NEONATOLOGY DIVISIONDepartment of Child Health Medical School

University of Sumatera Utara

Direct Causes of Neonatal DeathsWorld Health Organization. State of the World’s Newborns 2001

Infections 32% Asphyxia 29% Complications of prematurity 24% Congenital anomalies 10% Other 5%

NEONATAL SEPSIS

DEFENITION

Neonatal sepsis is a clinical syndrome

Of sistemic illness accompanied by

bacteremia occuring in the first month

of life

PATHOPHYSIOLOGY

1. Early-onset disease Present in the first 5-7 days of life Acquired the organism during the

intrapartum period from the maternal genital tract.

Usually vertical transmission from mother

Treponemes, viruses, Listeria, Candida

PATHOPHYSIOLOGY

2. Late-onset diseaseOnset first week of lifeHistory of obsteric complicationsHorizontal transmissionPredilection for central nervous

system

Pathogens in Late Onset Sepsis in VLBW NeonatesNICHD Neonatal Research Network Experience (Pediatrics 2002)

Organism %Gram positive organisms 70.2Staphylococcus- coagulase negative 47.9Staphylococcus aureus 7.8Group B Streptococcus 2.3

Gram negative organisms 17.6E.coli 4.9Klebsiella 4.0Pseudomonas 2.7Enterobacter 2.5

Fungi 12.2Candida albicans 5.8Candida parapsilosis 4.1

PATHOPHYSIOLOGY

3. Nosocomial sepsisOccurs in high-risk newborn infantInvasive monitoring used in NICUBreaks in the natural barrier function of

the skin and intestine

4. Causative organismMost common group B strptococci (GBS)

RISK FACTOR

1. Prematurity and low birth weight

2. Rupture of membranes: > 18 h

3. Maternal peripartum fever (>380C) or infection.

4. Amniotic fluid problems: meconium-stained or foul smelling, cloudy amniotic fluid

5. Resuscitation at birth

RISK FACTOR

6. Multiple gestation

7. Invasive procedures

8. Infant with galactosemia

9. Iron therapy: enhances the growth of

many organism

CLINICAL PRESENTATION

1. Temperature irregularity: hypo or

hyperthermia

2. Change in behavior: lethargy, irritability,

or change in tone.

3. Skin: poor peripheral perfusion, cyanosis, mottling, pallor, petechiae, rashes, sclerema, or jaundice.

Pseudomonas sepsis with DIC

Invasive Candidiasis

CLINICAL PRESENTATION

4. Feeding problem: feeding intolerance, vomiting, diarrhea, abdominal distention.

5. Cardiopulmonary: tachypnea, respiratory distress, apnea, tachycardia, hypotention.

6. Metabolic: hypo or hyperglycemia or metabolic acidosis.

DIAGNOSIS

1. Laboratory studies Cultures: blood and body fluids Gram’s stain of various fluids Adjunctive laboratory tests: WBC count with

differential, platelet count, acute phase reactant (CRP, IL-1β, IL-6, IL-8, and TNF), surface neutrophil CD11.

Miscellaneous tests: bilirubin, glucose, sodium

Lumbar Puncture

Possibility of meningitis 1-10% Not all infants with meningitis will have specific symptoms

15% of babies with meningitis will have negative blood culture

Abnormal white blood cell count

Total WBC count < 5000 /L, > 25.000/LTotal neutrophil count: <1000/LImmature to total neutrophil ratio > 0.2Immature to mature neutrophil ratio > 0.2

bandform

neutrophil

C- Reactive Protein

Acute phase reactant: synthesized in 6 to hours Normal: < 1.6 mg/ dl on day 1, then < 1.0 mg/ dl Falsely elevated with asphyxia, meconium

aspiration, PROM May not be positive early (only 60% sensitivity) Repeated tests more useful (up to 84%

sensitivity) Negative Predictive value: 90%

DIAGNOSIS

2. Radiologic studiesChest x-rayUrinary tract imaging

3. Other studies: examination of the placenta

Chest X Ray

Group B streptococcal sepsis:

diffuse ground glass opacity indistinguishable from HMD

Persistent focal parenchymal lung findings

Group B StrepPneumonia

Treatment of Neonatal Sepsis

Specific Antibiotics: Ampicillin +

Aminoglycoside (gentamicin)

In nosocomial sepsis, staphylococcal coverage with Vancomycin + aminoglycoside or 3th generation of cephalosporin.

Treatment of Neonatal Sepsis

Supportive care Temperature Cardiorespiratory Hematological

- DIC: FFP, Vit K, exchange transfusion- Neutropenia: recombinant human granulocyte colony-stimulating factor (rhG

CSF) or recombinant human granulocyte macrofag colony-stimulating factor CNS: seizure controle Metabolic: monitor and treat hypo or hyperglycemia and metabolic acidosis.

Reduction of Nosocomial Infection

HandwashingEarly feedingMaternal breast milkIntravenous immunoglobulinDecrease use of broad spectrum

antibioticsDecrease use of H2 receptor blockers

Prevention of Sepsis