Neonatal sepsis is a clinical syndrome of infection in the first four weeks of life that can cause multi-organ dysfunction and death if not recognized and treated early. It is a significant problem in India, causing 20% of neonatal deaths. The presentation and risk factors differ between early onset sepsis (<72 hours) which is usually caused by maternal pathogens and late onset sepsis (>72 hours) which is usually nosocomial. Treatment involves supportive care, administration of antibiotics, and recognition/prevention of risk factors like prematurity and invasive procedures. Handwashing and maintaining sterile techniques are essential to prevent hospital-acquired infections.
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Neonatal Sepsis
Clinical syndrome of bacteremia with systemic
signs and symptoms of infection in the first
four weeks of life.
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• Incidence:India: 9-60/1000 live births
(average:38/1000)
• Almost 5 times higher than in developed
countries
• Causes 20% of neonatal deaths
• Incidence is 5-10 times higher in LBW and
preterms than normal weight term babies
4. 7We CareEarly Late
Onset <72 hrs >72 hrs
Source Maternal Environmental
genital tract (nosocomial)
Risk factor Prematurity Prematurity
Amnionitis,
Maternal infection
Presentation Fulminant slowly progressive
Multisystem focal
Pneumonia frequent Meningitis frequent
Mortality 5-50% 10-15%
Early vs Late onset sepsis
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• Gram – ve : LPS / endotoxin
• Gram +ve :lipoteichoic acid – peptidoglycan
• Activation of
– Coagulation pathway
– Complement System
– Cytokines
• Multiorgan dysfunction
Mechanism of injury
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• Immunological response to infection
• Release of a cascade of cytokines
– both pro and anti inflammatory
– secondary to bacterial endotoxins or exotoxins
• Cytokines SIRS
septic shock +
MSOF
Sepsis is a very rapidly progressive condition
which can kill even before diagnosis
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ETIOLOGY
• E coli
• Klebsiella
• CONS
• Staphylococcus aureus
• GBS
• Pseudomonas
• Acinetobacter
• Citrobacter
• Candida albicans and non albicans candida
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1. Feeding ability reduced
2. No spontaneous
movement
3. Temperature >380
C
4. Prolonged capillary refill
time
5. Lower chest wall
indrawing
6. Resp. rate > 60/minute
7. Grunting
8. Cyanosis
9. H/o of convulsions
ClinicalClinical featuresfeatures of severeof severe
infectionsinfections
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Diagnosis of neonatal sepsis
Direct
- Isolation of organisms from blood, CSF, urine
is diagnostic
Indirect
-Screening tests
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Sepsis screen
Leukopenia (TLC < 5000mm3
)
Neutropenia (ANC < 1800/mm3
)
Immature neutrophil to total neutrophil
(I/T) ratio (> 0.2)
Micro-ESR (> 15mm 1st
hour)
CRP +ve
*If two or more tests are positive treat infant as neonatal sepsis
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Meningitis
10-15 percent cases of sepsis have meningitis
Meningitis can be often missed clinically
LP must be done in all cases of late onset &
symptomatic early onset sepsis
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Management
• Mainstays of therapy:
– Early recognition
– ABC’s - supportive care
– Appropriate and adequate antimicrobials
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Management: Supportive care
Keep the neonate warm
If sick, avoid enteral feed
Start IV fluids,
infuse 10% dextrose to maintain normoglycemia
Maintain fluid and electrolyte balance and tissue
perfusion
If CRT >3 sec, infuse 10 ml/kg normal saline bolus.
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Supportive care
• cyanosed / RR >60/min / severe chest
retractions
– Start oxygen by hood
• sclerema
– Consider exchange blood transfusion/IVIG.
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Suspected neonatal sepsis
Start parenteral antibiotics
Send cultures (report in 72 hrs)
Culture -ve Culture +ve
Clinically no
sepsis (Stop Ab)
Clinically ill
(Cont Abx7-10D)
Pneumonia, Sepsis
(Cont Ab X 7-10D)
Meningitis, Osteomyelitis
(Cont Ab X 3-6 wks)
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Choice of antibiotics
• Pneumonia or Sepsis
Penicillin Aminoglycoside
(Ampicillin or Cloxacillin) (Gentamicin or Amikacin)
• Meningitis
Ampicillin + Gentamicin
Or
Gentamicin or Amikacin + Cefotaxime or Ceftriaxone
+
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• Change to Third gen CP in case of gm-ve
enteric bacilli like E.coli.
• L.monocytogen: resistant to cp treat with
ampicillin and gentamycin.
• Add Vancomycin if MRSA and enterococci.
• VRE add linezolid/quinipristin.
• Pseudomonas: combination of two agents like
ceftazidime,piperacillin/tazobactem,genta/am
ikacin.
Which Antibiotics
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• ESBLs: many strains of E.
coli,klebsiella,pseudomonas serratia etc found
with these resistant enzymes.
Carbapenems,cefepime and
pipera/tazobactem are most effective.
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Other measures in LOS
• IVIG
• G-CSF
• PROBIOTICS
• LACTOFERRIN
• EARLY ENTERAL FEEDING.
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Superficial infections
Pustules - After puncturing, clean
with betadine and apply
local antimicrobial
Conjunctivitis - Ciprofloxacin eye
drops
Oral thrush - Local application of
nystatin or Clotrimazole
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Five ‘cleans’ to prevent
infection
• Clean hands
• Clean cord tie
• Clean cord
• Clean surface
• Clean blade
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Cleans
• Surfaces : housekeeping
• Hands
– 2 minutes wash : first time
– Use of disinfectant between any outer object and baby
– Rolled up sleeves
– Nails
– Rings , watches
– Nail polish
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A scanned picture of steps of hand
washing
Six steps of hand washing
Step 1
Wash palms with fingers
Step 2
Wash back of hands
Step 3
Wash fingers & knuckles
Step 5
Wash finger tips
Step 6
Wash wrists
Step 4
Wash thumbs
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Hand washing
Simplest, most effective measure for preventing
hospital acquired infections
2 minutes hand washing prior to entering nursery
15 seconds of hand washing before touching baby
Alcohol based hand rub effective but costly
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The birth of a baby
• Are we able to maintain asepsis in the delivery
room?
– Mother
– Birth attendant for the mother
– Birth attendant for the baby
– Objects in the resuscitation of the baby
– Hygiene of practices at the time of birth
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Prevention of Infections
• Exclusive breast feeding
• Keep cord dry
• Hand washing by care givers
• Hygiene of baby
• No unnecessary interventions
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Intravenous lines:
Peripheral
• Skin preparation
• Maintenance after insertion
• Extravasation/thrombophlebitis
• Flushing solutions
• Change IV infusion sets daily
• Replace IV tubings used to give blood / blood
products at end of infusion
• Barrier precautions during line change
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Disposal of waste and soiled linen
• Safe disposal
• Colour coding
• Sharps
• Infected wastes
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Work culture
Sterile gowns and linen for babies
Hand washing by all
Regular cleaning of unit
No sharing of baby belongings
Dispose waste-products in separate bins
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Control of hospital
infections
Hand washing by all staff
Isolation of infectious patient
Use plenty of disposable items
Avoid overcrowding
Aseptic work culture
Infection surveillance
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Control of hospital outbreak of
infections
Epidemiological investigation
Increased emphasis on hand washing
Reinforce all preventive measures
Review of protocols of nursery
Screen all personnel
Review of antibiotic policy
Cohorting of infants
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Fumigation
Use Potassium permanganate 70 gm
with 170 ml of 40% formalin for 1000
cubic feet area for 8-24 hours
alternatively
Bacillocid spray for 1-2 hours may be equally
effective
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Conclusions
• High index of clinical suspicion
• Look for lab evidence of sepsis
• Start parenteral antibiotics (I.V.)
• Provide supportive care
• Review culture report
• Practise barrier nursing to prevent cross-
infection
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• Neonatal sepsis is a serious disease
• Suspect early and admit to NICU/Ward
• Start AB in preterms for suspected sepsis
(maternal risk factors )even if asymptomatic
• Treat all cases of probable or proven sepsis
with antibiotics
• Give supportive and adjunctive treatment
• Prognosticate cautiously