the
first month of life.
2. pathogenic organism gain access into the blood stream.
3. septicemia, meningitis, pneumonia, arthritis, osteomyelitis, and urinary tract
infections.
Cont.…
1. Sepsis is the commonest cause of neonatal mortality; it is responsible for
about 30-50% of the total neonatal deaths in developing countries.
2. It is estimated that up to 20% of neonates develop sepsis and approximately
1% die of sepsis related causes.
3. Sepsis related mortality is largely preventable with prevention of sepsis
itself, timely recognition, rational antimicrobial therapy and aggressive
supportive care.
Etiology
• E coli
•Staphylococcus aurous
•Klebsiella
•Acenobacter
•Pseudomonas
•Coagulase negative staphylococci
Etiology cont.…
 “Early” Pathogens (first week)
1. Group B Strep (GBS)
2. E. coli
3. Gram negative rods (esp. in urine)
 Occasional Salmonella sepsis
4. Listeria monocytogenes
5. Herpes Simplex
6. Enterovirus
Etiology cont.…
 “Late” Pathogens (~1-2 weeks)
1. GBS or group A strep
2. Enteric/Enterococcus in urine
3. HSV
4. Enterovirus
5. RSV
Why the Worry?
Neonatal immune system immature
Perinatal exposure to pathogens via birth canal
High rate of infection in kids less than 3 months with fevers
◦ >4% age 0-28 days with bacteremia or meningitis (drops to 1% by 3 months)
◦ Almost 10% with UTI
◦ Rates increase with degree of fever
◦ 39C with >10% rate of bacteremia

Well appearing infant may have an infection

Pathophysiology
 Based on age of presentation
1. Early onset NN sepsis
2. Late onset NN sepsis
Early onset NN sepsis
 Characterized by sudden onset and fulminant course that can progress rapidly to septic
shock and death.
 <72hr of life
 Vertical transmission ( antepartum and intrapartum)
 Trans placental
 PROM > 18hrs
 Vaginal flora or pathogen
Early onset NN sepsis cont...
 Multisystem fulminant illness ( prominent respiratory system )
Organism colonization
 Skin, Conjunctiva
 Oropharynx and Nasopharynx
Umbilical cord
 Trauma of mucosal surface lead to infection
 Mortality rate 15-50%
Risk factors

1. Low birth weight (<2500 grams) or prematurity

2. Febrile illness in the mother with evidence of bacterial infection within 2 weeks prior to
delivery
3. Foul smelling and/or meconium stained liquor
4. Rupture of membranes >24 hours
5. Single unclean or > 3 sterile vaginal examination(s) during labor
6. Prolonged labor (sum of 1st and 2nd stage of labor > 24 hrs)
7. Perinatal asphyxia (Apgar score <4 at 1 minute)
Late onset NN sepsis
 Usually insidious but it can be fulminant
 >72hr of life
 Horizontal transmission
 Nosocomial
 community acquired infection
 Usually generalized as pneumonia and meningitis
 10-20% mortality rate
Predisposing factors
1. LBW
2. Lack of breast feeding
3. Poor cord care
4. Superficial infection
5. Aspiration of feeds
Signs/Symptoms
TONE AND BEHAVIOR SKIN

◦ Poor tone ◦ Poor perfusion

◦ Weak suck ◦ Cyanosis
◦ Shrill cry (meningitis) ◦ Mottling
◦ Weak cry ◦ Pallor
◦ Irritability ◦ Petechiae (over helming sepsis)
◦ Lethargic state (meningitis) ◦ Unexplained jaundice
◦ Seizure (meningitis)
Signs/Symptoms
CARDIOPULMONARY TEMPERATURE IRREGULARITY
◦ Tachypnea ◦ Hyperthermia
◦ Tachycardia for age ◦ Hypothermia
◦ Bradycardia in first few days of life
◦ Bradypnea
◦ Retractions
◦ Hypotension for age
◦ Low PO2
◦ Apnea
◦ flaring
Signs/Symptoms
Feeding Problems
◦ Vomiting
◦ Diarrhea
◦ Abdominal distension
◦ Hypo or
Hyperglycemia
EMERGENCY TRIAGE
Emergency Signs All infants must be initially assessed for signs needing emergency care. These
signs include:
1. Gasping breathing or apnea
2. Severe respiratory distress
3. Central cyanosis
4. Shock (poor perfusion indicated by cool peripheries with capillary refill longer than 3
seconds and weak, fast pulse)
5. Coma (these infants are unconscious and do not respond to stimuli)
6. Convulsions
Diagnosis
1. CBC ( neutropenia “ominous” )
2. Blood culture ( prior to start antibiotics )
3. Urine culture
4. Sepsis screen ( 2 of these parameter )
 TLC < 5000/mm3
 ANC < 1800/mm3
 I/T more than 20%
 CRP > 1mg/dl
 Micro ESR >15ml / first hour
Diagnosis cont.…
5. Lumbar puncture ( meningitis )
Normal CSF examination in neonates {(mean(range)}
 Protein > 150mg/dl
 Glucose < 30mg/dl Preterm Term Test
 Leukocyte > 20/micl     Cells
)0-29(9 )0-32(7 WBCs
7. Chest radiography 57% 61% Polymorphonuclear cell

)65-150(115 )20-170(90 Protein (mg/dl)

)24-63(50 )34-119(52 Glucose (mg/dl)

Deferential diagnosis
RESPIRATORY CNS SYMPTOMS FEEDING INTOLERANCE
1. TTN <= 72hr 1. ICH ( CT, anisocoria ) 1. NEC

2. MAS (stained,CXR) 2. Drug withdrawal ( history ) 2. GI perforation

3. Aspiration pneumonia 3. Inborn error of metabolism 3. GI obstruction

4. RDS ( CXR )
5. HSV ( swab )
Complication
BACTERIAL SEPSIS MENINGITIS

1. Endocarditis 1. immediate
1. Ventriculitis
2. Abscess formation
2. Cerebritis
3. Septic joint 3. Brain abscess

4. Residual disability 2. Late

1. Hearing lose
5. Osteomyelitis
2. Development delay
6. Bone destruction 3. Cerebral palsy
4. Seizure disorder
5. hydrocephalus
Management
 Maintain normal temperature
 Oxygen ( Humidified and warmed )
1. When a baby need supplemental oxygen
 Central cyanosis
 Need for resuscitation
 Respiratory distress
Management
 Signs of shock 1. Push N.saline or Ringer lactate
 10ml/kg/5-10min
1. CRT > 3sec
 We can repeat upto 3 times next 30-45min
2. Weak pulse
2. If there is no response
3. Tachycardia > 160b/min  Dopamine
4. Cold extremities  Dobutamine
 Adrenaline
5. Very pale color
6. Lethargic
Management
 Maintenance fluid
 2ml /kg dextrose 10%
Add potassium if diuresis is present
 Feeding
Management

EOS
Management of neonatal seizure
 TABC
 Correction of hypoglycemia and hypocalcemia
 2ml/kg dextrose 10% bollus
 2ml/kg calcium gluconate 10% single dose
 8ml/kg/day calcium gluconate for 3 days ( if serum calcium level shows hypocalcemia )
 0.25ml/kg/IM magnesium 50% ( if hypocalcemia is not corrected )
 Management of neonatal seizure
 Antiepileptic drug
1. First line ( phenobarbital and phenytoin )
1. Phenobarbital 20g/kg/inf 20 min upto 40mg/kg ( maximum )

2. Second line ( midazolam or lorazepam )

1. Lorazepam 0.05mg/kg/B/2-3min
2. Midazolam 0.15mg/kg/B then 0.1-0.4mg/kg/hr

3. Lidocaine 4mg/kg/B/iv then 2mg/kg/hr then tapered

4. Paraldehyde
5. Sodium valproate
6. Vigabatrin
7. Topiramate
 THE END

Thank you
References
1. Nelson 21th
2. GHAI 9th
3. Principles of pediatrics and neonatal emergencies
4. AIIM protocol
5. Parwiz Akbar khan
6. internet