Typhus Gaol Fever, Epidemic Typhus Tabradillo, War Fever, Jail Fever.
Newborn fever 100512
Transcript of Newborn fever 100512
Neonatal Fever
2010-5-12
李浩遠醫師林口長庚醫院兒童內科
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Reliable Temperature Measurementn All measurements are estimates of the body’s
true core temp—central circulation=aorta and pulmonary artery.
n RECTAL—gold standardn Esophageal—accurate but impracticaln Tactile and axillary—inaccurate, varies
considerably with environmental temperaturen Tympanic—inaccurate in age <3 years
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Some Definitions
n Infant - <1 year
n Neonate - < I month
n “early onset” - < 7 days
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Small/premature =
n Poor antibody responsen Poor neutrophil responsen Poor complement activationn Impaired macrophage activityn Poor T cell functionn Reduced placental IgG
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Three Barriers to Infection
NORMALFLORA
SKIN ANDMUCOUS
MEMBRANES
IMMUNITY
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Impaired Barriers
n Thin skin
n Raw umbilicus
n Invasive devices
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
A Hazardous Journey
n The uterus: Listeria monocytogenesn The birth canal: group B streptococcusn E colin The unit: Acinetobacter baumaniin Devices: CNSn The attendants: Staph aureus
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Fever Source of Neonates
n The majority of febrile neonates presenting to the ED have a nonspecific viral illness
n 12% have serious bacterial infections (SBI)n Infected by more virulent bacterian More likely to develop serious sequelae from viral
infectionsn GBS is associated with high rates of meningitis(39%),
non-meningeal foci(10%), and sepsis(7%)n The most common bacterial infections are UTI and
occult bacteremia
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Clinical Presentations
n Not breathing welln Not feeding welln Not looking well
lethargic irritable mottledn Fever and tachycardia n Seizures AND NOT A BLOOD TEST OR X-RAY!
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Neonatal PEn PE is felt to be unreliable in detecting many serious
bacterial infections. n Meningitis should always be considered—up to 10%
appear well, only 15% have a bulging fontanelle, and 10-15% have nuchal rigidity. So, a high index of suspicion is important!!! ~20% will not have fever initially.– Hyperthermia or hypothermia– Lethargy or irritability– Poor feeding or vomiting– Apnea– Dyspnea– Jaundice– Hypotension– Diarrhea or abdominal distension– Bulging fontanelle– seizures
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Risk Factors
n Risk Factors– Preterm– Membrane rupture: before labor onset or
prolonged>12 hours– Chorioamnionitis or maternal peripartum fever– UTI– Multiple pregnancy– Hypoxia or Apgar score <6– Poverty or age <20
n 1/3-1/2 neonatal sepsis will have no risk factors!
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Diagnosis and Treatmentn if <28 days of age and rectal temp> 38ºC
– Admit– Blood Culture– Urine Culture—cath specimen– Lumbar Puncture
• Cell count, protein, glucose, culture, PCR– Parenteral Antibiotics
• Ampicillin + Gentamicin(Cefotaxime), consider Acyclovir(primary maternal infxn, esp if delivered vaginally, PROM, fetal scalp electrodes, skin eye or mouth lesions, seizures, CSF pleocytosis)
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Early Onset GBS Disease
n 376 cases in 2001n 39 died
Important because:n Identified risk factorsn Preventable
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Risk Factors
n Previous baby affected by GBSn GBS in urine at any time this pregnancyn Preterm labourn Prolonged ROMn Fever in labour
(RCOG guidelines 2003)
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Screening Based Strategy
n 27% carry it (rectal plus vaginal swabs)
n Antibiotic prophylaxis 86% reduction
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
The Disease
n Early onsetn Low apgarn Sepsisn Pneumonia
n GBS causes 70% early onset sepsisn Low birth weight
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Devices
n Initial responsen Getting worse
n Central line in situn ?CNS
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Coagulase negative staphylococci
n Gram positive coccin Normal skin floran Low grade pathogen in normal hostn Hydrophobic cell surface (adheres)n Polysaccharide production - biofilmn Neonatal infections
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Neonatal Unit B/C
n CNS 234n Stau 17n E.coli 19n GNB’s 32n GBS 18
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Attendants
n Staph aureusn Phage type 3A/3Cn Exfoliative toxin A
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Outbreak Control
n Swabs of all staff handling newbornsn Check all hands
n One individual handled 17/18 affectedn Epidemic strain from nose, axillan All other staff negativen Treatment of carrier ended outbreak
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Staphylococcus aureus
n Looks like CNS and..n Normal flora (30% adults) but..n Highly pathogenicn Exfoliative toxin A - SSSSn Potential for cross infection
n Treated with flucloxacillin
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Control Measures
Wash hands
and
check hands
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
Conclusions
n Infection: significant hazard to neonaten Bacteria for every occasion
n Smaller is frailern Never give up on a neonate
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com
P D F c r e a t e d w i t h p d f F a c t o r y t r i a l v e r s i o n www.pdffactory.com