Neonatal septicemia

Neonatal Septicemia Li Yijuan First Affiliated Hospital SUMS

Will They Have Good Future ???

Objectives What will I learn? Etiologies and risk factors Symptoms Diagnosis Treatment

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

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.

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

Pathogen Staphylococcus Escherichia coli Conditional pathogen Group B streptococcus

Group B -hemolytic streptococcus

Route of Infection Prenatal infection infection during delivery postnatal infection

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

Risk Factors (maternal and neonatal) Major Maternal prolonged Rupture of Membranes >24 hours Intrapartum maternal fever >38 C (>100.4 F) Chorioamnionitis Sustained Fetal Tachycardia >160 beats per minute Minor Intrapartum maternal fever >37.5 C (>99.5 F) Twin Gestation Premature infant (<37 weeks) Maternal Leukocytosis ( White Blood Cell count >15000) Rupture of Membranes > 12 hours Tachypnea (<1 hour) Maternal Group B Streptococcus Colonization Low APGAR (<5 at 1 minute) Low birth weight (<1500 grams) Foul lochia

What makes a neonate’s immune system susceptible to sepsis? Maturity Immaturity or

You’re Right!!!! The immaturity of a neonate’s immune system makes them MORE SUSCEPTIBLE to sepsis.

Why are newborns so vulnerable to infection? Non-specific immunity Specific immunity

Why are newborns so vulnerable to infection? IMMUNE SYSTEM Neutrophils – Qualitative and quantitative Complement and immunoglobulin levels decreased T cells- antigenically naïve limited cytokine production

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

Clinical menifestations EOS LOS Onset Within 7 days >7 days Source Prenatal During delivery During delivery Postnatal(nosocomial ) Pathogens G - bacili S taphylococcus ; Opportunitic P resentation Mortality P neumonia High Bacteremia and / or meningitis Low

Symptoms of Neonatal Sepsis The symptoms are not concrete and vary widely Tachypnea Heart Rate Changes Feeding difficulties Difficulty Breathing Temperature Instability J aundice Irritability

Bleeding tendency Poor perfusion

Enlargement of liver and spleen

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

Clinical manifestation The symptoms are so broad , non-specific , and acute deterioration , How to make a diagnosis as early as possible ?

Laboratory studies Evidence for inflammation Evidence for infection Evidence for multiorgan system disease

Laboratory Examination: CBC WBC<5×10 9 /L or WBC>20× 10 9 /L I/T≥0.2 ， toxic granules thrombocytopenia <100×10 9 /L

Reference values for neutrophilic cells Manroe BL, J Pediatr 1979;95:89-98.

Total neutrophils Immature neutrophil I/T ratio

Lab examination:CRP CRP α1-AG α1-AT

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

Summary Is there a diagnostic marker for neonatal sepsis?

Great answer! You’re correct! There is NOT a specific diagnostic marker, only determinants of infection

Summary The best approach for diagnosis of systemic bacterial infection: use of multiple markers (e.g. CRP, IL-6, TNF  , CD64), and serial measurements

Diagnosis history – high risk factors clinical manifestation --nonspecific S/S lab results - abnormal blood routine, CRP, positive culture or detection of organisms

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

Treatment  Antibiotics therapy  management of complications  supporting therapy  Clearance of infectious focus  Immunotherapy

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

Dosages of antibiotics for newborns

Supporting therapy Nursing care --warm environment --oxygen supply correction of acidosis and electrolyte disturbance fluid , glucose and nutrition balance

Management of complications Shock DIC Cerebral edema Pulmonary hemorrhage

Immunotherapy IVIG Exchange transfusion Granulocyte transfusion ， G-CSF Platelet transfusion

Questions Could prophylatic IVIG reduce the morbidity and mortality of neonatal sepsis? Might prophylatic IVIG interfere the development of the neonatal IM system?

Neonatal septicemia

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