NEONATAL SEPSIS Ekawaty Lutfia Haksari Perinatology, Department of Child Health Gadjah Mada University

Trends in child mortality among those younger than 5 years and in first 28days of life (Lawn et al. 4 million neonatal deaths:When?Where?Why?Lancet 2005;365: )

Worldwide causes of neonatal mortality Save the Children. Saving Newborn Lives. Washington, 2000

NEONATAL SEPSIS Systemic infection important cause morbidity & mortality Laboratory, clinical diagnose – difficult  leading to delayed treatment

ONSET OF NEONATAL SEPSIS Early onset sepsis - Onset 0-72 hours of age - Acquired around birth - Usually vertical transmission - mother Late onset sepsis - Onset >72 hours age - Acquired environtment - Hospital acquired or nosocomial infection

Risk factors – Late onset neonatal sepsis Prematurity/ low birth weight In hospital Invasive procedures: ventolator, iv lines, central lines, urine catheter, chest tube Contact with infectious disease- doctors, nurses, babies with with infections, siblings Not fed maternal breast milk

CLINICAL DIAGNOSIS oEarly sign very subtle, non specific  very quickly to late sign  death oAnticipate possible severe infection carefull examine observe them – slight changes  early diagnosis, T/

Algorithms - symptoms/signs  health workers to identify neonatal sepsis  referral/ home treatment (WHO, 2002)

Newborn has not been well since birth Well infant  1 or > signs neonatal sepsis poor feeding + sucking

SIGNS OF INFECTION (WHO, 2002) Early signsLate signsLocal/specific sign Not able to feed /suck, after fedding normally Lethargy Abnormal body temp Breathing difficulties Severe lethargy Unconciousness Seizure Apnea Jaundice Sclerema Bleeding Diarrhoea Abdominal distension Umbilical redness Pus draining-eyes  movement of limb Crying-limb is touch/moved Swelling,warmth, redness- limb/joint Bulging fontanelle Opisthotonus

Possible infection (Kosim, 2004) AB Breathing difficulties Seizure Unconciousness Abnormal body temperature (sepsis) Delivery problem (sepsis) Condition  (sepsis) Tremor Lethargy Weak Irritability Onzet day 4 (sepsis) Poor feeding (sepsis)

Risk factors of early onset Maternal history-uterine infection PROM > 18 hours Birth weight <2000g or gestation age < 35 weeks Signs of infection  possible severe infection Kosim, 2004

Perinasia 1991 POSSIBLE SEPSIS Clinically sepsis at least 1 sign is found in 4 out of 6 group categories Risk factors Surjono, 2004

Perinasia konsensus 1991 Clinically sepsis at least 1 sign is found in 4 out of 6 group categories: (1) General condition (2) Gastrointestinal system (3) Respiratory system (4) cardiovascular system (5) central nervous system (6) hematologic system

(1) General condition not doing well, poor feeding, temperature instability, sclerema (2) Gastrointestinal system abdominal distention, vomiting, diarrhea, hepatomegaly (3) Respiratory system apnea, dyspnea, tachypnea, retraction, flaring, grunting, cyanosis

(4) Cardiovascular system tachycardia, bradycardia, poor perfussion (5) Central nervous system irritability, lethargy, tremor, seizure (6) Hematologic system jaundice, splenomegaly, pallor, petechiae, bleeding, leucopenia, ratio immature/mature neutrophil (I/T>0,2), thrombocytopenia, toxic granulation

CLINICALLY SEPSIS (cont) Not doing well Poor feeding Lethargy Respiratory problem Hypothermia > hyperthermia (Yu & Monintja, 1997)

C-reactive protein (CRP) Chest X-Ray Gold standard Culture – body fluid: blood, urine, stools, endotracheal aspirates, cerebrospinal fluid (CSF), pleural or pus Diagnosis (cont)

TREATMENT Specific: Antibiotics - Ampicillin and Gentamicin - Cephalosporin Supportive care - Temperature - Cardiorespiratory - Hematological - Gastrointestinal - Immunological ?

Antibiotic resistance pattern in developing countries (from Vergnano S, et al. Arch Dis Child Fetal Neonatal Ed 2005)

Supportive Care Temperature support- hypothermia GI support - vomiting, ileus Cardiorespiratory support - hypoxia, apnea, ARDS, hypotension, shock Hematological support: anemia, thrombocytopenia, DIC Neurological support- seizures

SUGGESTIONS TO PREVENT NEONATAL SEPSIS Treat mother’s infections - pregnancy Use clean delivery practices -labor and birth Use infection prevention steps – labor,birth and post natal care Treat a mother with antibiotics -labor - she has the sign of infection / prolonged rupture membrane >18hours

suggestions Wash the hands before and after handling each newborn Rooming in – normal newborn Do not bring the baby into contact with sick people Isolate a sick newborn from healthy ones

suggestions Teach the mother & family - to keep the baby away from sick people - to use infection prevention steps, especially hand washing

Human milk Enteral feeding - human milk is generally regarded as beneficial Breastfeed the newborn exclusively (Kramer, 2002; Beck, 2004)

HUMAN MILK (cont) NICU:  incidence of neonatal infection (el-Mohandes, 1997; Tysson, 1997; Xanthou,1998; Hanson, 2002) Early full enteral feeding significantly  the risk of late onset of septichaemia - extremely premature infant (Ronnestad, 2005)

LOCALIZED INFECTIONS Umbilical cord: uncovered, clean and dry Skin infection Eye infection Oral trush (WHO 2002, Kosim 2004, Beck 2004)

PREVENTION OF NOSOCOMIAL INFECTION The lay out & organisation - the neonatal unit may have an important effect on infection control practices Hand washing is a cornerstone of infection control