SlideShare una empresa de Scribd logo
1 de 86
Descargar para leer sin conexión
Neonatal bacterial infections by upasana patra
SPECTRUMOF NEONATAL BACTERIALINFECTIONS-
EARLY DIAGNOSIS, TREATMENT & OUTCOME
• BY DR UPASANA PATRA
• GUIDE: Dr SANTOSH PRADHAN
• ASST PROFESSOR, DEPT OF PAEDIATRICS
• MKCG MCH
SEPTICEMIA
UTI
CONJUNCTIVITIS OSTEOMYELITIS
TETANUS
MENINGITIS PNEUMONIA
SKIN
INFECTIONS
SEPTIC
ARTHRITIS
Neonatal Sepsis
Early Onset
• < 72 hrs
• Acquired around birth
• Intrapartum
transmission
• Fulminant course
Late Onset
• > 72 hrs-90 days
• Environment
• Nosocomial or hospital
acquired
• Slower progression
RISK
FACTORS
CAUSATIVE
AGENTS
NEONATAL
SEPSIS
Risk factors - EOS
Maternal GBS colonization (especially if
untreated during labor)
Premature rupture of membranes (PROM)
Preterm rupture of membranes (<37 wks)
Prolonged rupture of membranes (> 18 HRS)
Prematurity
Maternal urinary tract infection
Chorioamnionitis
Multiple pregnancies
GBS
Other
Streptococcus
Gram negative
organisms
E COLI
Klebsiella,
Pseudomonas,
Haemophillus
Bacteroids
Fragilis
Coagulase
Negative
Staphylococcus
Enterococcus
Listeria monocytogens
Citrobacter diversus
EOS
Common pathogens of neonatal sepsis in developed countries
Early-onset Late-onset
Pathogen Frequency
(%)
Pathogen Frequency
(%)
Group B Streptococcus 43–58 Coagulase-negative Staphylococcus 39–54
E. coli 18–29 E. coli 5–13
Other gram-negative bacteria 7–8 Klebsiella sp. 4–9
S. aureus 2–7 S. aureus 6–18
Coagulase-negative Staphylococcus 1–5 Candida albicans 6–8
L. monocytogenes 0.5–6 Enterococcus sp. 6–8
P. aureginosa 3–5
Other Candida species 3–4
a
Common pathogens of neonatal sepsis in developing countries
Community-acquired Hospital-acquired
Pathogen Frequency (%) Pathogen
Klebsiella sp.
S. aureus
E. coli
Group B Streptococcus
S. pneumonia
Salmonellasp.
14–21
13–26
8–18
2–8
2–5
1–5
Klebsiella sp.
S. aureus
E. coli
Coagulase-negative Staphylococcus
Pseudomonas sp.
Enterobacter sp.
Candida sp.
16–28
8–22
5–16
8–28
3–10
4–12
0.3–3
Frequency (%)
JournalofTropicalPediatrics,2015, 61, 1–13 doi: 10.1093/tropej/fmu079
Clinical Review
Early onset sepsis among very low birth weight infants in the developed countries
LOS
• 2 TYPES- A)HEALTHY TERM INFANTS IN COMMUNITY
B) HOSPITAL ACQUIRED PREMATURE INFANTS IN NICU
• Acc to NICHD- 77%-Gram positive org
18%-Gram negative org
8%-Fungal
Factors that confer a greater risk for LOS .
Coagulase –
negative
staphylococcus
Enterobacter
Citrobacter
serratia
LOS
Staphylococcus
aureus Enterococci
Multidrug resistant
gram negative rods
(E COLI
KLEBSIELLA
PSEUDOMONAS)
13
Diagnosis of Neonatal Sepsis -
clinical signs and symptoms
Clinical Signs: early signs non- specific, may be subtle
• Respiratory distress- 90%
• Apnea
• Temperature instability-  temp more common
• Decreased activity
• Irritability
• Poor feeding
• Abdominal distension
• Hypotension, shock, purpura, seizures- late signs
SYMPTOMS
SYSTEM SIGNS
Respiratory (MC) Apnea
Tachypnea
Grunting, nasal flaring
Retractions
Decreased oxygen saturation
Metabolic acidosis
Respiratory failure
Cardiovascular Decreased cardiac output
Tachycardia/ Bradycardia
Hypotension
Poor perfusion
Central nervous Temperature instability
Lethargy, depressed sensorium
Cont..
SYSTEM SIGNS
Hypotonia
Irritability, seizures
Gastrointestinal Feeding intolerance
Poor sucking
Ileus
Abdominal distention
Vomiting, diarrhea
Integumentary Jaundice, Pallor
Cellulitis, abscess
Petechiae, Purpura
Sclerema
Erythema multiforme & Ecthyma
Metabolic signs
• Hypoglycemia
• Hyperglycemia
• Metabolic acidosis
Differential Diagnoses
Respiratory distress syndrome
Transient tachypnoea of newborn
Meconium Aspiration Syndrome
Pneumothorax
Congenital anomalies
Bowel Obstruction in the Newborn
Intracranial haemorrhage
Hydrocephalous
Electrolyte abnormalities
Hypothyroidism
Congenital cyanotic heart disease
Inborn error of metabolism
Congenital adrenal hyperplasia
Congenital viral disease
Congenital Diaphragmatic Hernia
Hemolytic Disease of Newborn
Necrotizing Enterocolitis
Pulmonary Hypoplasia
Dehydration
NEONATAL MENINGITIS
The clinical presentation is usually nonspecific.
• Meningitis must be excluded in any infant being evaluated for
sepsis or infection.
Forced posture of newborn with meningitis
Meningitis
The principal pathogens in neonatal meningitis are GBS (36% ), E coli
(31%), and Listeria species (5-10%). Other organisms :
S pneumoniae
S aureus
S epidermidis
H influenzae
Pseudomonas species
Klebsiella species
Serratia species
Enterobacter species
Proteus species
Neonatal bacterial infections by upasana patra
Meningitis
• Ventriculitis
• Arachnoiditis
• Vasculitis
• Cerebral edema
• Infarction
Mortality rate in neonatal meningitis is approximately 10 percent
Survivors– Neurological sequelae & lifelong impairments
20% of survivors- severe disability,
35% of survivors-mild to moderate disability
Neonatal Pneumonia
Infectious
GBS
Haemophilus influenzae
Gram neg bacilli
Listeria monocytogens
Enterococci
Staphylococcus aureus
Non infectious
Diffuse alveolar damage
Organising pneumonia
Aspiration
Non specific interstotial
 Klebsiella & S aureus- generate severe lung damage, microabscesses and empyema
Early onset GBS pneumonia has fulminant course, with mortality in first 48 hours of life.
If the infant has remained hospitalized in NICU with endotracheal intubation and
mechanical ventilation, the organisms may include Staphylococcus or Pseudomonas .
Neonatal bacterial infections by upasana patra
DIAGNOSIS
TREATMENT
PREVENTION
There is No Substitute for Clinical Acumen
25
‘’RULE OUT’’
SEPSIS
‘’RULE IN’’
SEPSIS
Diagnostictests
Definitive,Specific
•
•
•
•
•
•
Bloodculture
CSFculture
Urine culture
Trachealaspirate culture
Polymerase chain reaction
Latexparticle agglutination
test
•
•
•
•
Nonspecific,Diagnostic
White blood cell count
C-reactiveprotein(CRP)
Micro ESR
Other acutephase
reactants
27
Sepsisscreen
• Doneto rule out sepsisrather than to rule in
sepsis.
• Consistsof :
– C-reactiveprotein (CRP),
– Total leukocytecount(TLC),
– Absolute neutrophil count(ANC),
– Immatureto total neutrophil ratio (ITR),
– micro-erythrocyte sedimentation rate(μ-ESR)
– Plateletcount
28
29
Twoor more parameters of thesepsisscreenare
positive ->sepsisscreenpositive
If all the parameters of the sepsisscreenare negative
in aneonate ->low probability ofsepsis, antibiotics
need not be started and the neonate must be
monitoredclinically.
Thescreenmust be repeated after 12hours.
Twoconsecutive completely negative screens are
suggestiveof nosepsis.
30
31
32
33
34
Micro-ESR
• Measures ESR in vertically placed capillary tube in
1 hour.
• Normal: day of life plus 3 mm/ hr, up to a
maximum of 14 mm/ hr
• > 15mm is abnormal in 1st hour
• Poor sensitivity and specificity
– False positive tests with hemolysis
– False negative tests with DIC
CRP vs PROCALCITONIN
• Level>1mg/dl-
abnormal
• Takes 10-12hrs
• Half life-24-48hrs
• Peak-12-24hrs
• Serial
measurement>Single
values
• Cut off-2.4ng/ml
• Takes2-4hrs
• Half life-24-30hrs
• Peak-6-8hrs
36
BLOOD CULTURE
Gold standard for diagnosis of bacteremia
• Add at least 1.0 ml blood obtained by sterile
venipuncture to 5-10 ml culture broth (ideally 2
bottles)
• Most bacteria grow within 24 to 36 hours
• BACTEC and BACT/ALERT blood culture system
Baby has risk factors and clinical signs of sepsis but
blood culture is negative
Blood cultures are positive in only 2 to 25% of babies with clinically suspected sepsis.
37
38
Neonatal bacterial infections by upasana patra
40
Neonatal bacterial infections by upasana patra
• Culture positive after 72 hours
• Polymicrobial culture
• Growth of purely skin organisms
43
Lumbar Puncture
Possibility of meningitis 1-10%
Sepsis & meningitis overlap
INDICATIONS
Blood culture positive
Symptomatic infants with high risk for EOS condition stable
to tolerate LP
Negative blood culture treated empirically for clinical
diagnosis of sepsis
LOS- prior to starting antibiotics
15% of babies with meningitis will have negative blood
cultures
CSF values
CSF COMPONENTS TERM NEONATES PRETERM(VLBW)
Cells/mm3 8 (0-30cells) 5 (0-44)
PMN(%) 60% 8% (0-66)
CSF Protein(mg/dl) 90 (20-170) 148 (54-370)
CSF glucose(mg/dl) 52 (34-119) 67 (33-217)
CSF/Blood glucose(%) 51 (44-248)
44
AIIMS PROTOCOL
45
Urine culture
Sterile specimen obtained by sterile
catheterization or by suprapubic bladder
aspiration(ideal)
UTI-single uropathogenic pathogen >50000
CFU/ml
10000-50000CFU/ml with associated
pyuria(WBC>5/HPF)
Any 1 organism from suprapubic aspiration
• Cultures from central lines
• Surface cultures
• Endotracheal cultures
• Gastric aspirate cultures>More than 5 neutrophils/HPF
indicate exposureto chorioamnionitis.
Poor Sensitivity and Specificity
46
DEVELOPING BIOMARKERS
SERUM AMYLOID A
LIPOPOLYSACCHARIDE BINDING/MANNOSE BINDING
PROTEIN
47
OTHER BIOMARKERS
Alpha-1 antitrypsin
Fibronectin
Haptoglobulin
Lactoferrin
neopterin
48
CYTOKINES &CHEMOKINES
• IL-6,8,10,TNF-alpha,IFN-gamma,TGF-beta
• Increase very rapidly
• Normalise within 24 hrs
• Increase IL-10 to TNF-alpha ratio  severe LOS in VLBW
infants
• IL-6,IL-10 & RANTES  morbidity in sepsis with DIC
49
Combination of cytokine profiles inc likelihood of identifying infection more than
single measurements
CELL SURFACE ANTIGENS
• CD 11b, 14,16, 64 etc
• CD 64 sensitive biomarker for EOS & intraabdominal
infections even before rise of CRP
• Pentraxin 3 (PTX3)
• Angiopoietins 1 & 2 low ang1 & high ang2 predict
poor prognostic outcome of sepsis
• STREM-1
• SuPAR
50
hs CRP (high sensitive CRP)
sISAM-1 (soluble intracellular adhesion molecule 1)
Soluble E-selectin
MOLECULAR TECHNOLOGY
• q PCR- Detect bacterial DNA in body fluid of host suspected of
infection
• FISH
ADVANTAGE
 Underlying pathological events
 Development of new diagnostic approaches
 Algorithms
 Score systems
BIOFLUID ANALYSIS saliva,urine
52
GENOMICS
• To identify genes that demonstrate altered regulation during
infection
• Focus on chemokine mRNA expression & its relation to infection
• Inc IL8  Perinatal infection
• Inc IL8 & MCP-1Perinatal asphyxia
PROTEOMICS
Involve separation of proteins based n intrinsic properties like
molecular weight, isoelectric point or affinity to metals or
antibodies
Identify protein signatures & functionally expressed metabolites
during specific disease states
53
METABOLOMICS
• Use spectrometric techniques
• NMR
• Mass spectrometry
of urine , blood or tissue
54
Evaluation of extent of the
disease
• LPfor meningitis
• Urine examination
• CXR
• Xrayerect abdomen
• Stool for occultblood
• Bone scan
• Neuroimaging
55
Look for biochemicalabnormalities
• Blood glucose
• Blood urea
• Serumcreatinine
• TSB
• Serumelectrolytes
• ABG
56
Cloherty
Neonatal bacterial infections by upasana patra
Management of Women With Preterm Prelabor Rupture
of Membranes.
A C O G C O M M I T T E E O P I N I O N , 2 0 1 9
Antibiotic Regimen for Group B Streptococcus
Prophylaxis in Labor
In 2018, the stewardship and charge for updating the GBS prophylaxis guidelines
were transferred from the CDC to ACOG and the American Academy of Pediatrics
Prevention of LOS
• IV IG
• G-CSF / GM-CSF
• Probiotics
• Lactoferrin
• Antistaphylococcal monoclonal antibodies
• Prophylactic vancomycin
• Establishment of early enteral feedings
• Antibiotic restriction
• Surveillance practices
Neonatal bacterial infections by upasana patra
http://newbornsepsiscalculator.org.
Sepsis Calculator - Assessment of EarlyOnset
Sepsis in Infants > 35 Weeks
• Three groups of infants require a blood culture and antibiotic treatment
without delay:
Unwell appearing infants.
Infants whose sibling had EOS.
Infants whose mother currently has Group A Streptococcal infection.
calculation of EOS score:
 Gestational age.
 Highest maternal antepartum temperature
 Duration of rupture of membranes.
 GBS status
 Maternal intrapartum antibiotics.
NEWBORN CLINICAL PRESENTATION
The EOS risk score then incorporates the newborn clinical presentation as:
Well appearing.
Equivocal signs.
Clinical illness.
Definition of Equivocal Clinical Signs
Clinical Parameters Assessed Equivocal signs
Heart rate > 160/min 2 clinical parameters abnormal for >2hrs
Respiratory rate > 60/min or
Temperature > 38.0°C or <36.4 C 1 clinical parameter abnormal for 4 hrs
Respiratory distress
Interpretation of EOS Risk Score Results and
Management
• Management Plan for GREEN Group:
• Routine care.
• Early discharge possible
• Management Plan for YELLOW Group:
• BLOOD CULTURE AND OBSERVATION.
• No routine full blood count or CRP.
• Infants with equivocal signs - observation in neonatal unit; when signs normalised.
• Infants with medium risk, but normal exam may be observed (3 hourly vital signs) on
postnatal wards until blood culture result available.
• If abnormal clinical parameters develop, the infant requires urgent paediatric review
• If equivocal signs develop, infant requires transfer to neonatal unit
• Management Plan for RED Group:
• TAKE BLOOD CULTURE AND TREAT WITH EMPIRIC ANTIBIOTICS.
• With the blood culture, take full blood count and CRP.
Treatment of neonatal sepsis may
be divided into
antimicrobal therapy supportive care
(for the suspected or
known pathogen)
The initial diagnosis of sepsis is, by necessity, a clinical one
because it is imperative to begin treatment before
the results of culture appear
Supportive therapy
Respiratory
Oxygen and ventilation as necessary
Cardiovascular
Volume expanders,Dopamine, FFP to correct
perfusion
Hematologic
Treat bleeding- vit k,FFP, fresh blood, platelet
CNS
Treat seizures with phenobarbital
Metabolic
Treat hypoglycemia/hyperglycemia and
metabolic acidosis
Principles for antibiotic use
• Empiric initiation of
antibiotics
• Switch antibiotics based
on susceptibility patterns
• Define duration of
antibiotic therapy
• Use only when bacterial infections
are likely and discontinue empiric
treatment when they have not
been identified.
• Change the antibiotic agents to
those with the narrowest
spectrum.
• Establish a final duration of
antibiotic management based on
the disease process.
71
First line therapy
Ampicillin
+
Gentamicin
Baby not responding to first line antibiotics
• 3rd generation cephalosporin
– cefotaxime
– ceftazidime
72
AAP RECOMMENDATION
AIIMS PROTOCOL FOR SEPSIS
Neonatal bacterial infections by upasana patra
Duration of Antibiotic therapy
• Gram negative septicemia: 14 days
• Group B Strep septicemia: 10-14 days
• Gram negative meningitis: 21 days minimum
• Group B Strep meningitis: 14 - 21 days
• Culture negative sepsis
• Asymptomatic neonate at risk of EOS ?
• Suspected EOS/ LOS & neonate asymptomatic over time ?
• Suspected EOS/ LOS & neonate improves but doesnot become
asymptomatic ?
• Osteoarticular infection should be treated for 3 to 4 weeks
• Ventriculitis should be treated for at least 4 weeks.
Upgradation of Empirical Antibiotics
NO CLINICAL IMPROVEMENT IN 48-72 hrs
Extremely sick babies start with higher antibiotics
as per clinical situation
DEVELOPMENT OF SCLEREMA
Newer antibiotics-Beta lactamase
inhibitors
• Production of beta lactamase by gram
negative bacteria greatest threat to efficacy of
antibiotics
• To counteract this-Beta lactamase inhibitors
combined with Beta lactam antibiotics
• New- Avibactam, Relebactam, Vaborbactam
ADJUNCTIVE IMMUNOTHERAPIES for EOS
• DVET
• Granulocyte transfusion
• IV IG
• Recombinant G-CSF & GM-CSF
• Activated protein C
• Pentoxifyllin
Background
• Neonatal sepsis may be categorized as early-onset or
late-onset. Of newborns with early-onset sepsis, 85%
present within 24 hours, 5% present at 24-48 hours,
and a smaller percentage present within 48-72
hours.
• Onset is most rapid in premature neonates.
• Early-onset sepsis is associated with acquisition of
microorganisms from the mother.
• Late-onset sepsis occurs at 4-90 days of life and is
acquired from the caregiving environment.
• ANAEROBIC BACTERIAL INFECTIONS
• T/t-Metronidazole
• Neonatal tetanus
• T/t- TIG , Penicillin
• FOCAL BACTERIAL INFECTIONS
• Cellulitis
• Pustulosis
• Omphalitis
OPTHALMIA NEONATRUM/
CONJUNCTIVITIS
• Chlamydia trachomatis (oculogenitalis)
• Other bacterial causes : gonococcus (rare),
staphylococcus, pseudomonas, etc.
• Chemical – silver nitrate
• Viral : herpes simplex (type II)
TREATMENT
Prophylaxis : 1% silver nitrate solution
0.5% erythromycin opthalmic ointment,
1% tetracycline,
2.5% povidone iodine solution
administered within 1 hour of birth.
Treatment depend upon the specific aetiology.
• Gonococcal –Ceftriaxone 50 mg/kg/q 12 h IM/IV.
Uncomplicated-Single dose
Complicated - 7 days
• Chlamydia – erythromycin suspension 40 mg/kg daily
orally divided into 4 doses for 14 days
Osteomyelitis & Septic arthritis
Causative organism
Sites
Treatment
TAKE HOME MESSAGES
Gram negative organisms MCC for neonatal sepsis in India
PCT superior to CRP in early diagnosis of Neonatal sepsis
serial C-reactive protein levels and serial assessment of
immature:total neutrophil counts provide the best negative
predictive value for neonatal sepsis.
Hematological scoring system –screening test for early
diagnosis of neonatal infections
PCR reduces antibiotic use & length of stay in hospital
1st line drug-Ampicillin+Gentamicin
Treatment should be according to antibiotic susceptibility to
prevent emergence of MRSA, VRSA, VRE
REFERENCES
• CLOHERTY AND STARK’S MANUAL OF NEONATAL CARE 8th
EDITION
• AIIMS PROTOCOL,2nd EDITION
• NELSON TEXTBOOK OF PAEDIATRICS,21st INTERNATIONAL
EDITION
• Neonatal Infectious DiseasesEvaluation of Neonatal Sepsis,
Andres Camacho-Gonzalez, MD, MSca,*, Paul W. Spearman,
MDa
, Barbara J.Stoll, MDb
• Biomarkers for neonatal sepsis: recent developments
Authors Mally P, Xu J, Hendricks-Muñoz K
“ I am not sure exactly what heaven will be like,
but i do know that when we die and it comes time
for god to judge us, He will not ask, How many
good things have you done in your life, rather he
will ask, HOW MUCH LOVE did u put into what you
did?”

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
37454656 preeclampsia-atypical-sibai
37454656 preeclampsia-atypical-sibai37454656 preeclampsia-atypical-sibai
37454656 preeclampsia-atypical-sibai
 
Acute pancreatitis : Definition, Diagnosis and Management
Acute pancreatitis : Definition, Diagnosis and ManagementAcute pancreatitis : Definition, Diagnosis and Management
Acute pancreatitis : Definition, Diagnosis and Management
 
Acls
Acls Acls
Acls
 
Pathology of the Adrenal Gland
Pathology of the Adrenal GlandPathology of the Adrenal Gland
Pathology of the Adrenal Gland
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Acute Pancreatitis by dr anoop
Acute Pancreatitis by dr anoopAcute Pancreatitis by dr anoop
Acute Pancreatitis by dr anoop
 
Hellp
Hellp Hellp
Hellp
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
ACUTE PANCREATITIS
ACUTE PANCREATITISACUTE PANCREATITIS
ACUTE PANCREATITIS
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Renal Diagnostic Tests OR Investigations
Renal Diagnostic Tests OR InvestigationsRenal Diagnostic Tests OR Investigations
Renal Diagnostic Tests OR Investigations
 
acute pancreatitis
 acute pancreatitis acute pancreatitis
acute pancreatitis
 
Acute pancreatitis nikhil
Acute pancreatitis nikhilAcute pancreatitis nikhil
Acute pancreatitis nikhil
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Adrenal insufficiency
Adrenal insufficiencyAdrenal insufficiency
Adrenal insufficiency
 
Antibiotics
AntibioticsAntibiotics
Antibiotics
 
Disorders of micturation
Disorders of micturationDisorders of micturation
Disorders of micturation
 

Similar a Neonatal bacterial infections by upasana patra

Neonatal sepsis
Neonatal sepsisNeonatal sepsis
Neonatal sepsisdrskverma2
 
NEPHRITIC SYNDROME / APSGN IN CHILDREN
NEPHRITIC SYNDROME / APSGN IN CHILDREN NEPHRITIC SYNDROME / APSGN IN CHILDREN
NEPHRITIC SYNDROME / APSGN IN CHILDREN Sajjad Sabir
 
Nephritic vs nephrotic syndrome6npoqoa8qakc (1).pdf
Nephritic vs nephrotic syndrome6npoqoa8qakc (1).pdfNephritic vs nephrotic syndrome6npoqoa8qakc (1).pdf
Nephritic vs nephrotic syndrome6npoqoa8qakc (1).pdfArun170190
 
Perinatal asphyxia.lecture.pptx
Perinatal asphyxia.lecture.pptxPerinatal asphyxia.lecture.pptx
Perinatal asphyxia.lecture.pptxAmirAhmedGeza
 
Perinatal asphyxia.lecture.pptx
Perinatal asphyxia.lecture.pptxPerinatal asphyxia.lecture.pptx
Perinatal asphyxia.lecture.pptxAmirAhmedGeza
 
Neuroendocrine tumors of pancreas
Neuroendocrine tumors of pancreasNeuroendocrine tumors of pancreas
Neuroendocrine tumors of pancreasvipul1992bhu
 
Neonatal sepsis in brief
Neonatal sepsis in briefNeonatal sepsis in brief
Neonatal sepsis in briefUjjwalMandal11
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisDrbd Soni
 
Acute-Pancreatitis copy 1.pptx
Acute-Pancreatitis copy 1.pptxAcute-Pancreatitis copy 1.pptx
Acute-Pancreatitis copy 1.pptxUgo161BB
 
Neonatal Sepsis
Neonatal SepsisNeonatal Sepsis
Neonatal SepsisCSN Vittal
 
Neonatal sepsis kinara
Neonatal sepsis kinaraNeonatal sepsis kinara
Neonatal sepsis kinaraKinara Kenyoru
 
Mahsa - presentation on Sepsis 8-4-22.pptx
Mahsa - presentation on Sepsis 8-4-22.pptxMahsa - presentation on Sepsis 8-4-22.pptx
Mahsa - presentation on Sepsis 8-4-22.pptxBishan Rajapakse
 
Leptospirosis in child in mumbai
Leptospirosis in child in mumbaiLeptospirosis in child in mumbai
Leptospirosis in child in mumbaiChetanChaudhari62
 
Neonatal sepsis_.pptx
Neonatal sepsis_.pptxNeonatal sepsis_.pptx
Neonatal sepsis_.pptxghfgfghfgh
 

Similar a Neonatal bacterial infections by upasana patra (20)

Neonatal sepsis
Neonatal sepsisNeonatal sepsis
Neonatal sepsis
 
Neonatal sepsis
Neonatal sepsisNeonatal sepsis
Neonatal sepsis
 
Ventriculitis.pptx
Ventriculitis.pptxVentriculitis.pptx
Ventriculitis.pptx
 
NEPHRITIC SYNDROME / APSGN IN CHILDREN
NEPHRITIC SYNDROME / APSGN IN CHILDREN NEPHRITIC SYNDROME / APSGN IN CHILDREN
NEPHRITIC SYNDROME / APSGN IN CHILDREN
 
Neonatal sepsis
Neonatal sepsisNeonatal sepsis
Neonatal sepsis
 
NEONATAL SEPSIS
NEONATAL SEPSISNEONATAL SEPSIS
NEONATAL SEPSIS
 
Nephritic vs nephrotic syndrome6npoqoa8qakc (1).pdf
Nephritic vs nephrotic syndrome6npoqoa8qakc (1).pdfNephritic vs nephrotic syndrome6npoqoa8qakc (1).pdf
Nephritic vs nephrotic syndrome6npoqoa8qakc (1).pdf
 
Perinatal asphyxia.lecture.pptx
Perinatal asphyxia.lecture.pptxPerinatal asphyxia.lecture.pptx
Perinatal asphyxia.lecture.pptx
 
Perinatal asphyxia.lecture.pptx
Perinatal asphyxia.lecture.pptxPerinatal asphyxia.lecture.pptx
Perinatal asphyxia.lecture.pptx
 
Neuroendocrine tumors of pancreas
Neuroendocrine tumors of pancreasNeuroendocrine tumors of pancreas
Neuroendocrine tumors of pancreas
 
Neonatal sepsis in brief
Neonatal sepsis in briefNeonatal sepsis in brief
Neonatal sepsis in brief
 
Neonatal sepsis and antibiotic therapy in newborns
Neonatal sepsis and antibiotic therapy in newbornsNeonatal sepsis and antibiotic therapy in newborns
Neonatal sepsis and antibiotic therapy in newborns
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Acute-Pancreatitis copy 1.pptx
Acute-Pancreatitis copy 1.pptxAcute-Pancreatitis copy 1.pptx
Acute-Pancreatitis copy 1.pptx
 
Neonatal Sepsis
Neonatal SepsisNeonatal Sepsis
Neonatal Sepsis
 
Neonatal sepsis kinara
Neonatal sepsis kinaraNeonatal sepsis kinara
Neonatal sepsis kinara
 
Mahsa - presentation on Sepsis 8-4-22.pptx
Mahsa - presentation on Sepsis 8-4-22.pptxMahsa - presentation on Sepsis 8-4-22.pptx
Mahsa - presentation on Sepsis 8-4-22.pptx
 
Leptospirosis in child in mumbai
Leptospirosis in child in mumbaiLeptospirosis in child in mumbai
Leptospirosis in child in mumbai
 
Case capsules
Case capsulesCase capsules
Case capsules
 
Neonatal sepsis_.pptx
Neonatal sepsis_.pptxNeonatal sepsis_.pptx
Neonatal sepsis_.pptx
 

Último

Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 

Último (20)

Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 

Neonatal bacterial infections by upasana patra

  • 2. SPECTRUMOF NEONATAL BACTERIALINFECTIONS- EARLY DIAGNOSIS, TREATMENT & OUTCOME • BY DR UPASANA PATRA • GUIDE: Dr SANTOSH PRADHAN • ASST PROFESSOR, DEPT OF PAEDIATRICS • MKCG MCH
  • 4. Neonatal Sepsis Early Onset • < 72 hrs • Acquired around birth • Intrapartum transmission • Fulminant course Late Onset • > 72 hrs-90 days • Environment • Nosocomial or hospital acquired • Slower progression
  • 6. Risk factors - EOS Maternal GBS colonization (especially if untreated during labor) Premature rupture of membranes (PROM) Preterm rupture of membranes (<37 wks) Prolonged rupture of membranes (> 18 HRS) Prematurity Maternal urinary tract infection Chorioamnionitis Multiple pregnancies
  • 8. Common pathogens of neonatal sepsis in developed countries Early-onset Late-onset Pathogen Frequency (%) Pathogen Frequency (%) Group B Streptococcus 43–58 Coagulase-negative Staphylococcus 39–54 E. coli 18–29 E. coli 5–13 Other gram-negative bacteria 7–8 Klebsiella sp. 4–9 S. aureus 2–7 S. aureus 6–18 Coagulase-negative Staphylococcus 1–5 Candida albicans 6–8 L. monocytogenes 0.5–6 Enterococcus sp. 6–8 P. aureginosa 3–5 Other Candida species 3–4 a Common pathogens of neonatal sepsis in developing countries Community-acquired Hospital-acquired Pathogen Frequency (%) Pathogen Klebsiella sp. S. aureus E. coli Group B Streptococcus S. pneumonia Salmonellasp. 14–21 13–26 8–18 2–8 2–5 1–5 Klebsiella sp. S. aureus E. coli Coagulase-negative Staphylococcus Pseudomonas sp. Enterobacter sp. Candida sp. 16–28 8–22 5–16 8–28 3–10 4–12 0.3–3 Frequency (%) JournalofTropicalPediatrics,2015, 61, 1–13 doi: 10.1093/tropej/fmu079 Clinical Review
  • 9. Early onset sepsis among very low birth weight infants in the developed countries
  • 10. LOS • 2 TYPES- A)HEALTHY TERM INFANTS IN COMMUNITY B) HOSPITAL ACQUIRED PREMATURE INFANTS IN NICU • Acc to NICHD- 77%-Gram positive org 18%-Gram negative org 8%-Fungal
  • 11. Factors that confer a greater risk for LOS .
  • 13. 13 Diagnosis of Neonatal Sepsis - clinical signs and symptoms Clinical Signs: early signs non- specific, may be subtle • Respiratory distress- 90% • Apnea • Temperature instability-  temp more common • Decreased activity • Irritability • Poor feeding • Abdominal distension • Hypotension, shock, purpura, seizures- late signs
  • 14. SYMPTOMS SYSTEM SIGNS Respiratory (MC) Apnea Tachypnea Grunting, nasal flaring Retractions Decreased oxygen saturation Metabolic acidosis Respiratory failure Cardiovascular Decreased cardiac output Tachycardia/ Bradycardia Hypotension Poor perfusion Central nervous Temperature instability Lethargy, depressed sensorium
  • 15. Cont.. SYSTEM SIGNS Hypotonia Irritability, seizures Gastrointestinal Feeding intolerance Poor sucking Ileus Abdominal distention Vomiting, diarrhea Integumentary Jaundice, Pallor Cellulitis, abscess Petechiae, Purpura Sclerema Erythema multiforme & Ecthyma
  • 16. Metabolic signs • Hypoglycemia • Hyperglycemia • Metabolic acidosis
  • 17. Differential Diagnoses Respiratory distress syndrome Transient tachypnoea of newborn Meconium Aspiration Syndrome Pneumothorax Congenital anomalies Bowel Obstruction in the Newborn Intracranial haemorrhage Hydrocephalous Electrolyte abnormalities Hypothyroidism Congenital cyanotic heart disease Inborn error of metabolism Congenital adrenal hyperplasia Congenital viral disease Congenital Diaphragmatic Hernia Hemolytic Disease of Newborn Necrotizing Enterocolitis Pulmonary Hypoplasia Dehydration
  • 18. NEONATAL MENINGITIS The clinical presentation is usually nonspecific. • Meningitis must be excluded in any infant being evaluated for sepsis or infection. Forced posture of newborn with meningitis
  • 19. Meningitis The principal pathogens in neonatal meningitis are GBS (36% ), E coli (31%), and Listeria species (5-10%). Other organisms : S pneumoniae S aureus S epidermidis H influenzae Pseudomonas species Klebsiella species Serratia species Enterobacter species Proteus species
  • 21. Meningitis • Ventriculitis • Arachnoiditis • Vasculitis • Cerebral edema • Infarction Mortality rate in neonatal meningitis is approximately 10 percent Survivors– Neurological sequelae & lifelong impairments 20% of survivors- severe disability, 35% of survivors-mild to moderate disability
  • 22. Neonatal Pneumonia Infectious GBS Haemophilus influenzae Gram neg bacilli Listeria monocytogens Enterococci Staphylococcus aureus Non infectious Diffuse alveolar damage Organising pneumonia Aspiration Non specific interstotial  Klebsiella & S aureus- generate severe lung damage, microabscesses and empyema Early onset GBS pneumonia has fulminant course, with mortality in first 48 hours of life. If the infant has remained hospitalized in NICU with endotracheal intubation and mechanical ventilation, the organisms may include Staphylococcus or Pseudomonas .
  • 24. DIAGNOSIS TREATMENT PREVENTION There is No Substitute for Clinical Acumen
  • 25. 25
  • 27. Diagnostictests Definitive,Specific • • • • • • Bloodculture CSFculture Urine culture Trachealaspirate culture Polymerase chain reaction Latexparticle agglutination test • • • • Nonspecific,Diagnostic White blood cell count C-reactiveprotein(CRP) Micro ESR Other acutephase reactants 27
  • 28. Sepsisscreen • Doneto rule out sepsisrather than to rule in sepsis. • Consistsof : – C-reactiveprotein (CRP), – Total leukocytecount(TLC), – Absolute neutrophil count(ANC), – Immatureto total neutrophil ratio (ITR), – micro-erythrocyte sedimentation rate(μ-ESR) – Plateletcount 28
  • 29. 29
  • 30. Twoor more parameters of thesepsisscreenare positive ->sepsisscreenpositive If all the parameters of the sepsisscreenare negative in aneonate ->low probability ofsepsis, antibiotics need not be started and the neonate must be monitoredclinically. Thescreenmust be repeated after 12hours. Twoconsecutive completely negative screens are suggestiveof nosepsis. 30
  • 31. 31
  • 32. 32
  • 33. 33
  • 34. 34 Micro-ESR • Measures ESR in vertically placed capillary tube in 1 hour. • Normal: day of life plus 3 mm/ hr, up to a maximum of 14 mm/ hr • > 15mm is abnormal in 1st hour • Poor sensitivity and specificity – False positive tests with hemolysis – False negative tests with DIC
  • 35. CRP vs PROCALCITONIN • Level>1mg/dl- abnormal • Takes 10-12hrs • Half life-24-48hrs • Peak-12-24hrs • Serial measurement>Single values • Cut off-2.4ng/ml • Takes2-4hrs • Half life-24-30hrs • Peak-6-8hrs
  • 36. 36 BLOOD CULTURE Gold standard for diagnosis of bacteremia • Add at least 1.0 ml blood obtained by sterile venipuncture to 5-10 ml culture broth (ideally 2 bottles) • Most bacteria grow within 24 to 36 hours • BACTEC and BACT/ALERT blood culture system
  • 37. Baby has risk factors and clinical signs of sepsis but blood culture is negative Blood cultures are positive in only 2 to 25% of babies with clinically suspected sepsis. 37
  • 38. 38
  • 40. 40
  • 42. • Culture positive after 72 hours • Polymicrobial culture • Growth of purely skin organisms
  • 43. 43 Lumbar Puncture Possibility of meningitis 1-10% Sepsis & meningitis overlap INDICATIONS Blood culture positive Symptomatic infants with high risk for EOS condition stable to tolerate LP Negative blood culture treated empirically for clinical diagnosis of sepsis LOS- prior to starting antibiotics 15% of babies with meningitis will have negative blood cultures
  • 44. CSF values CSF COMPONENTS TERM NEONATES PRETERM(VLBW) Cells/mm3 8 (0-30cells) 5 (0-44) PMN(%) 60% 8% (0-66) CSF Protein(mg/dl) 90 (20-170) 148 (54-370) CSF glucose(mg/dl) 52 (34-119) 67 (33-217) CSF/Blood glucose(%) 51 (44-248) 44 AIIMS PROTOCOL
  • 45. 45 Urine culture Sterile specimen obtained by sterile catheterization or by suprapubic bladder aspiration(ideal) UTI-single uropathogenic pathogen >50000 CFU/ml 10000-50000CFU/ml with associated pyuria(WBC>5/HPF) Any 1 organism from suprapubic aspiration
  • 46. • Cultures from central lines • Surface cultures • Endotracheal cultures • Gastric aspirate cultures>More than 5 neutrophils/HPF indicate exposureto chorioamnionitis. Poor Sensitivity and Specificity 46
  • 47. DEVELOPING BIOMARKERS SERUM AMYLOID A LIPOPOLYSACCHARIDE BINDING/MANNOSE BINDING PROTEIN 47 OTHER BIOMARKERS Alpha-1 antitrypsin Fibronectin Haptoglobulin Lactoferrin neopterin
  • 48. 48
  • 49. CYTOKINES &CHEMOKINES • IL-6,8,10,TNF-alpha,IFN-gamma,TGF-beta • Increase very rapidly • Normalise within 24 hrs • Increase IL-10 to TNF-alpha ratio  severe LOS in VLBW infants • IL-6,IL-10 & RANTES  morbidity in sepsis with DIC 49 Combination of cytokine profiles inc likelihood of identifying infection more than single measurements
  • 50. CELL SURFACE ANTIGENS • CD 11b, 14,16, 64 etc • CD 64 sensitive biomarker for EOS & intraabdominal infections even before rise of CRP • Pentraxin 3 (PTX3) • Angiopoietins 1 & 2 low ang1 & high ang2 predict poor prognostic outcome of sepsis • STREM-1 • SuPAR 50
  • 51. hs CRP (high sensitive CRP) sISAM-1 (soluble intracellular adhesion molecule 1) Soluble E-selectin
  • 52. MOLECULAR TECHNOLOGY • q PCR- Detect bacterial DNA in body fluid of host suspected of infection • FISH ADVANTAGE  Underlying pathological events  Development of new diagnostic approaches  Algorithms  Score systems BIOFLUID ANALYSIS saliva,urine 52
  • 53. GENOMICS • To identify genes that demonstrate altered regulation during infection • Focus on chemokine mRNA expression & its relation to infection • Inc IL8  Perinatal infection • Inc IL8 & MCP-1Perinatal asphyxia PROTEOMICS Involve separation of proteins based n intrinsic properties like molecular weight, isoelectric point or affinity to metals or antibodies Identify protein signatures & functionally expressed metabolites during specific disease states 53
  • 54. METABOLOMICS • Use spectrometric techniques • NMR • Mass spectrometry of urine , blood or tissue 54
  • 55. Evaluation of extent of the disease • LPfor meningitis • Urine examination • CXR • Xrayerect abdomen • Stool for occultblood • Bone scan • Neuroimaging 55
  • 56. Look for biochemicalabnormalities • Blood glucose • Blood urea • Serumcreatinine • TSB • Serumelectrolytes • ABG 56
  • 59. Management of Women With Preterm Prelabor Rupture of Membranes. A C O G C O M M I T T E E O P I N I O N , 2 0 1 9
  • 60. Antibiotic Regimen for Group B Streptococcus Prophylaxis in Labor
  • 61. In 2018, the stewardship and charge for updating the GBS prophylaxis guidelines were transferred from the CDC to ACOG and the American Academy of Pediatrics
  • 62. Prevention of LOS • IV IG • G-CSF / GM-CSF • Probiotics • Lactoferrin • Antistaphylococcal monoclonal antibodies • Prophylactic vancomycin • Establishment of early enteral feedings • Antibiotic restriction • Surveillance practices
  • 65. Sepsis Calculator - Assessment of EarlyOnset Sepsis in Infants > 35 Weeks • Three groups of infants require a blood culture and antibiotic treatment without delay: Unwell appearing infants. Infants whose sibling had EOS. Infants whose mother currently has Group A Streptococcal infection. calculation of EOS score:  Gestational age.  Highest maternal antepartum temperature  Duration of rupture of membranes.  GBS status  Maternal intrapartum antibiotics.
  • 66. NEWBORN CLINICAL PRESENTATION The EOS risk score then incorporates the newborn clinical presentation as: Well appearing. Equivocal signs. Clinical illness. Definition of Equivocal Clinical Signs Clinical Parameters Assessed Equivocal signs Heart rate > 160/min 2 clinical parameters abnormal for >2hrs Respiratory rate > 60/min or Temperature > 38.0°C or <36.4 C 1 clinical parameter abnormal for 4 hrs Respiratory distress
  • 67. Interpretation of EOS Risk Score Results and Management • Management Plan for GREEN Group: • Routine care. • Early discharge possible • Management Plan for YELLOW Group: • BLOOD CULTURE AND OBSERVATION. • No routine full blood count or CRP. • Infants with equivocal signs - observation in neonatal unit; when signs normalised. • Infants with medium risk, but normal exam may be observed (3 hourly vital signs) on postnatal wards until blood culture result available. • If abnormal clinical parameters develop, the infant requires urgent paediatric review • If equivocal signs develop, infant requires transfer to neonatal unit • Management Plan for RED Group: • TAKE BLOOD CULTURE AND TREAT WITH EMPIRIC ANTIBIOTICS. • With the blood culture, take full blood count and CRP.
  • 68. Treatment of neonatal sepsis may be divided into antimicrobal therapy supportive care (for the suspected or known pathogen) The initial diagnosis of sepsis is, by necessity, a clinical one because it is imperative to begin treatment before the results of culture appear
  • 69. Supportive therapy Respiratory Oxygen and ventilation as necessary Cardiovascular Volume expanders,Dopamine, FFP to correct perfusion Hematologic Treat bleeding- vit k,FFP, fresh blood, platelet CNS Treat seizures with phenobarbital Metabolic Treat hypoglycemia/hyperglycemia and metabolic acidosis
  • 70. Principles for antibiotic use • Empiric initiation of antibiotics • Switch antibiotics based on susceptibility patterns • Define duration of antibiotic therapy • Use only when bacterial infections are likely and discontinue empiric treatment when they have not been identified. • Change the antibiotic agents to those with the narrowest spectrum. • Establish a final duration of antibiotic management based on the disease process.
  • 71. 71 First line therapy Ampicillin + Gentamicin Baby not responding to first line antibiotics • 3rd generation cephalosporin – cefotaxime – ceftazidime
  • 75. Duration of Antibiotic therapy • Gram negative septicemia: 14 days • Group B Strep septicemia: 10-14 days • Gram negative meningitis: 21 days minimum • Group B Strep meningitis: 14 - 21 days • Culture negative sepsis • Asymptomatic neonate at risk of EOS ? • Suspected EOS/ LOS & neonate asymptomatic over time ? • Suspected EOS/ LOS & neonate improves but doesnot become asymptomatic ? • Osteoarticular infection should be treated for 3 to 4 weeks • Ventriculitis should be treated for at least 4 weeks.
  • 76. Upgradation of Empirical Antibiotics NO CLINICAL IMPROVEMENT IN 48-72 hrs Extremely sick babies start with higher antibiotics as per clinical situation DEVELOPMENT OF SCLEREMA
  • 77. Newer antibiotics-Beta lactamase inhibitors • Production of beta lactamase by gram negative bacteria greatest threat to efficacy of antibiotics • To counteract this-Beta lactamase inhibitors combined with Beta lactam antibiotics • New- Avibactam, Relebactam, Vaborbactam
  • 78. ADJUNCTIVE IMMUNOTHERAPIES for EOS • DVET • Granulocyte transfusion • IV IG • Recombinant G-CSF & GM-CSF • Activated protein C • Pentoxifyllin
  • 79. Background • Neonatal sepsis may be categorized as early-onset or late-onset. Of newborns with early-onset sepsis, 85% present within 24 hours, 5% present at 24-48 hours, and a smaller percentage present within 48-72 hours. • Onset is most rapid in premature neonates. • Early-onset sepsis is associated with acquisition of microorganisms from the mother. • Late-onset sepsis occurs at 4-90 days of life and is acquired from the caregiving environment.
  • 80. • ANAEROBIC BACTERIAL INFECTIONS • T/t-Metronidazole • Neonatal tetanus • T/t- TIG , Penicillin • FOCAL BACTERIAL INFECTIONS • Cellulitis • Pustulosis • Omphalitis
  • 81. OPTHALMIA NEONATRUM/ CONJUNCTIVITIS • Chlamydia trachomatis (oculogenitalis) • Other bacterial causes : gonococcus (rare), staphylococcus, pseudomonas, etc. • Chemical – silver nitrate • Viral : herpes simplex (type II)
  • 82. TREATMENT Prophylaxis : 1% silver nitrate solution 0.5% erythromycin opthalmic ointment, 1% tetracycline, 2.5% povidone iodine solution administered within 1 hour of birth. Treatment depend upon the specific aetiology. • Gonococcal –Ceftriaxone 50 mg/kg/q 12 h IM/IV. Uncomplicated-Single dose Complicated - 7 days • Chlamydia – erythromycin suspension 40 mg/kg daily orally divided into 4 doses for 14 days
  • 83. Osteomyelitis & Septic arthritis Causative organism Sites Treatment
  • 84. TAKE HOME MESSAGES Gram negative organisms MCC for neonatal sepsis in India PCT superior to CRP in early diagnosis of Neonatal sepsis serial C-reactive protein levels and serial assessment of immature:total neutrophil counts provide the best negative predictive value for neonatal sepsis. Hematological scoring system –screening test for early diagnosis of neonatal infections PCR reduces antibiotic use & length of stay in hospital 1st line drug-Ampicillin+Gentamicin Treatment should be according to antibiotic susceptibility to prevent emergence of MRSA, VRSA, VRE
  • 85. REFERENCES • CLOHERTY AND STARK’S MANUAL OF NEONATAL CARE 8th EDITION • AIIMS PROTOCOL,2nd EDITION • NELSON TEXTBOOK OF PAEDIATRICS,21st INTERNATIONAL EDITION • Neonatal Infectious DiseasesEvaluation of Neonatal Sepsis, Andres Camacho-Gonzalez, MD, MSca,*, Paul W. Spearman, MDa , Barbara J.Stoll, MDb • Biomarkers for neonatal sepsis: recent developments Authors Mally P, Xu J, Hendricks-Muñoz K
  • 86. “ I am not sure exactly what heaven will be like, but i do know that when we die and it comes time for god to judge us, He will not ask, How many good things have you done in your life, rather he will ask, HOW MUCH LOVE did u put into what you did?”