Neonatal septicemia
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Neonatal SepticemiaNeonatal Septicemia
Li Yijuan
First Affiliated Hospital
SUMS
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Will They Have Good Future ???
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Objectives
What will I learn?
Etiologies and risk factors
Symptoms
Diagnosis
Treatment
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Introduction
Common -20% of VLBW has sepsis
-In term 0.1%-Inter-institution difference 11-32% (NICHD net work)
Serious-mortality is 3-5 times more for infant with sepsis in NICU
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What is Neonatal Sepsis?
Neonatal Septicemia is a generalized
infection characterized by the proliferation
of organisms in the blood circulation during
the first month of life.
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Some basic definitions
• SIRS(systemic inflammatory response syndrome ) - fever, tachypnoea, tachycardia, abnormal WBC
• Sepsis- systemic response to infection
• Severe sepsis- sepsis with organ dysfunction, hypotension
• Septic shock- severe sepsis with multiorgan
dysfunction
difficult to apply these definitions and a staging
system to the newborn
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Pathogen
• Staphylococcus • Escherichia coli• Conditional pathogen • Group B streptococcus
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Staphylococcus
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E. Coli
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• Staphylococcus epidermidis
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• Pseudomonas aeruginosa
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Klebsiella
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• Clostridium perfringens
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Group B -hemolytic streptococcus
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Route of Infection
• Prenatal infection
• infection during delivery
• postnatal infection
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Sepsis Risk Factors
• Prematurity
• Birth weight
– Term 0.1%
– 1,000 -1,500 g 10%
– <1,000 g 35%
– <750 g. 50%
• Delay enteral feeding and Prolonged TPN
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I.Risk Factors (maternal and neonatal)A.Major
1.Maternal prolonged Rupture of Membranes >24 hours 2.Intrapartum maternal fever >38 C (>100.4 F) 3.Chorioamnionitis 4.Sustained Fetal Tachycardia >160 beats per minute
B.Minor 1.Intrapartum maternal fever >37.5 C (>99.5 F) 2.Twin Gestation 3.Premature infant (<37 weeks) 4.Maternal Leukocytosis (White Blood Cell count >15000) 5.Rupture of Membranes > 12 hours 6.Tachypnea (<1 hour) 7.Maternal Group B Streptococcus Colonization 8.Low APGAR (<5 at 1 minute) 9.Low birth weight (<1500 grams) 10.Foul lochia
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What makes a neonate’s immune system susceptible to sepsis?
Maturity
Immaturity
or
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You’re Right!!!!
The immaturity of a neonate’s immune system makes them MORE SUSCEPTIBLE to sepsis.
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Why are newborns so vulnerable to infection?
Non-specific immunity
Specific immunity
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IMMUNE SYSTEM
Neutrophils –Qualitative
and quantitative
Complement andimmunoglobulinlevels decreased
T cells- antigenically naïve
limited cytokineproduction
Why are newborns so vulnerable to infection?
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• Poor skin barrier
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• Umbilical stump
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Classification
• Early onset sepsis (EOS):– bacteria acquired before and during delivery– 5-7/1000 live birth– 1.5% of VLBW infants had EOS (intrapartum
antibiotics)
• Late onset sepsis (LOS): – bacteria acquired after delivery (Nosocomial
or community)– 20% of VLBW infants
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Clinical menifestationsClinical menifestationsClinical menifestationsClinical menifestations
EOS LOS
Onset Within 7 days >7 days
Source Prenatal
During delivery
During delivery
Postnatal(nosocomial )
Pathogens G-bacili Staphylococcus;
Opportunitic
Presentation
Mortality
Pneumonia
High
Bacteremia and / or meningitis
Low
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Symptoms of Neonatal Sepsis
The symptoms are not concrete and vary widely
Tachypnea Heart Rate Changes
Feeding difficulties
Difficulty Breathing Temperature Instability
Jaundice Irritability
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Omphalitis
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Bleeding tendencyPoor perfusion
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Enlargement of liver and spleen
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toxical paralytic ileus
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NEC
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NEC
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dyspnea
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Clinical presentation
Early warning signs are often non-specific and subtle
easily confused with non-infective causes (e.g. apnea of prematurity, variation in environmental temperature or
acute exacerbation of chronic lung disease)
clinical course alarmingly fulminant
septic shock + DIC
death
Non-specific, multi- systems/organs involved
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Clinical manifestationClinical manifestation
The symptoms are so broad , non-specific,
and acute deterioration,
How to make a diagnosis as early as possible ?
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Laboratory studies
• Evidence for inflammation
• Evidence for infection
• Evidence for multiorgan system disease
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Laboratory Examination: CBC
• WBC<5×109/L or WBC>20× 109/L
• I/T≥0.2 , toxic granules
• thrombocytopenia <100×109/L
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Reference values for neutrophilic cells
Manroe BL, J Pediatr 1979;95:89-98.
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Total neutrophils
Immature neutrophil
I/T ratio
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Lab examination:CRP
• CRP
• α1-AG
• α1-AT
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Lab Exam: Organism detection
blood culture
culture of body fluid and secretion
plasma brown layer smear
--Detection of antigen: usually for antibody
of GBS or E coli in CSF, blood and urine
--Molecular biochemical method PCR
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Summary
Is there a diagnostic marker
for neonatal sepsis?
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Great answer! You’re correct!
• There is NOT a specific diagnostic marker, only determinants of infection
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Summary
The best approach for diagnosis of systemic bacterial infection:
• use of multiple markers (e.g. CRP, IL-6, TNF, CD64), and
• serial measurements
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Diagnosis • history
–high risk factors• clinical manifestation
--nonspecific S/S• lab results
- abnormal blood routine,
CRP, positive culture
or detection of organisms
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Therapy
• Infection should be the first thought
when an infant has symptoms
• Aggressive treatment should begin before
the diagnosis is confirmed.
• Therapy can be discontinued if sepsis is
excluded
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Treatment
Antibiotics therapy
management of complications
supporting therapy
Clearance of infectious focus
Immunotherapy
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Antibiotic therapy
• using antibiotics as early as possible
• choose antibiotics according to drug sensitivity
• giving drugs intravenously
• combine effective drugs to make synergism
• enough therapeutic course
• consider the possible side effects
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Dosages of antibiotics for newborns
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Supporting therapy
• Nursing care
--warm environment
--oxygen supply
• correction of acidosis and electrolyte
disturbance
• fluid , glucose and nutrition balance
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Management of complications
• Shock
• DIC
• Cerebral edema
• Pulmonary hemorrhage
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Immunotherapy
• IVIG
• Exchange transfusion
• Granulocyte transfusion , G-CSF
• Platelet transfusion
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Questions
• Could prophylatic IVIG reduce the
morbidity and mortality of neonatal
sepsis?
• Might prophylatic IVIG interfere the
development of the neonatal IM
system?
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Thank you for your attentionThank you for your attention