Authors: Professor Baha Diaa Moohee Alosy,
Departments of Pediatrics- Collage of Medicine.
University of Tikrit -IRAQ.
Neonatal Infection & / or sepsis
Objectives
❖
identify the approach of
Neonatal Infection
❖
Identify clinical
manifestation of
Neonatal
Infection
❖
Know the treatment for
Neonatal Infection
Background
Neonatal sepsis may be categorized as early onset (day of life 0-3) or late onset (day
of life 4 or later). Of neorns with early-onset sepsis, 85% present within 24 hours
(median age of onset 6 hours), 5% present at 24-48 hours, and a smaller percentage
present within 48-72 hours. Onset is most rapid in premature neonates
.
Early-onset sepsis is associated with acquisition of microorganisms from the mother
is more common in early-onset sepsis, whereas
meningitis and
are more common in late-onset
sepsis. Early-onset sepsis is 10 to 20 times more likely to occur
in premature, very low birthweight infants.
Etiology
The microorganisms most commonly associated with early-
onset infection include the following
[1]
:
Group B Streptococcus (GBS)
Coagulase-negative Staphylococcus
Late-onset sepsis occurs at 4-90 days of life and is
acquired from the environment. Organisms that have
been implicated in late-onset sepsis include the
following:
•
Coagulase-negative Staphylococcus
•
E coli
•
Klebsiella
•
Enterobacter
•
Candida
•
GBS
•
Serratia
•
Acinetobacter
•
Anaerobes
Early-onset neonatal sepsis
Risk factors implicated in neonatal sepsis reflect the
level stress and illness experienced by the fetus at
delivery, as well as the hazardous uterine
environment surrounding the fetus before delivery.
The most common risk factors associated with early-
onset neonatal sepsis include, but are not limited to,
the following:
Maternal GBS colonization (particularly in the setting
of inadequate prophylactic treatment)
Premature rupture of membranes (PROM)
Preterm rupture of membranes
Prolonged rupture of membranes
Premature birth
Maternal urinary tract infection (UTI)
Maternal fever greater than 38ºC (100.4ºF)
Other factors that are associated with or predispose to
early-onset sepsis include the following :
Low Apgar score (< 6 at 1 or 5 minutes)
Poor prenatal care
Poor maternal nutrition
Low socioeconomic status
Black mother
History of recurrent abortion
Maternal substance abuse
Low birth weight
Difficult delivery
Birth asphyxia
Meconium staining
Congenital anomalies
•
Late-onset sepsis is associated with the
following risk factors
[20]
:
•
Prematurity
•
Central venous catheterization (duration >10
days)
•
Urinary catheterization
•
Chronic mechanical ventilation
•
Failure to advance enteral feeding
•
nasal cannula or continuous positive airway
pressure (CPAP)
•
Use of H
2
-receptor blocker or proton pump
inhibitor (PPI)
•
Gastointestinal tract pathology
•
Meningitis
•
The principal pathogens in neonatal meningitis
are GBS (36% of cases), E coli (31%),
and Listeria species (5%-10%). Other organisms
that may cause meningitis include the following:
•
S pneumoniae
•
S aureus
•
S epidermidis
•
H influenzae
•
Pseudomonas species
•
Klebsiella species
•
Serratia species
•
Enterobacter species
•
Proteus species
Epidemiology
•
The incidence of culture-proven early-onset
sepsis in the United States is approximately 0.3-2
per 1000 live births. Of the 7%-13% of neonates
who are evaluated for neonatal sepsis, only 3%-
8% of those screened will have culture-proven
sepsis.
Age-, race-, and sex-related demographics
•
Premature infants have an increased incidence of sepsis, with a
significantly higher occurrence in infants with a birth weight lower than
1500 g (11-22.7 per 1000 live births) than in infants born at 37 weeks or
later (0.3-0.98 per 1000 live births).
•
Black infants have an increased incidence of GBS disease and late-onset
sepsis. This is observed even after other risk factors such as low birth
weight and younger maternal age have been controlled
•
Prognosis
➢
With early diagnosis and treatment of neonatal sepsis, most term infants
will not experience associated long-term health problems. However, if
early signs or risk factors are missed, mortality increases. Residual
neurologic damage occurs in 15%-30% of neonates with septic meningitis.
➢
Mortality from neonatal sepsis may be as high as 50% for infants who are
not treated. Infection is a major cause of mortality during the first month
of life, contributing to 13%-15% of all neonatal deaths. Low birth weight
and gram-negative infection are associated with worse outcomes.
➢
Neonatal meningitis occurs in 2-4 cases per 10,000
live births and contributes significantly to mortality
from neonatal sepsis; it is responsible for 4% of all
neonatal deaths.
➢
In preterm infants who have had sepsis, impaired
neurodevelopment is a concern. Proinflammatory
molecules may negatively affect brain development
in this patient population. In a large study of 6093
premature infants who weighed less than 1000 g at
birth, preterm infants with sepsis who did not have
meningitis had higher rates of cerebral palsy (odds
ratio [OR] 1.4-1.7), developmental delay (OR 1.3-
1.6), and vision impairment (OR 1.3-2.2) as well as
other neurodevelopmental disabilities than infants
who did not have sepsis
Neonatal Sepsis Clinical Presentation
•
History
An awareness of the many risk factors associated
with neonatal sepsis prepares the clinician for
early identification and effective treatment,
thereby reducing morbidity and mortality.
Among these risk factors are the following:
•
Maternal group B Streptococcus (GBS) status
•
Prolonged and/or premature rupture of
membranes (PPROM)
•
Premature delivery
•
Chorioamnionitis
1.
Signs
1. Respiratory distress
(90%)
2. Apnea
4. Flaring or
grunting
5. Irregular
respirations
2. Temperature instability
sustained over 1 hour
(30%)
1. Newborn
Temperature < 97
F (36 C)
2. Newborn
Temperature >
99.6 F (37 C)
3. Gastrointestinal
symptoms
4. Neurologic
3. Tachycardia
1. Pallor or skin
or
3. Cold or clammy
1.
Labs
suggestive of
Count
1. Decreased
below 5000
/mm3
2. Increased
above
25000
/mm3
(ANC) < 1000
/mm3
3. Bands to total
ratio > 0.2
4. Immature to
mature
ratio > 0.2
(positive in 5-10% of
1. Indicated for
1. Indications
2. Specific Tests
1. Indicated for late-
perinatal period
(age <3 days old)
Differential Diagnoses
Hemolytic Disease of the Newborn
▪
Metabolic Disorders
Pediatric Congenital Diaphragmatic Hernia
Pediatric Congestive Heart Failure
•
Management: General
▫ Monitor infant for signs of
▫ Antibiotic indications (contrast
with observation only)
Symptomatic infants
Asymptomatic infants with
>2 risk factors (see above)
▫ Continue monitoring and
antibiotics for 48 to 72 hours
Indications to continue
antibiotics 14 to 21 days
Symptomatic newborn
positive
Discontinue antibiotics and
monitoring if
s negative at 48
to 72 hours and
No signs of
on
examination
▫ Signs of
with negative
culture
Consider
infection
•
Management: Antibiotics for
Early Onset (age <1 week)
▫ Bacterial spectrum
(not
common)
Listeria (rare in United
States)
▫ Primary Antibiotic Protocol
(
dose often used
empirically)
: 50 mg/kg/dose IV
or IM q12 hours
: 100
mg/kg/dose IV or IM q12
hours
Gestation <28 weeks: 2.5
mg/kg/dose IV/IM q24
hours
Gestation <34 weeks: 2.5
mg/kg/dose IV/IM q18
hours
Gestation >34 weeks: 2.5
mg/kg/dose IV/IM q12
hours
▫ Alternative Options
Alternative Protocol 1
(dosed as
above)
50
mg/kg/dose IV or IM q12
hours
Alternative Protocol 2
(dosed as
above)
50 mg/kg IV
or IM q24 hours
•
Management: Antibiotics
for Late Onset (age 1-4
weeks)
▫ Coverage broadened over
early onset
epidermidis
▫ )
▫ Antibiotic Dosing for infant over 7 days old
(the higher dose in possible
Weight <2 kg: 25-50 mg/kg/dose IV or IM q8 hours
Weight >2 kg: 25-50 mg/kg/dose IV or IM q6 hours
Gestation <37 weeks: 2.5 mg/kg/dose IV/IM q12 hours
Gestation >37 weeks: 2.5 mg/kg/dose IV/IM q8 hours
▫ Primary Protocol 1
(dosed as above)
50 mg/kg/dose IV or IM q8 hours
▫ Primary Protocol 2
(dosed as above)
75 mg/kg/dose IV or IM q24 hours
▫ Alternative Protocol
(dosed as above)
(dosed as above)
•
Prevention
Rupture of Membranes GBS Prophylaxis
▫ Routine Group B Strep Screening in pregnancy (36 weeks
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