Neonatal Sepsis Nancy Roberto,CNP Children’s Hospital Medical Center

Immune System Specific Nonspecific Monocytes Macrophages Neutrophils Skin and mucous membranes Chemical barrier Inflammatory response Interferon Phagocytosis Cell mediatedHumoral T-lymphocytesComplementB-lymphocytes AntibodiesDeath of antigen T helper Tsuppressor T cytotoxic Lymphokines Viral, fungal, protzoan, and some bacterial protection Graft rejection Skin hypersensitivity Immune surveillance IgA Viral Protection IgD Function unknown IgE Allergy & Parasitic Infestation IgG Bacterial protection IgM Bacterial protection

Definition of Neonatal Sepsis n A clinical syndrome of systemic illness accompanied by bacteremia occurring in the first month of life (Gomella,Cunningham and Eyal, 1994)

Pathogenesis of Neonatal Sepsis n Early onset infection: usually multisystem, fulminant illness with prominent respiratory symptoms n Late onset infection: usually has an identifiable focus, most often meningitis, in addition to sepsis n Nosocomial infection: horizontal transmission from NICU environment

Causative Organisms n Primary Sepsis: usually vaginal flora, GBS, gram- negative enteric organisms (E Coli), Listeria monocytogenes, Staphylococcus, Streptococci (including enterococci), anaerobes, and Haemophilus influenzae n Nosocomial Sepsis: Staphylococci (S. Epidermidis and S.Aureus), gram negative rods (Pseudomonas, Klebsiella, Serratia, Proteus) and fungal organisms.

Risk Factors for Sepsis Maternal n Poor PNC and/or nutrition n Multiple gestation n Low socioeconomic status n Recurrent AB n Substance abuse n Prolonged ROM (>24 hours) n Maternal fever/infection n Meconium stained or foul-smelling amniotic fluid n Prolonged or difficult labor Neonatal n Prematurity n LBW n Birth asphyxia n Meconium staining n Resuscitation n Invasive procedures n Congenital anomalies (spinal and abdominal wall defects) n Immune defects, asplenia

Clinical Presentation n Thermoregulation n Neurologic n Skin n Gastrointestinal n Cardiac n Respiratory n Metabolic n Hematologic Bacteremia

Thermoregulation n Normal temperature ranges (degrees Celsius) n Skin= n Rectal= n Axillary= degrees lower than skin temperature n Hypothermia n Hyperthermia n Temperature instability

Neurologic Symptoms n Lethargy n Irritability n Decreased muscle tone n Increased muscle tone n Poor feeding n Seizures

Skin n Poor peripheral perfusion n Cyanosis n Mottling n Pallor n Petechiae n Rashes n Jaundice

Hematologic n WBC values n Neutropenia n Thrombocytopenia - Fungal and G-Negative organisms associated with lower PLT and more prolonged low PLT count (Guida, et al 2003 Pediatrics) n Anemia n Disseminated intravascular coagulation

Cardiac n Tachycardia n Bradycardia n Hypotension n Prolonged capillary refill n Weak peripheral pulses n Cyanosis

Respiratory n Tachypnea n Grunting n Flaring n Retractions n Apnea n Cyanosis/desaturation n Poor air movement n Increasing oxygen requirement

Gastrointestinal n Poor feeding n Emesis n Gastric residuals n Abdominal distention n Visible or palpable bowel loops n Diarrhea or bloody stools

Metabolic n Hyperglygemia n Hypoglycemia n Hyponatremia n Metabolic acidosis

Diagnostic Work-up n CBC with differential n Cultures (Blood, Urine, CSF, tracheal aspirate) n X-rays n Blood gases n Urinalysis n PT, PTT, Fibrinogen, FSP or D-dimer

Bacterial Infection n Blood (Septicemia) n CSF (Meningitis) n Pneumonia n Urinary tract infection n Ophthalmia n Otitis media n Necrotizing enterocolitis

Fungal Infection n Thrush n Cutaneous candidiasis n Acute disseminated (systemic) candidiasis

Viral Infection n Rubella n Cytomegalovirus (CMV) - Breastmilk main source of perinatally acquired CMV. More concern in ELBW infants (Yasuda et al, 2003, Pediatrics) n Herpes simplex virus (HSV) n Hepatitis B virus n Hepatitis C virus n AIDS (Human immunodeficiency virus-HIV)

Acronym for Microorganisms Responsible for Infection of the Fetus (Remington & Klein, 2001) n TORCHES n To= Toxoplasma gondii n R= Rubella virus n C= Cytomegalovirus n H= Herpes simplex virus n E= Enteroviruses n S= Syphilis (Treponema pallidum n CLAP n C= Chickenpox (varicella- zoster virus) n L= Lyme disease (Borrelia burgdorferi) n A= AIDS (human imunodeficiency virus) n P= Parvovirus B19

Management of Sepsis n Universal precautions n Initial therapy: Broad spectrum antibiotic coverage n Continuing therapy: Based on culture and sensitivity n Isolation

Complications & Supportive Therapy n Respiratory n Cardiovascular n Hematologic n CNS n Metabolic n Family

Case Study #1 Risk Factors in Neonatal Sepsis

Case Study #2 Clinical Presentation in Neonatal Sepsis