NEONATAL SEPSIS

JKUAT, Department of Paediatrics

 OBJECTIVES
 Definition and Introduction
 Epidemiology
 Risk Factors for Neonatal sepsis
 Etiology
 Clinical features
 Differential diagnosis
 Investigation
 Treatment
 Follow up/ Prognosis
 INTRODUCTION
 Neonatal sepsis is a clinical syndrome of
systemic illness accompanied by bacteremia in
the first month of life
 It includes septicemia, pneumonia, meningitis,
Urinary tract infection, osteomyelitis, etc
 Superficial infections like conjunctivitis and oral
thrush are not usually included under neonatal
sepsis
 INTRODUCTION

CAUSES OF Sepsis

NEONATAL DEATHS 29%

Prematurity
38%
Others
13%
Asphyxia
20%
EARLY ONSET NEONATAL SEPSIS (EONS)
 Infection within 72 hrs of birth
 (Some books put it as infection occurring in the first 7 days of life)
 85% of EoNS present within 24 hrs, 5% present at
24-48 hours and 10% between 48-72 hours
 Onset is most rapid in premature neonates
 Usually multisystem fulminant illness with
prominent respiratory symptoms (probably due
to aspiration of infected amniotic fluid)
 EARLY ONSET NEONATAL SEPSIS
 High mortality rate
– 5-20%
 Typically acquired during intrapartum period
from maternal genital tract
– Associated with maternal chorioamnionitis
– Transplacental infection or an ascending infection
from the cervix
 LATE ONSET NS (LONS)
 Infection after 72 hours from birth. (4-90 days of
life)
 (Some definitions put it as infection after the first week of life)

 Less association with obstetric complications

 Usually have an identifiable focus
– Most often meningitis or sepsis
 Acquired from maternal genital tract or human
contact.
 Acquired from the caregiving environment
 COMPARING EONS vs LONS
EONS LONS

ONSET <72 hrs >72 hrs

SOURCE Maternal Environmental,

genital tract community
acquired,
nosocomial
RISK FACTOR Prematurity Prematurity
Amnionitis,
Maternal infection
PRESENTATION Fulminant Slowly progressive
Multisystem focal
Pneumonia frequent Meningitis frequent
MORTALITY 5-50% 10-15%
 EPIDEMIOLOGY
 General incidence is 1-8 per 1000 live births
 <1000g : 26 per 1000 live births
 1000-2000g: 8-9 per 1000 live births
 Higher incidence of neonatal sepsis in VLBWs
 EPIDEMIOLOGY
 Mortality rate is high (13-25%)
– Higher rates in premature infants and those with
early fulminant disease
– EONS mortality rate close to 20%, LONS mortality
rate close to 5%
• Residual neurologic damage occurs in 15-30%
of neonates with septic meningitis
 RISK FACTORS (Maternal)
 Chorioamnionitis ▪ Poor prenatal care
 Maternal fever>38C ▪ Poor maternal nutrition
 Foul smelling liquor ▪Maternal substance abuse
 Fetal tachycardia
 Prolonged/preterm rupture of membranes (> 18
hrs)
 Multiple examinations, prolonged labour
 Maternal UTI
 Maternal GBS colonization
 RISK FACTORS (Neonatal)
 Low birth weight ▪ Congenital anomalies
 Prematurity ▪ Low apgar scores
 Birth asphyxia
 Twins (multiple gestation)
 Male sex
 Disruption of skin barrier
 Lack of breast feeds
 Meconium staining at delivery
 Resuscitation at birth
 Other illness
 Other RISK FACTORS
 Prolonged intensive care
 Long lines and cannulas
 Urinary catheters
 Ventilation support
 Prolonged antibiotic use
 Total parenteral nutrition
 Steroids
 Low Socioeconomic status
 Late onset sepsis Risk factors
• Late onset neonatal sepsis is associated with the
following risk factors
– Prematurity
– Central venous catheterization (duration >10 days)
– Nasal cannulae or continous positive airway pressure (CPAP)
use
– H2 receptor blocker or proton pump inhibitor use
– GI tract pathology
 ETIOLOGY (BACTERIAL)
 Early Onset Neonatal Sepsis (EONS):
– Group B Streptococcus (GBS): Streptococcus
agalactiae
– Escherichia Coli
– Coagulase negative staphylococcus epidermidis
– Other gram negative bacilli esp in urine: Klebsiella
pneumoniae, Pseudomonas, (occasional Salmonella
sepsis)
– Listeria monocytogenes
– Streptococcus species eg. Viridans
 Due to maternal or perinatal factors
 ETIOLOGY (BACTERIAL)
 Late Onset Neonatal Sepsis (LOS):
– Coagulase-negative staphylococcus: Staphylococcus
epidermidis
– Staphylococcus aureus
– Gram negative bacilli eg. Klebsiella etc
– Candida spp.
– Group A streptococcus
– Pneumococcus, meningococcus, H. influenzae
 Nosocomial or focal infection
 ETIOLOGY (VIRAL)
 Congenital
– Enteroviruses (eg. Coxsackievirus A & B)
– Herpes Simplex Virus (HSV)
– TORCH infections
 Acquired
– HIV
– Varicella
– Respiratory syncytial virus
– Adenovirus

Can be either early or late onset sepsis

 ETIOLOGY (OTHERS)
 Candida
 Anaerobic bacteria
 CLINICAL FEATURES
 Temperature  Skin
irregularity – Poor perfusion
– Fever – Cyanosis
– Hypothermia – Mottling
 Tone and Behavior – Pallor
– Poor tone – Petechiae
– Weak suck – Unexplained jaundice
– Shrill cry
– Weak cry
– Irritability
– Lethargy
 CLINICAL FEATURES
 Feeding Problems  Cardiopulmonary
– Poor feeding – Tachypnea
– Vomiting – Retractions
– Diarrhea – Tachycardia for age
– Abdominal – Bradycardia in first
distension few days of life
– Hypo or – Hypotension for
Hyperglycemia age
– Low PO2
– Apnoea
 CLINICAL FEATURES
 Sunken fontanelle
 Bulging or pulsating fontanelle
 Babies can be bacteremic but look well
 INVESTIGATIONS
 Cultures
– Blood
• Confirms sepsis
• 94% grow by 48 hours of age
– Urine
• Don’t need in infants <24 hours old because UTIs are exceedingly
rare in this age group
– CSF
• Controversial
• May be useful in clinically ill newborns or those with positive
blood cultures
 INVESTIGATIONS
 Full Hemogram (wbc and differential)
– Low or high WBC
– Neutropenia can be an ominous sign
– I:T (Immature to Total Neutrophil) ratio > 0.2 is of good
predictive value
– Serial values can establish a trend
 Acute phase reactants
– C reactive protein (rises early, monitor serial values)
– ESR rises late
– Procalcitonin
 Urinalysis
 Other tests: bilirubin, RBS, UECs
 INVESTIGATIONS
 CXR
– Obtain in infants with respiratory symptoms
– Difficult to distinguish GBS or Listeria pneumonia
from uncomplicated Respiratory distress
syndrome
 Renal ultrasound and/or Voiding cystourethrogram
(VCUG) in infants with accompanying urinary tract
infection
 TREATMENT
 Mainstays of therapy:
 Early recognition
 ABC’s - supportive care
 Appropriate and adequate antimicrobials
 TREATMENT
 Supportive care
 Keep the neonate warm
 If sick, avoid enteral feed
 Start IV fluids,
o infuse 10% dextrose to maintain normoglycemia
 Maintain fluid and electrolyte balance and tissue
perfusion
 If Capillary refill time >3 sec, infuse 10 ml/kg normal
saline bolus.
 TREATMENT
 Supportive care ctd
 Cyanosed / RR >60/min / severe chest retractions
– Start oxygen
 Sclerema
– Consider exchange blood transfusion/IVIG.
*IVIG=Intavenous immune globulin

 Treat seizures with phenobarbital

 TREATMENT
 Definitive Therapy
 Age 0 to ~4-6 weeks
– Ampicillin or crystalline penicillin + Aminoglycoside
– Ampicillin or crystalline penicillin + Cefotaxime
 Ampicillin kills GBS and Listeria monocytogenes
 Gentamicin and Cefotaxime for Gram negative
bacilli
• Ceftriaxone not recommended (but not
contraindicated) - causes neonatal hepatitis and biliary
sludging
 TREATMENT
 After 4-6 weeks, ampicillin and a 3rd generation
cephalosporin
– Offers better coverage for community acquired organisms
– At 4-8 weeks, switch to cephalosporin alone.
 Cephalosporins rapidly induce the production of
extended spectrum b-lactamases, cephalosporinases
and fungal colonization, and hence, are best avoided
as empirical antibiotics.
 TREATMENT
 If the expected clinical improvement with the
ongoing line of antibiotics does not occur, a
change can be considered. Allow a minimum of
48-72 h of observation before declaring the
particular line as having failed.
 In case the neonate is extremely sick or
deteriorating , a decision may be taken to
bypass the first line of antibiotics and start with
the second-line of antibiotics
 TREATMENT
 Preventive therapy
 Screening for GBS at 35-37 weeks
 Intrapartum antibiotics given to:
– GBS bacteruria during pregnancy
– Prior infant with early onset sepsis with GBS
– GBS unknown with risk factors: (Temp > 38°C, Gestational age < 37
weeks, Rupture of membranes >18 hours)
 Ensure clean, aseptic deliveries
 Keep cord dry
 Prompt evaluation and treatment of any sick looking
neonate
 TREATMENT
Preventive therapy ctd
 Exclusive breastfeeding
 Hand washing by care givers
 Hygiene of baby
 No unnecessary interventions and avoid
unnecessary handling of the baby
 Control of hospital infections by: Isolation of
infectious pts, use disposable items, avoid
overcrowding, aseptic work culture, infection
surveillance
 PROGNOSIS
 Low birth weight and gram negative infection
are associated with adverse outcomes
 The fatality rate is 2 to 4 times higher in LBW
infants than in full-term infants.
 Septic meningitis in preterm infants may lead
to neurological disabilities
– May acquire hydrocephalus or periventricular
leukomalacia
 PROGNOSIS
 The overall mortality rate of EoNS is 3 to 40% (that
of early-onset GBS infection is 2 to 10%)
 That of LoNS is 2 to 20% (that of late-onset GBS is
about 2%).
 Mortality in LoNS highly depends on the etiology
of the infection; infections caused by gram-ve
bacilli or Candida spp have rates of up to 32 -36%.
 Extremely LBW infants who develop bacterial or
candidal sepsis have a significantly greater risk of
poor neurodevelopmental outcome.
QUESTIONS