Neonatal SepsisNeonatal Sepsis

Islamic University Islamic University

Nursing College Nursing College

Definition & IncidenceDefinition & Incidence Clinical syndrome of systemic illness Clinical syndrome of systemic illness

accompanied by bacteremia occurring accompanied by bacteremia occurring in the first month of life.in the first month of life.

Incidence Incidence 1-8/1000 live births.1-8/1000 live births. 1-250 live premature births.1-250 live premature births. 13-27/1000 live births for infants < 1500g13-27/1000 live births for infants < 1500g

Mortality rate is 13-25%Mortality rate is 13-25% Higher rates in premature infants and Higher rates in premature infants and

those with early fulminant diseasethose with early fulminant disease

Early OnsetEarly Onset

First 5-7 days of life First 5-7 days of life

Usually multisystem fulminant illness with Usually multisystem fulminant illness with

prominent respiratory symptoms (probably due prominent respiratory symptoms (probably due

to aspiration of infected amniotic fluid)to aspiration of infected amniotic fluid)

High mortality rate High mortality rate 5-20%5-20%

Typically acquired during intrapartum period Typically acquired during intrapartum period

from maternal genital tractfrom maternal genital tract

Associated with maternal chorioamnionitisAssociated with maternal chorioamnionitis

Late OnsetLate Onset May occur as early as 5 days but is most May occur as early as 5 days but is most

common after the first week of life.common after the first week of life.

Less association with obstetric complicationsLess association with obstetric complications

Usually have an identifiable focus.Usually have an identifiable focus.

Most often meningitis or sepsis.Most often meningitis or sepsis.

Acquired from maternal genital tract or Acquired from maternal genital tract or

human contact.human contact.

Nosocomial sepsisNosocomial sepsis Occurs in high-risk newborns.Occurs in high-risk newborns.

Pathogenesis is related to: Pathogenesis is related to:

The underlying illness of the infant.The underlying illness of the infant.

The flora in the NICU environment.The flora in the NICU environment.

invasive monitoring.invasive monitoring.

Breaks in the barrier function of the skin and Breaks in the barrier function of the skin and

intestine allow for opportunistic infection.intestine allow for opportunistic infection.

Causative organismsCausative organisms

Primary sepsisPrimary sepsis Group B streptococcusGroup B streptococcus Gram-negative enterics (esp. Gram-negative enterics (esp. E. coliE. coli)) Listeria monocytogenes, StaphylococcusListeria monocytogenes, Staphylococcus, ,

other streptococci (entercocci), other streptococci (entercocci), H. fluH. flu Nosocomial sepsisNosocomial sepsis

Varies by nurseryVaries by nursery Staphylococcus epidermidis, Pseudomonas, Staphylococcus epidermidis, Pseudomonas,

Klebsiella, ProteusKlebsiella, Proteus, and yeast are most , and yeast are most commoncommon

Risk factorsRisk factors Prematurity and low birth weightPrematurity and low birth weight Premature and prolonged rupture of membranesPremature and prolonged rupture of membranes Maternal peripartum feverMaternal peripartum fever Amniotic fluid problems.Amniotic fluid problems. Resuscitation at birth, fetal distressResuscitation at birth, fetal distress Multiple gestationMultiple gestation Invasive proceduresInvasive procedures GalactosemiaGalactosemia Other factors: sex, race, variations in immune Other factors: sex, race, variations in immune

function, hand washing in the NICUfunction, hand washing in the NICU

Clinical presentationClinical presentation

Clinical signs and symptoms are Clinical signs and symptoms are nonspecificnonspecific

Differential diagnosisDifferential diagnosis RDSRDS Metabolic diseaseMetabolic disease Hematologic diseaseHematologic disease CNS diseaseCNS disease Cardiac diseaseCardiac disease Other infectious processes (i.e. TORCH)Other infectious processes (i.e. TORCH)

Clinical presentationClinical presentation Temperature irregularity (high or low)Temperature irregularity (high or low) Change in behaviorChange in behavior

Lethargy, irritability, changes in toneLethargy, irritability, changes in tone

Skin changesSkin changes Poor perfusion, mottling, cyanosis, pallor, petechiae, Poor perfusion, mottling, cyanosis, pallor, petechiae,

rashes, jaundicerashes, jaundice

Feeding problemsFeeding problems Intolerance, vomiting, diarrhea, abdominal Intolerance, vomiting, diarrhea, abdominal

distensiondistension

CardiopulmonaryCardiopulmonary Tachypnea, grunting, flaring, retractions, apnea, Tachypnea, grunting, flaring, retractions, apnea,

tachycardia, hypotensiontachycardia, hypotension

MetabolicMetabolic Hypo or hyperglycemia, metabolic acidosisHypo or hyperglycemia, metabolic acidosis

DiagnosisDiagnosis

CulturesCultures BloodBlood

Confirms sepsisConfirms sepsis 94% grow by 48 hours of age94% grow by 48 hours of age

UrineUrine Don’t need in infants <24 hours old because UTIs Don’t need in infants <24 hours old because UTIs

are exceedingly rare in this age groupare exceedingly rare in this age group CSFCSF

Controversial Controversial May be useful in clinically ill newborns or those with May be useful in clinically ill newborns or those with

positive blood culturespositive blood cultures

Adjunctive lab testsAdjunctive lab tests White blood cell count and differentialWhite blood cell count and differential

Neutropenia can be an ominous signNeutropenia can be an ominous sign I:T ratio > 0.2 is of good predictive valueI:T ratio > 0.2 is of good predictive value Serial values can establish a trendSerial values can establish a trend

Platelet countPlatelet count Late sign and very nonspecificLate sign and very nonspecific

Acute phase reactantsAcute phase reactants CRP rises early, monitor serial valuesCRP rises early, monitor serial values ESR rises lateESR rises late

Other tests: bilirubin, glucose, sodiumOther tests: bilirubin, glucose, sodium

Maternal studiesMaternal studies

Examination of the placenta and Examination of the placenta and fetal membranes for evidence of fetal membranes for evidence of chorioamnionitischorioamnionitis

ManagementManagement

AntibioticsAntibiotics Primary sepsis: ampicillin and Primary sepsis: ampicillin and

gentamicingentamicin Nosocomial sepsis: vancomycin and Nosocomial sepsis: vancomycin and

gentamicin or cefotaximegentamicin or cefotaxime Change based on culture sensitivitiesChange based on culture sensitivities Don’t forget to check levelsDon’t forget to check levels

Supportive therapySupportive therapy RespiratoryRespiratory

Oxygen and ventilation as necessaryOxygen and ventilation as necessary

CardiovascularCardiovascular Support blood pressure with volume expanders and/or Support blood pressure with volume expanders and/or

pressorspressors

HematologicHematologic Treat DIC with FFP and/or cryoTreat DIC with FFP and/or cryo

CNSCNS Treat seizures with phenobarbitalTreat seizures with phenobarbital Watch for signs of SIADH (decreased UOP, Watch for signs of SIADH (decreased UOP,

hyponatremia) and treat with fluid restrictionhyponatremia) and treat with fluid restriction

MetabolicMetabolic Treat hypoglycemia/hyperglycemia and metabolic Treat hypoglycemia/hyperglycemia and metabolic

acidosisacidosis

Complication:Complication:

Meningitis & neurological damage, Meningitis & neurological damage,

shock, pneumonia, DIC, congestive shock, pneumonia, DIC, congestive

heat failure, heat failure,

Considered high mortality rate. Considered high mortality rate.

Medical managementMedical management

Antibacterial according to culture.Antibacterial according to culture.

Supportive treatment: oxygen Supportive treatment: oxygen

therapy, fluids and caloric therapy, fluids and caloric

maintenance.maintenance.

Nursing interventionNursing intervention Infection control in the NICU.Infection control in the NICU.

Isolation to minimize cross infection.Isolation to minimize cross infection.

Suction as needed.Suction as needed.

Oxygen.Oxygen.

After discharge, teach family to monitor After discharge, teach family to monitor

fever, give treatment as needed. fever, give treatment as needed.