1. Neonatal Infections May 2005 Dr Patricia Fenton Sheffield Children’s Hospital

2. Neonatal Infections Hazard analysis at critical control point A baby production line Uterus to push chair

3. The Bad News Is….. No Pictures

4. The Good News Is…. 994 out of every 1000 infants born in the UK survive

5. Some Definitions n Infant - <1 year n Neonate - < I month n “early onset” - < 7 days

6. Infant Deaths 93-97 (Number) n E and W figures n Neonates account for 67% of deaths n Infection is NOT a major cause of neonatal death.

7. A Hazardous Journey n The uterus: Listeria monocytogenes n The birth canal: group B streptococcus n The unit: Acinetobacter baumanii n Devices: CNS n The attendants: Staph aureus

8. Three Barriers to Infection NORMAL FLORA SKIN AND MUCOUS MEMBRANES IMMUNITY

9. Impaired Barriers n Thin skin n Raw umbilicus n Invasive devices

10. Small/premature = n Poor antibody response n Poor neutrophil response n Poor complement activation n Impaired macrophage activity n Poor T cell function n Reduced placental IgG

11. Clinical Presentations n Not breathing well n Not feeding well n Not looking well lethargic irritable mottled n Fever and tachycardia n Seizures AND NOT A BLOOD TEST OR XRAY!

12. Listeria monocytogenes n 1-3 cases per million per year E&W n 17 pregnancy associated cases 2001 n >300 pregnancy assoc. 87-89 n Soft cheese, paté and chilled meals n All animals n 5% humans in bowel

13. Listeria - an interesting organism n G + rod n Flagellae-RT not BT n Tumbling motility n Haemolytic BA n Invasin (IC) n Actin tails n Listerioloysin O

14. Log10 bacteria per ml

15. Disease Spectrum n Influenza like illness (maternal) n Sepsis with stillbirth n Neonatal sepsis/meningitis n Sepsis/meningitis in impaired immunity (at any age)

16. Treatment, Outcome and Control n Ampicillin or amoxycillin n Plus gentamicin n One third fatal n Avoidance, food quality measures, high level of suspicion, early treatment

17. Early Onset GBS Disease n 376 cases in 2001 n 39 died Important because: n Identified risk factors n Preventable

18. Risk Factors n Previous baby affected by GBS n GBS in urine at any time this pregnancy n Preterm labour n Prolonged ROM n Fever in labour (RCOG guidelines 2003)

19. Screening Based Strategy n 27% carry it (rectal plus vaginal swabs) n Antibiotic prophylaxis 86% reduction n Treat 1000, prevent 1.4

20. Risk Factor Strategy n 25% women have one or more risk n Antibiotic prophylaxis 69% reduction n Treat 1000, prevent 2

21. The Disease n Early onset n Low apgar n Sepsis n Pneumonia n GBS causes 70% early onset sepsis n Low birth weight

22. Prevention n Choose your mother carefully (IgG) n Be big (mortality 6% vs. 18%) n Penicillin AT ONSET OF LABOUR

23. Christmas Day HH n Premature 35/40 n No ANC n Septic, ventilated n Extubated day 11 n Home “to die” BUT….

24. The Unit n 24 cots (2x6 bedded 1x12 bedded) n Zero to two cases per year for 5 years n 4 month period 11 cases clinical sepsis n All cases in one 6 bedded ward area

25. The Bug n Acinetobacter baumannii n Gram negative cocco-bacillus n Water-dwelling saprophyte n Long survival on dry surfaces n Mattresses, air con, ventilators n Up to 25% normal human skin flora n Dissemination via hands?

26. What Happened Next? Cultured everything.

27. Results? n Nothing n Followed each baby and everything that happened to them

28. And they found n Hydrocolloid dressings-large sheets n Cut and stored n Used on skin n CULTURE POSITIVE OUTBREAK STRAIN

29. What happened next? n Practice stopped n Outbreak ended n 3 babies died

30. Lessons Learnt n A knowledge of background infection rates useful (none to 11) n Susceptible patients are just that n Plastic wallets make good incubators

31. Devices n Initial response n Getting worse n Central line in situ n ?CNS

32. Coagulase negative staphylococci n Gram positive cocci n Normal skin flora n Low grade pathogen in normal host n Hydrophobic cell surface (adheres) n Polysaccharide production - biofilm n Neonatal infections

33. Neonatal Unit B/C n CNS234 n Stau 17 n E.coli 19 n GNB’s 32 n GBS 18

34. Attendants n 6 week period n 4 blistered babies n Early discharge n 14 more identified n Staph aureus n Phage type 3A/3C n Exfoliative toxin A

35. Outbreak Control n Swabs of all staff handling newborns n Check all hands n One individual handled 17/18 affected n Epidemic strain from nose, axilla, peri n All other staff negative n Treatment of carrier ended outbreak

36. Staphylococcus aureus n Looks like CNS and.. n Normal flora (30% adults) but.. n Highly pathogenic n Exfoliative toxin A - SSSS n Potential for cross infection n Treated with flucloxacillin

37. Control Measures Wash hands and check hands

38. Conclusions n Infection: significant hazard to neonate n Journey womb to push chair n Bacteria for every occasion n Smaller is frailer n Never give up on a neonate

39. Our Aim at SCH Family focused service Putting the needs and welfare of children first