Neonatal Sepsis

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Neonatal Sepsis

• Author Sherrill Roskam RNC MN NNP CNS
• Updated presentation Susan Greenleaf RNC, BSN

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Objectives

• Identify major causative organisms and routes of
  transmission of sepsis.
• Discuss clinical manifestations and modalities
  used in diagnosis of sepsis.
• Describe antibiotic therapy used in the treatment
  of neonatal sepsis.

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Sepsis

• Definition A systemic response to an invasive
  organism. Frequently signified by a positive
  blood culture.
• A systemic illness due to the presence of
  bacteria and or bacterial toxins in the blood

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Neonatal Immune System

• Sepsis occurs in 1-81000 term infants and 1250
  premature infants
• Neonates are immunocompromised even at term
  gestation
• The neonatal immune system is functional at
  birth, but not mature

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Sepsis

• Two types of sepsis
• Early-onset sepsis, with in the first 72 hours of
  life
• Late-onset sepsis, those infections acquired
  later by horizontal transmission. Highest risk
  for the first month of life

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Predisposing Factors Pregnancy

• Prematurity
• PROM lt 36 weeks
• Prolonged ROM
• Prolonged labor
• Excessive manipulation

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Predisposing Factors Maternal

• History of infection
• Bacterial
• Viral
• History of GBS bacteriuria
• History of previously affected infant
• Temperature in labor

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Predisposing Factors Neonatal

• Invasive procedures
• Resuscitation
• Intubation
• IV starts / PICC lines
• Umbilical Catheterization
• Skin colonization

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Predisposing Factors Nursery

• Humidifiers
• Respiratory therapy equipment
• Staff members
• Unsterile equipment
• Scales
• Stethoscopes
• Thermometers

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Transmission

• Transplacental
• Ascending
• Birth
• Nosocomial
• Antibodies
• IgG
• IgM
• IgA

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Human Immunoglobulins

• Antibodies are the immunoglobulins produced in
  response to specific antigens
• IgG is the only antibody that crosses the
  placenta and provides immuological protection
  over the first few months
• Transfer peaks at 32 weeks gestation

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Immunoglobulins cont.

• IgM and IgA are directly responsible for
  antibodies against bacteria
• Neonatal IgM production starts at 30 weeks
  gestation and increases over the first year of
  life
• IgA passes through breast milk to provide early
  defense against infection. Found in the
  intestinal tract.

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Causative OrganismsBacterial

• Group B strep
• E Coli
• Haemophilus Influenzae
• Coagulase Negative Staph
• Staph Aureus
• Neisseria Meningitis
• Listeria

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Causative Organisms Viral Maternal in origin

• Toxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes
• Hepatitis B
• HIV

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Recognition Clinical Signs

• Temperature instability
• Lethargy
• Pallor, mottling, poor cap refill
• Respiratory distress
• Poor feeding
• Apnea
• Neurologic
• Jaundice
• Hypoglycemia

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Recognition

• Recognition is of utmost importance, because
  newborns with sepsis can get very sick very fast
• Be aware of risk factors review maternal history

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Diagnostic tests for sepsis

• CBC
• Cultures
• Blood Most common Gold Standard
• Urine
• Surface - only indicates colonization
• CSF Lumbar puncture
• CRP

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C-Reactive Protein

• What is CRP?
• Laboratory test that identifies an inflammatory
  response in the body.
• Binds to Calcium and phosphocholine sites
  forming CRP-ligand complexes.

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CRP

• CRPs unique binding characteristics have led to
  the identification of elevated CRP levels in over
  70 different infectious and noninfectious
  disorders.
• It is associated with acute and chronic
  inflammatory disorders.

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CRP Continued. . .

• Paired mother and infant sampling shows that CRP
  does not cross the placenta.
• 4 types of inflammatory response to tissue injury
• Infectious, noninfectious, chemical, physical or
  immunologic toxins.

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Use of CRP

• 2 schools of thought
• Early diagnostic tool for confirming sepsis
• Screening tool to r/o the presence of sepsis

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CRP Levels What is normal?

• In the neonatal period Level of 10mg/L is
  considered normal
• Healthy full-term and preterm infants may range
  from 2 to 5mg/L during the first few days of
  life.

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More than 1 Level?

• Conflicting information about obtaining more than
  one level
• Serial CRP levels drawn 12 to 24 hours after
  onset of S/S of sepsis may be superior to a
  single level.

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More About the CBC WBC

• White cell count
• Differential
• Neutrophils - bacteria fighting cells
• Polys, Segs - most mature
• Bands - immature
• Metas really immature
• Absolute Neutrophil Count
• IT Ratio

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White Blood Cells

• The main defense against invading microorganisms
• Neutrophils (pack man cells) and
  macrophages(monocytes)
• Circulating cells that migrate to sites of
  inflamation, ingesting and killing foreign
  material or bacteria (phagocytosis)
• Small stores in neonates, not as effective in
  killing bacteria, quickly depleted

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Differential of the WBC

• Mature Neutrophils Segmented
• Immature Neutrophils Bands
• Monocytes
• Basophils
• Eosinophils
• Lymphocytes

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Neutrophils

• As mature neutrophols (polys, segs, neuts, or
  PMNs) are mobilized and consumed in the presence
  of a pathogen, their numbers decrease and
  immature cells are released from the bone marrow.
• Immature neutrophils (bands, metas or stabs)

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Absolute Neutrophil Count (ANC)

• Helps determine how many neutrophils are
  available to fight bacterial infections
• Premature infants have lower ANC than term
  infants
• Must plot on the Manroe chart

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How to calculate an ANC

• Identify the immature and the mature neutrophils
  on the CBC.
• Add the segs, bands and metas ( total number of
  neutrophils) together and turn it into a
  percentage
• Multiply this number by the total WBC
• This resulting number is the ANC

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Manroe Chart
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Figure it out

• WBC 20,000
• Differential is expressed as a percent of total
  white cells
• Polys (Segs, Neuts) 48
• Bands 12
• Lymphs 20
• Monos 17
• Eso 3

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Figure it out

• ANC Absolute number of neutrophils
• WBC X Neutrophils
• ANC WBC X Neutrophils
• 20,000 X .6 (60) 12,000

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Manroe Chart
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Immature to Total Ratio (IT)

• An Increased IT ratio is called a left shift. It
  show an increase in the number of immature sells
• An IT ratio of gt.25 may indicate sepsis
• I/T ratio Ratio of immature to total
  neutrophils
• ___Bands Meta___
• Polys Bands Meta

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Figure it out

• WBC 20,000
• Differential is expressed as a percent of total
  white cells
• Polys (Segs, Neuts) 48
• Bands 12
• Lymphs 20
• Monos 17
• Eso 3

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Figure it out

• I/T ratio Bands Metas
• Polys Bands Metas
• 12/600.2 (not indicative of sepsis)
• If WBC 3000 Polys 30 and Bands 15
• 15/450.33 (indicative of sepsis)
• 3,000 X .45 (45) 1,350

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Platelet Count

• Normal Values
• VLBW 275,000 /- 60,000
• Preterm 290,000 /- 60,000
• Term 310,000 /- 60,000
• Infants with infection may have a low platelet
  count

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Management

• Support Systems
• Neutral Thermal Environment
• Monitor
• Cardiac/Respiratory
• Pulse Oximetry
• Vital signs
• Feedings
• IV

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Management (cont)

• Antibiotics
• Ampicillin 50-100 mg/kg/dose IV q8-12 hours
• Varies with gestation and age
• Gentamicin 4 mg/kg/dose IV q24-48 hours
• Varies with gestation
• Give over 30 minutes
• Monitor Gent levels
• Antiviral
• Acyclovir 20 mg/kg/dose IV q8
• Give over 1 hour
• Do not refrigerate

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Prognosis

• Prognosis depends on organism involved and when
  treatment started

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A bit more practice

• CBC results
• WBC 10.4
• Metamyelocytes 0
• Band Neutrophils 14
• Segmented neutrophils 5
• Platelets 141,000
• What is the ANC and the IT ratio?

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CBC Practice

• CBC results
• WBC 1.3
• Metamyelocytes 2
• Band Neutrohils 17
• Segmented Neutrophils 42
• Platelets 262,000
• Calculate the ANC and IT ratio

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CBC Practice

• CBC results
• WBC 6.3
• Metamyelocytes 6
• Band Neutrophils 44
• Segmented Neutrophils 23
• Platelets 95,000
• What is the ANC and the IT ratio?

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Same patient, 6 hours later

• CBC results
• WBC 0.8
• Metamyelocytes 2
• Band Neutrophils 4
• Segmented Neutrophils 2
• Platelets 24,000
• What is the ANC and IT ratio?

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References

• Behrman, R. E., Kliegman, R.M.,Editors (1998)
  Nelson Essentials of Pediatrics, 3rd Ed.
  Philadelphia W.B. Saunders Co.
• Cloherty, J.P., Eichenwald, E.C., Stark, A.R.
  (2004) Manual of Neonatal Care, 5th Ed.
  Philadelphia Lippincott, Williams Wilkins.
• Hengst, J.M., The Role of C-Reactive Protein in
  the Evaluation and Management of Infants with
  Suspected Sepsis. Advances in Neonatal Care.
  20033(1)3-13.

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References

• Karlsen, K.A. (2001) The S.TA.B.L.E. Program
  Transporting Newborns the S.T.A.B.L.E.Way,
  Learner Manual, 8th Ed.
• Merenstein, G.B., Gardner, S.L. (2002) Handbook
  of Neonatal Intensive Care, 5th Ed. St.
  LouisMosby Inc.