| ID | 363 |
|---|---|
| Name | NEONATAL SEPSIS or SEPTICEMIA |
| Cause | Causative organisms: According to the period of infections: 1. Prenatal infection (i.e blood-borne transplacental infection of the foetus)-e.g Syphilis, Tuberculosis; (virus: Cytomegalovirus, Rubella, Parvovirus B19, Varicella, & also HSV, HIV, Hepatitis B, Hepatitis C Virus). 2. Perinatal infections (i.e during delivery or ascending infection after ruptured membrane)- viz. GBS, enteric organisms (e.g E. coli), streptococcus type B & D, klebsiella, pseudomonas, proteus, gonococci, chlamydia, & anerobic bacteria (tetanus) etc. Common viruses are CMV, HSV, and HIV. 3. Postnatal infection (or nosocomial infection)- viz. coagulase-negative staphylococci, gram-negative bacilli (E. coli, Klebsiella pneumonie, Salmonella, Enterpbacter, Citrobacter, Pseudomonas eruginosa, Serratia). Enterococci, S. aureus, and Candida. Anerobic bacteria (tetanus). Viruses include enteroviruses, CMV, hepatitis A, adenoviruses, influenza virus, rhinovirus, parainfluenza, HSV, and rotavirus. Community acquired bacterial infection such as Streptococcus pneumonie usually occurs in newborn infants after discharge from the hospital. |
| Signs Symptoms | Early symptoms may include irritability, lethargy, or poor feeding. Others may quickly develop respiratory distress, fever, hypothermia or hypotension with poor perfusion and shock. |
| Diagnosis | Diagnosis: A. Clinical history- including maternal history of prenatal & perinatal problems & infections. B. Physical examinations- for clinical manifestations (as above) C. Laboratory Investigations - 1. Blood for- CBC (complete blood count) with Micro-ESR - culture & sensitivity (from peripheral vein). 2. Urine-R/E, C/S. 3. Pus from septic spots- gram stain. 4. X-ray chest & abdomen- if suspected & necessiates. 5. CSF study- when meningitis is suspected. 6. C-reactive protein (CRP)- increased (T) in infection . 7. Heptaglobin- increased (T) in infection. |
| Investigations | Laboratory investigations Full blood count (FBC) and CRP Blood cultures Lumbar puncture Urine culture (‘in-out’ catheter or suprapubic aspiration) Swabs of specific lesions (skin swabs of pustules, eye swabs for eye discharge etc.) Imaging Chest X-ray (if respiratory signs present on examination) Abdominal X-ray (if abdominal signs present on examination) Other investigations |
| Management | Management: 1. Antibiotic therapy: Initial empirical treatment of early-onset bacterial infections should be started immediately with broad-spectrum coverage, usually a combination of ampicillin plus an aminoglycoside (e.g gentamicin) or third-generation cephalosporin by i.m. or i.v route. This combination covers most of the gram ‘+ve’ enterococci & gram ‘-ve’ enteric bacilli (e.g. e. coli, klebsiella, pseudomonas etc.). Late-onset infections can also be caused by the same organisms, but coverage may need to be extended to include coagulase negative staphylococci. But once the organisms has been identified by gram stain & or culture, the most appropriate drugs should be selected. Nosocomial infections caused by staphylococci should be treated with methicillin or nafcillin for S. aureus or, more often with, vancomycin for coagulase-negative staphylococci or methicillin-resistent S. aureus. Most of the gram-negative enteric bacteria are usually treated by ampicillin & an aminoglycoside (e.g gentamicin) or a 3rd-generation cephalosporin (cefotaxime or ceftazidime). Entarococci is treated with ampicillin or piperacillin & an aminoglycoside. Incase of GBS, penicillin (e.g ampicillin) alone is sufficient. Anerobic bacterial infections are treated with clindamycin or metronidazole Now a day, third-generation cephalosporins such as cefotaxime, ceftriaxone are found very effective in the treatment of neonatal sepsis & meningitis. However, the routine use of these cephalosporins in nosocomial infections may cause rapid emergence of bacterial resistance. The duration of therapy in most cases of neonatal sepsis is 7-10 days or at least 5-7 days after a clinical response has occured. Ampicillin dose- 50mg/kg/day i.v or i.m b.d if body wt < 2 kg & age < 7 days. 75mg/kg/day i.v or i.m b.d if body wt < 2 kg & age > 7 days. 75mg/kg/day i.v or i.m t.d.s if body wt > 2kg & age < 7 days. l00mg/kg/day i.v or i.m t.d.s if body wt > 2kg & age > 7 days. Methicillin dose- 50-75mg/kg/day i.v or i.m b.d if wt < 2kg. for 7 days. 75-100mg/kg/day i.v or im b.d it wt > 2kg. for 7-10 days. Gentamicin dose- 5mg/kg/day i.v or i.m b.d in 1st week of life. 7.5mg/kg/day i.v or i.m, t.d.s after 1st week. Vancomycin dose- 15mg/kg initially then l0mg/kg every 12 hours in neonate up to 1 week. 15mg/kg initially then l0mg/kg every 8 hours in neonate up to 2-4 weeks. l0mg/kg every 8 hours in infant overl month. 3rd generation cephalosporins- such as ceftriaxone, cefotaxime, ceftazidime, moxalactum etc. are also have been found effective in treating neonatal sepsis caused by gm-ve enteric bacilli. So many authorities recommend cefotaxime (or ceftriaxone) as the treatment of choice against gm-ve enteric bacilli rather than gentamicin. In this context ampicillin/cefotaxime combination may be an effective alternative to ampicillin /gentamicin. Cefotaxime dose- l00mg/kg/day i.v or i.m b.d in 1st week of life. 150mg/kg/day i.v or i.m t.d.s after 1st week. Ceftriaxone dose-50mg/kg/day by i.v infusion onece daily in 1st week of life (neonate). 75mg/kg/day by i.v or by deep i.m injection onece daily after 1st week of life (infant). In H. influenze infections, ampicillin in effective; in resistant cases 2nd generation cephalosporin (viz. cefaclor, cefuroxine) are also found very effective. In infections due to anerobes (& also group B streptococci)- inj. penicillin G is effective & sufficient. Penicillin injection dose- 50,000-75,000 units/kg/day i.v b.d or t.d.s if wt.< 2 kg in 1st week of life. 100,000 units/kg/day i.v t.d.s or q.d.s if wt > 2kg after 1st week. 2. Supportive therapy & treatment of complications. a. Management of fluid & electrolyte balance. b. If respiratory distress- O2 inhalation. c. Fresh whole blood transfusion- if needed. d. If jaundice is severe- exchange transfusion. e. If hypotension- support of B.P. with inotrophic agents such as, dopamine, steroids, f. Control of convulsion, correction of metabolic acidosis and hypocalcemia (if any). 3. Nursing care & nutrition a. Proper nursing care, b Parenteral (or oral) nutrition is to be maintained. |
| Introduction | Neonatal sepsis or septicemia may be defined as a clinical syndrome characterized by symptomatic general & systemic illnesses due to disseminated bacterial infection in the neonatal period. Neonatal sepsis or septicemia may be early or late onset. |
| History | |
| Etiology | Bacteria such as Escherichia coli (E coli), Listeria, and some strains of streptococcus. Group B streptococcus (GBS) has been a major cause of neonatal sepsis |
| Clinical Features | Clinical features: Usual presentations- 1. Fever or hypothermia due to temperature instability. 2. Relactant to feed. 3. Vomiting (& may be diarrhoea) 4. Lethergy & poor cry. 5. Resp. distress or dyspnoea. 6. Abdominal distension. 7. Hepatomegaly. 8. Jaundice. 9. Septic spots or pustules. Rare presentations- 10. Pallor. 11. Petechie, purpura. 12. Bleeding manifestations. 13. Scleroderma. 14. Splenomegaly. 15. Drowsy & 16. Abnormal moro reflex. |
| Preventions | Preventing and treating infections in mothers, including HSV. Providing a clean place for birth. Delivering the baby within 12 to 24 hours of when the membranes break (Cesarean delivery should be done in women within 4 to 6 hours or sooner of membranes breaking.) |
| Treatment | The antibiotics commonly used to treat neonatal sepsis include ampicillin, gentamicin, cefotaxime, vancomycin, erythromycin, and piperacillin. The choice of antibiotic agents should be based on the specific organisms associated with sepsis, the sensitivities of the pathogen, and the prevailing nosocomial infection trends in the nursery. Viral infections, such as herpes and fungal infections, can masquerade as bacterial infections |
| Complications | Septic shock (dangerously low blood pressure) Neonatal seizures. Apnea/bradycardia. Respiratory distress (which may be difficult to distinguish from respiratory distress syndrome) Feeding issues. Meningitis (infection around the brain and spinal cord) |
| Prognosis | Prognosis of neonatal septicemia: Current mortality rate in neonatal sepsis ranges from 10-40% in developed countries . In developing countries, it is still very high. Rates vary depending on the - - Time & manner of disease onset, - Etiologic agent, - Degree of prematurity, - Presence & severity of associated disease |
| Types | 1 Early-onset sepsis (EOS) 2 Late-onset sepsis (LOS) |
| Classification | |
| Observation | |
| Pathology |
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