Neonatal Sepsis

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Neonatal Sepsis

• Nancy Roberto,CNP
• Childrens Hospital Medical Center

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Immune System
Specific
Nonspecific
Monocytes Macrophages Neutrophils
Cell mediated
Humoral
T-lymphocytes
Complement
B-lymphocytes
Antibodies
Death of antigen
T helper Tsuppressor T cytotoxic Lymphokines
Skin and mucous membranes Chemical
barrier Inflammatory response Interferon Phagocyto
sis
Viral, fungal, protzoan, and some bacterial
protection Graft rejection Skin
hypersensitivity Immune surveillance
IgA
IgD
IgE
IgG
IgM
Allergy Parasitic Infestation
Viral Protection
Function unknown
Bacterial protection
Bacterial protection
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Definition of Neonatal Sepsis

• A clinical syndrome of systemic illness
  accompanied by bacteremia occurring in the first
  month of life (Gomella,Cunningham and Eyal, 1994)

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Pathogenesis of Neonatal Sepsis

• Early onset infection usually multisystem,
  fulminant illness with prominent respiratory
  symptoms
• Late onset infection usually has an identifiable
  focus, most often meningitis, in addition to
  sepsis
• Nosocomial infection horizontal transmission
  from NICU environment

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Causative Organisms

• Primary Sepsis usually vaginal flora, GBS,
  gram-negative enteric organisms (E Coli),
  Listeria monocytogenes, Staphylococcus,
  Streptococci (including enterococci), anaerobes,
  and Haemophilus influenzae
• Nosocomial Sepsis Staphylococci (S. Epidermidis
  and S.Aureus), gram negative rods (Pseudomonas,
  Klebsiella, Serratia, Proteus) and fungal
  organisms.

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Risk Factors for Sepsis

• Maternal
• Poor PNC and/or nutrition
• Multiple gestation
• Low socioeconomic status
• Recurrent AB
• Substance abuse
• Prolonged ROM (gt24 hours)
• Maternal fever/infection
• Meconium stained or foul-smelling amniotic fluid
• Prolonged or difficult labor

• Neonatal
• Prematurity
• LBW
• Birth asphyxia
• Meconium staining
• Resuscitation
• Invasive procedures
• Congenital anomalies (spinal and abdominal wall
  defects)
• Immune defects, asplenia

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Clinical Presentation

• Thermoregulation
• Neurologic
• Skin
• Gastrointestinal
• Cardiac
• Respiratory
• Metabolic
• Hematologic

Bacteremia
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Thermoregulation

• Normal temperature ranges (degrees Celsius)
• Skin36.0-36.5
• Rectal36.5-37.5
• Axillary0.5-1.0 degrees lower than skin
  temperature
• Hypothermia
• Hyperthermia
• Temperature instability

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Neurologic Symptoms

• Lethargy
• Irritability
• Decreased muscle tone
• Increased muscle tone
• Poor feeding
• Seizures

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Skin

• Poor peripheral perfusion
• Cyanosis
• Mottling
• Pallor
• Petechiae
• Rashes
• Jaundice

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Hematologic

• WBC values
• Neutropenia
• Thrombocytopenia - Fungal and G-Negative
  organisms associated with lower PLT and more
  prolonged low PLT count (Guida, et al 2003
  Pediatrics)
• Anemia
• Disseminated intravascular coagulation

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Cardiac

• Tachycardia
• Bradycardia
• Hypotension
• Prolonged capillary refill
• Weak peripheral pulses
• Cyanosis

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Respiratory

• Tachypnea
• Grunting
• Flaring
• Retractions
• Apnea
• Cyanosis/desaturation
• Poor air movement
• Increasing oxygen requirement

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Gastrointestinal

• Poor feeding
• Emesis
• Gastric residuals
• Abdominal distention
• Visible or palpable bowel loops
• Diarrhea or bloody stools

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Metabolic

• Hyperglygemia
• Hypoglycemia
• Hyponatremia
• Metabolic acidosis

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Diagnostic Work-up

• CBC with differential
• Cultures (Blood, Urine, CSF, tracheal aspirate)
• X-rays
• Blood gases
• Urinalysis
• PT, PTT, Fibrinogen, FSP or D-dimer

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Bacterial Infection

• Blood (Septicemia)
• CSF (Meningitis)
• Pneumonia
• Urinary tract infection
• Ophthalmia
• Otitis media
• Necrotizing enterocolitis

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Fungal Infection

• Thrush
• Cutaneous candidiasis
• Acute disseminated (systemic) candidiasis

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Viral Infection

• Rubella
• Cytomegalovirus (CMV) - Breastmilk main source of
  perinatally acquired CMV. More concern in ELBW
  infants (Yasuda et al, 2003, Pediatrics)
• Herpes simplex virus (HSV)
• Hepatitis B virus
• Hepatitis C virus
• AIDS (Human immunodeficiency virus-HIV)

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Acronym for Microorganisms Responsible for
Infection of the Fetus(Remington Klein, 2001)

• TORCHES
• To Toxoplasma gondii
• R Rubella virus
• C Cytomegalovirus
• H Herpes simplex virus
• E Enteroviruses
• S Syphilis (Treponema pallidum

• CLAP
• C Chickenpox (varicella-zoster virus)
• L Lyme disease (Borrelia burgdorferi)
• A AIDS (human imunodeficiency virus)
• P Parvovirus B19

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Management of Sepsis

• Universal precautions
• Initial therapy Broad spectrum antibiotic
  coverage
• Continuing therapy Based on culture and
  sensitivity
• Isolation

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Complications Supportive Therapy

• Respiratory
• Cardiovascular
• Hematologic
• CNS
• Metabolic
• Family

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Case Study 1

• Risk Factors in Neonatal Sepsis

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Case Study 2

• Clinical Presentation in Neonatal Sepsis