Dr. Rahat bin Habib. MDDr. Rahat bin Habib. MDICMH, Matuail, Dhaka.ICMH, Matuail, Dhaka.

SEPSIS IN NEWBORNSEPSIS IN NEWBORN

All newborns enter an unsterile All newborns enter an unsterile environment,but infection develops in environment,but infection develops in

only a few.only a few.

ABSTRACTABSTRACT

****Infections are the single largest cause of neonatal Infections are the single largest cause of neonatal death globally.death globally.

**Clinical features of sepsis are non-specific in **Clinical features of sepsis are non-specific in neonates and a high index of suspicion is required neonates and a high index of suspicion is required for the timely diagnosis of sepsis.for the timely diagnosis of sepsis.

**It is responsible for about 30-50%of the total **It is responsible for about 30-50%of the total neonatal deaths in developing countries. neonatal deaths in developing countries.

**Neonatal death in our country is 37/1000 live **Neonatal death in our country is 37/1000 live birth. birth.

**sepsis related mortality is largely preventable **sepsis related mortality is largely preventable with rational antimicrobial therapy and aggressive with rational antimicrobial therapy and aggressive

supportive care.supportive care.

DEFINITIONDEFINITION

Neonatal sepsis is a clinical syndrome of Neonatal sepsis is a clinical syndrome of bacteremia characterized by systemic signs and bacteremia characterized by systemic signs and symptoms of infection in the first month of life.symptoms of infection in the first month of life.

Factors influencing neonatal septicemiaFactors influencing neonatal septicemia

1. Transmission of infection1. Transmission of infection ….transplacental ….transplacental

….vertical ….vertical ….from environment ….from environment

2. Immunologic deficiency2. Immunologic deficiency ….immunoglobulin ….immunoglobulin

….complement ….complement ….leukocyte ….leukocyte ….cytokines ….cytokines ….antibody ….antibody

Factors influencing neonatal Factors influencing neonatal septicemia…..contsepticemia…..cont

3. Gestational age & birth weight3. Gestational age & birth weight

4. Physical defence4. Physical defence ……poor skin condition. ……poor skin condition. ……raw umbilical stump. ……raw umbilical stump.

5. Advanced neonatal care.5. Advanced neonatal care.

Classification of neonatal sepsisClassification of neonatal sepsis

Neonatal sepsis can be classified into two major Neonatal sepsis can be classified into two major group : group :

1. Early onset sepsis: It presents 1. Early onset sepsis: It presents

within 7 days of life , usualy within 7 days of life , usualy

within 72 hours. within 72 hours.

2. late onset sepsis: It usually 2. late onset sepsis: It usually

presents after 7 days of lifepresents after 7 days of life

Charecteristics differenceCharecteristics difference

charecteristicscharecteristics EONSEONS LONSLONS

Age of onsetAge of onset Birth to 7 days, Birth to 7 days, usually within 72 usually within 72 hourshours

7 to 30 days7 to 30 days

Maternal obstetric Maternal obstetric complicationcomplication

commoncommon uncommonuncommon

prematurityprematurity frequentfrequent variesvaries

Organism sourceOrganism source Maternal genital Maternal genital tracttract

Maternal genital Maternal genital tract, environmenttract, environment

menifestationmenifestation multisystemmultisystem Multisystem, focalMultisystem, focal

Risk FactorsRisk Factors

Low birth weight (<2500gm) or Prematurity.Low birth weight (<2500gm) or Prematurity. Febrile illness in the mother within 2 weeks prior Febrile illness in the mother within 2 weeks prior

to delivery.to delivery. Foul smelling and/or meconium stained liquor.Foul smelling and/or meconium stained liquor. Rupture membrane for more than 24 hours.Rupture membrane for more than 24 hours. Single unclean or >3 sterile vaginal examination.Single unclean or >3 sterile vaginal examination. Prolonged labor.Prolonged labor. Severe perinatal asphyxia.Severe perinatal asphyxia.

EtiologyEtiology

Most common bacterial causes ofMost common bacterial causes of neonatal sepsis are:neonatal sepsis are: Klebsiella Klebsiella ActinatobacterActinatobacter E.ColiE.Coli PseudomonasPseudomonas Strep.pyogenStrep.pyogen Strep.PneumoniaeStrep.Pneumoniae Staphylococcus aureusStaphylococcus aureus

Organism responsible for sepsisOrganism responsible for sepsis

study in Dhaka Shishu Hospitalstudy in Dhaka Shishu Hospital

…….E. coli………………..30% …….E. coli………………..30% …….Klebsiela…………….23% …….Klebsiela…………….23% …….Staph. Aureus…….17% …….Staph. Aureus…….17% …….Pseusdomonus…..10% …….Pseusdomonus…..10% …….Streptococcus sp…10% …….Streptococcus sp…10% …….Acinatobacter……..10% …….Acinatobacter……..10%

Organism responsible for sepsis Organism responsible for sepsis

According to Nelson textbook….According to Nelson textbook….

……coagulase neg. staph. Aureus..29% ……coagulase neg. staph. Aureus..29% ………staph aureus……………………..08% ………staph aureus……………………..08%

………B hemolytic streptococci……..21% ………B hemolytic streptococci……..21% ……..E. coli……………………………….11% ……..E. coli……………………………….11% ……..Klebsiella……………………………11% ……..Klebsiella……………………………11% ………Pseudomonus……………………03% ………Pseudomonus……………………03% ………Fungus……………………………..08% ………Fungus……………………………..08%

Organism responsible for sepsis Organism responsible for sepsis

study in indiastudy in india ………Klebsiela ….………32.5% ………Klebsiela ….………32.5% ………staph. Aureus……13.6% ………staph. Aureus……13.6% ………pseudomonus……13% ………pseudomonus……13%

study in nepalstudy in nepal ……staph aureus……………………….38.8% ……staph aureus……………………….38.8%

……coagulase neg. staph. Aureus…21% ……coagulase neg. staph. Aureus…21% …….Klebsiela pn…………………………11.6% …….Klebsiela pn…………………………11.6% …….enterobac…………………………….9.7% …….enterobac…………………………….9.7%

ICMH DATA -2009ICMH DATA -2009

Total blood culture sample - 924Total blood culture sample - 924Growth of organism – 101Growth of organism – 101Percent of growth – 11%Percent of growth – 11%

ICMH DATA 2010ICMH DATA 2010 January – AprilJanuary – April Total Sample – 306Total Sample – 306 Growth of organisms - 86Growth of organisms - 86 % of growth – 28%% of growth – 28% Among the organismsAmong the organisms

…… ……..Staph. Aureus…….51%Staph. Aureus…….51% ……… ……….Acenatobacter……..25%.Acenatobacter……..25%

… ….E. coli………………..14%.E. coli………………..14% … ….Klebsiela……………. 03% … ….Klebsiela……………. 03% …….Pseudomonas…..03% …….Pseudomonas…..03%

Clinical features Clinical features

General:General: fever or hypothermia,fever or hypothermia, poor feeding, poor feeding, Lethargy,Lethargy, poor activity,poor activity,

Skin changeSkin change:: purpura, petechiae, Multiple purpura, petechiae, Multiple

pustules, Abscess, Sclerema, pustules, Abscess, Sclerema, Umbilical redness and discharge Umbilical redness and discharge

CNSCNS:: Irritability, seizure, hyporeflexia Irritability, seizure, hyporeflexia

Abnormal Moro reflex Abnormal Moro reflex Bulge fontanels , Bulge fontanels ,

Vacant stare, Vacant stare, High-pitched cry High-pitched cry

RespiratorRespiratory :y :

cyanosis, cyanosis,

apnea, tachypnea,apnea, tachypnea,

chest indrawning,chest indrawning,

nasal flaring,nasal flaring,

intercostal recession,intercostal recession,

GIT GIT ::

feed intolerance, feed intolerance, vomiting, diarrheavomiting, diarrhea

abdominal distension, abdominal distension, paralytic ileus,paralytic ileus,

necrotizing enterocolitis.necrotizing enterocolitis.

CVSCVS:: Poor perfusion, tachycardia, Poor perfusion, tachycardia,

bradycardia, hypotension, shock bradycardia, hypotension, shock

HepaticHepatic : : hepatomegaly, direct hyperbilirubinemia hepatomegaly, direct hyperbilirubinemia

Renal Renal :: acute renal failure acute renal failure

INVESTIGATIONINVESTIGATION

Treatment should be initiated in a neonate without Treatment should be initiated in a neonate without any delay, Only minimal and rapid investigations any delay, Only minimal and rapid investigations should be undertaken.should be undertaken.

1. 1. BLOOD CULTUREBLOOD CULTURE : :

It is the gold standard for diagnosis of It is the gold standard for diagnosis of septicemia and should be performed in all cases septicemia and should be performed in all cases of suspected sepsis prior to starting antibiotics. of suspected sepsis prior to starting antibiotics.

blood c/s (-)….80% caseblood c/s (-)….80% case blood c/s (+)…..20% caseblood c/s (+)…..20% case single org….97%single org….97% ( ref : 2 yrs study in nepal 2006 & ‘07)( ref : 2 yrs study in nepal 2006 & ‘07)

INVESTIGATION……..contINVESTIGATION……..cont

2. 2. SEPTIC SCREENSEPTIC SCREEN : :

Total leukocyte count <5000/mm Total leukocyte count <5000/mm Absolute neutrophil count Absolute neutrophil count

Immature/total neutrophil count >0.2 Immature/total neutrophil count >0.2 Micro ESR- >15 mm in 1 Micro ESR- >15 mm in 1stst hour hour C-reactive protein- >1o mg/dl C-reactive protein- >1o mg/dl

Comes atComes at Peak level atPeak level at

CRPCRP 7 hr7 hr 24 hr24 hr

ANC, I/T ratioANC, I/T ratio 22 hr22 hr 48 hr48 hr

Micro ESRMicro ESR 26 hr26 hr 48-72 hr48-72 hr

Investigation…….cont Investigation…….cont

3. 3. Lumber puncture:Lumber puncture:

In EOS:In EOS:

Positive blood culturePositive blood culture

oror

Clinical picture is consistent with septicemia. Clinical picture is consistent with septicemia.

In LOS:In LOS:

LP should be done in all infants prior to LP should be done in all infants prior to

starting antibiotics.starting antibiotics.

Investigation......contInvestigation......cont

4.4. Chest X-ray:Chest X-ray:

Should be considered in the presence ofShould be considered in the presence of

respiratory distress or apnea.respiratory distress or apnea.

5. 5. Urine for R/M/E & C/S.Urine for R/M/E & C/S.

from suprapubic puncture or catheterization.from suprapubic puncture or catheterization.

6. Hb%, platelet count, Blood sugar, Serum 6. Hb%, platelet count, Blood sugar, Serum electrolytes, X-ray abdomen-(if necessary) electrolytes, X-ray abdomen-(if necessary)

ManagementManagement

Supportive:Supportive:

1. Maintain body temperature.1. Maintain body temperature. 2. Provide oxygen if indicated.2. Provide oxygen if indicated. 3. Monitoring and correction of hypoglycemia.3. Monitoring and correction of hypoglycemia. 4. Infusion Normal saline if perfusion is poor. 4. Infusion Normal saline if perfusion is poor. 5. Blood transfusion if indicated.5. Blood transfusion if indicated. 6. Ensure feeding if possible breast feeding, 6. Ensure feeding if possible breast feeding, or give N-G tube feed with EBM, if the or give N-G tube feed with EBM, if the baby is very sick, can not tolerate oral feed baby is very sick, can not tolerate oral feed or suspected NEC give I/V fluidor suspected NEC give I/V fluid

Antimicrobial therapyAntimicrobial therapy

Indication in EOS……any 1 0f the followingIndication in EOS……any 1 0f the following

Presence 3 or more risk factors.Presence 3 or more risk factors. Presence of foul smelling liquor.Presence of foul smelling liquor. Two risk factors and a positive Two risk factors and a positive septic screen.septic screen. Strong clinical suspicion of sepsis.Strong clinical suspicion of sepsis.

Indication in LOS…….Indication in LOS……. Positive septic screenPositive septic screen oror Strong clinical suspicion of sepsisStrong clinical suspicion of sepsis

Empirical choice of antibioticsEmpirical choice of antibiotics

First lineFirst line

ampicillin + gentamycinampicillin + gentamycin Second lineSecond line

cefotaxime/ceftazidimecefotaxime/ceftazidime

+ +

amikacinamikacin Third lineThird line

ciprofloxacin/meropenum/imipenumciprofloxacin/meropenum/imipenum

If intestinal pathology suspected.……add metronidazoleIf intestinal pathology suspected.……add metronidazole

If nosocomial infection suspected……add cloxacillinIf nosocomial infection suspected……add cloxacillin

Doses of common antibiotics Doses of common antibiotics

Ampicillin: 50-100 mg/kg/dAmpicillin: 50-100 mg/kg/d

100-200 mg/kg/d in meningitis100-200 mg/kg/d in meningitis

Gentamycin: 5-7.5 mg/kg/dGentamycin: 5-7.5 mg/kg/d

Amikacin: 15-30 mg/kg/dAmikacin: 15-30 mg/kg/d

Cloxacillin: 50-100 mg/kg/dCloxacillin: 50-100 mg/kg/d

100-200 mg/kg/d in meningitis100-200 mg/kg/d in meningitis

Cefotoxime: 150 mg/kg/dCefotoxime: 150 mg/kg/d

200 mg/kg/d in meningitis 200 mg/kg/d in meningitis

Ceftazidime : 100-150 mg/kg/dCeftazidime : 100-150 mg/kg/d

Duration of treatmentDuration of treatment

Meningitis : Meningitis : 21 days21 days

Blood culture positive but no meningitis : Blood culture positive but no meningitis : 14 days14 days

Culture negative, sepsis screen positive and clinical Culture negative, sepsis screen positive and clinical course consistent with sepsis: course consistent with sepsis: 7 to 10 days7 to 10 days

All are negative but clinical course compatible with All are negative but clinical course compatible with sepsis: sepsis: 5 to 7 days5 to 7 days

All are negative & clinical course not compatible All are negative & clinical course not compatible with sepsis : with sepsis : stop antibiotics afterstop antibiotics after 3 days3 days

PreventionPrevention

maternal carematernal care

1. maintain maternal nutrition. 1. maintain maternal nutrition. 2. early diagnosis of maternal disease like 2. early diagnosis of maternal disease like DM, HTN & take appropriate measure. DM, HTN & take appropriate measure.

3. early diagnosis of maternal infection like 3. early diagnosis of maternal infection like UTI, chorioamnionitis & prompt treatment. UTI, chorioamnionitis & prompt treatment.

4. avoid unnecessary p/v exam. 4. avoid unnecessary p/v exam.

PreventionPrevention

Essential new born care:Essential new born care:

1. Clean delivery & clean cord care.1. Clean delivery & clean cord care.

2. Encouraging early & exclusive breast 2. Encouraging early & exclusive breast

feeding.feeding.

3. Hand washing before& after handling 3. Hand washing before& after handling

each baby.each baby.

4. Extra care for low birth weight baby . 4. Extra care for low birth weight baby .

PreventionPreventionNursery care:Nursery care:

1. Hand washing which includes 2 min scrub 1. Hand washing which includes 2 min scrub

before entering the nursery & 15 sec in between before entering the nursery & 15 sec in between

patientspatients

2. Strict routine for washing, disinfection & 2. Strict routine for washing, disinfection &

cleaning of cotscleaning of cots

3. Avoidance of overcrowding & of visit of an 3. Avoidance of overcrowding & of visit of an

infected staff or a relative. infected staff or a relative.

4. Isolation of infected infant in a separate cots.4. Isolation of infected infant in a separate cots.

5. minimal handling.5. minimal handling.

6. Skin care to maintain integrity of skin & cord care.6. Skin care to maintain integrity of skin & cord care.7. prompt antibiotic therapy for suspected/diagnosed 7. prompt antibiotic therapy for suspected/diagnosed

case. case.8. change bed cloth after bowel/bladder movement.8. change bed cloth after bowel/bladder movement.

9. aseptic technique for all sorts of procedure.9. aseptic technique for all sorts of procedure.10. routine change of NG tube & IV canulla10. routine change of NG tube & IV canulla

Statistical data of ICMHStatistical data of ICMHYearYear Total Total

neonatal neonatal admisionadmision

Neonatal Neonatal septicemia septicemia adm.adm.

%% Total Total neonatal neonatal deathdeath

Septicemic Septicemic pt deathpt death

%%

20072007 28422842 558558 19.63%19.63% 471471 139139 25%25%

20082008

20092009

20102010

23392339

22802280

560560

467467

441441

193193

20%20%

19.3%19.3%

34.46%34.46%

350350

319319

131131

157157

28%28%

29%29%