management of neonatal sepsis l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Management of Neonatal Sepsis PowerPoint Presentation
Download Presentation
Management of Neonatal Sepsis

Loading in 2 Seconds...

play fullscreen
1 / 30

Management of Neonatal Sepsis - PowerPoint PPT Presentation


  • 487 Views
  • Uploaded on

Management of Neonatal Sepsis. Niki Kosmetatos, MD Anthony Piazza, MD J. Devn Cornish, MD Emory University Department of Pediatrics. Incidence. Mortality 13-69% world wide 13-15% of all neonatal deaths (US) Meningitis 0.4-2.8/1000 live births (US 0.2-0.4/1000)

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Management of Neonatal Sepsis' - jana


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
management of neonatal sepsis

Management of Neonatal Sepsis

Niki Kosmetatos, MD

Anthony Piazza, MD

J. Devn Cornish, MD

Emory University

Department of Pediatrics

incidence
Incidence
  • Mortality
    • 13-69% world wide
    • 13-15% of all neonatal deaths (US)
  • Meningitis
    • 0.4-2.8/1000 live births (US 0.2-0.4/1000)
    • Mortality 13-59%; US 4% of all neonatal deaths
  • Sepsis
    • 1-21/1000 world wide; US1-8/1000 live births
    • Culture proven 2/1000 (3-8% of infants evaluated for sepsis)
    • Prematures <1000 g 26/1000 1000 - 2000 g 8-9/1000
predisposing factors
Predisposing Factors

General Host Factors

Prematurity

Race – GBS sepsis blacks>whites

Sex – sepsis & meningitis more common in males, esp. gram negative infections

Birth asphyxia, meconium staining, stress

Breaks in skin & mucous membrane integrity (e.g. omphalocoele, meningomyelocoele)

Environmental exposure

Procedures (e.g. lines, ET-tubes)

predisposing factors4
Predisposing Factors
  • Maternal/Obstetrical Factors
    • General– socioeconomic status, poor prenatal care, vaginal flora, maternal substance abuse, known exposures, prematurity, twins
    • Maternal infections –chorioamnionitis (1-10% of pregnancies), fever (>38° C/100.4° F), sustained fetal tachycardia, venereal diseases, UTI/bacteriuria, foul smelling lochia, GBS+, other infections
    • Obstetrical manipulation – amniocentesis, amnioinfusion, prolonged labor, fetal monitoring, digital exams, previa/abruption?
    • Premature & Prolonged ROM, preterm labor
predisposing factors5
Predisposing Factors

Overall sepsis rate 8/1000

Maternal Fever 4/1000

PROM 10-13/1000

Fever & PROM 87/1000

preterm labor prom
Preterm Labor/PROM
  • Prematurity (~10%) 15-25% due to maternal infection
  • >18-24h term; >12-18h preterm
  • Bacterial infection
    •  synthesis of PG
    • Macrophage TNF/IL stimulate PG synthesis, cytokine release**
    • Release of collagenase & elastase ROM
  • + Amniotic fluid cultures 15% (with intact membranes)
s epsis
SEPSIS

ORGANISMS

  • Group B strep (most common G+)
  • Coliforms(E. coli most common G-)
  • Listeria
  • Nosocomial infections
  • Staph epidermidis
  • Candida
  • Note: 50% G+ and 50% G-
routes of infection
Routes of Infection
  • Transplacental/Hematogenous
  • Ascending/Birth Canal
  • Nosocomial
transplacental hematogenous
Transplacental/Hematogenous
  • Organisms (Not just “TORCHS”)

Syphilis Herpes*

Toxoplasmosis Gonorrhea

Rubella Mumps

Cytomegalovirus TB

Acute Viruses HIV

Coxsackie Polio

Adenovirus GBS

Echo Malaria

Enterovirus Lyme

Varicella

Parvovirus*

ascending birth canal
Ascending/Birth Canal
  • Organisms - GI/GU flora, Cervical/Blood

E. Coli Herpes

GBS Candida

Chlamydia HIV

UreaplasmaMycoplasma

Listeria Hepatitis

Enterococcus Anaerobes

Gonorrhea Syphilis

HPV

nosocomial
Nosocomial
  • Organisms –

Skin Flora, Equipment/Environment

Staphylococcus – Coagulaseneg & pos

MRSA

Klebsiella

Pseudomonas/Proteus

Enterobacter

Serratia

Rotavirus

Clostridia – C dificile

Fungi

infection
Infection

Timing

  • Onset
    • Early Onset 1st 24 hrs 85 %

24-48 hrs 5%

    • Late Onset 7-90 days
symptoms
Symptoms
  • Non-specific/Common
    • Respiratory distress (90%) - RR, apnea (55%), hypoxia/vent need (36%), flaring/grunting
    • Temperature instability, feeding problems
    • Lethargy-irritability (23%)
    • Gastrointestinal – poor feeding, vomiting, abdominal distention, ileus, diarrhea
    • Color—Jaundice, pallor, mottling
    • Hypo- or hyperglycemia
    • Cardiovascular – Hypotension(5%), hypoperfusion, tachycardia
    • Metabolic acidosis NICHD data
symptoms14
Symptoms
  • Less common
    • Seizures
    • DIC
    • Petechiae
    • Hepatosplenomegaly
    • Sclerema
  • Meningitis symptoms
    • Irritability, lethargy, poorly responsive
    • Changes in muscle tone, etc.
evaluation
Evaluation
  • Non-specific
    • CBC/diff, platelets – ANC, I/T ratio
    • Radiographs
    • CRP
    • Fluid analysis – LP, U/A
    • Glucose, lytes, gases
  • Specific – Cultures, stains
  • Other – immunoassays, PCR, DNA microarray
results trigger points
Results “Trigger Points”
  • CBC
    • WBC <5.0, abs neutro <1,750, bands >2.0
    • I/T ratio > 0.2*
    • Platelets < 100,000
  • CRP > 1.0 mg/dl
  • CSF > 20 WBC’s with few or no RBC’s
  • Radiographs: infiltrates on CXR, ileus on KUB, periosteal elevation, etc.
treatment
Treatment
  • Prevention – vaccines, GBS prophylaxis, HAND-WASHING
  • Supportive – respiratory, metabolic, thermal, nutrition, monitoring drug levels/toxicity
  • Specific – antimicrobials, immune globulins
  • Non-specific – IVIG, NO inhibitors & inflammatory mediators
gbs s epsis
GBS SEPSIS

RISK FACTORS

  • Gestational age
  • Maternal well-being
  • Ruptured membranes > 18 hours
  • Location of delivery
  • Infant/Fetal symptomatology
  • Clinical suspicion
mothers in labor or with rom should be treated if
Mothers in labor or with ROM should be treated if:
  • Chorioamnionitis
  • History of previous GBS+ baby
  • Mother GBS+ or GBS-UTI this preg.
  • Mother’s GBS status unknown and:
    • < 37 wks gestation
    • ROM ≥ 18 hrs
    • Maternal temp ≥ 38o (100.4oF)
gbs s epsis21
GBS SEPSIS

INFANTS TO BE SCREENED

  • Maternal “chorioamnionitis”
  • Maternal illness (i.e. UTI, pneumonia)
  • Maternal peripartum fever > 38o(100.4oF)
  • Prolonged ROM ≥ 18 hrs (≥ 12 hrs preterm)
  • Mother GBS+ with inadequate treatment (< 4 hrs)
    • No screening necessary if C-section delivery with intact membranes
gbs s epsis22
GBS SEPSIS

INFANTS TO BE SCREENED

  • Prolonged labor (> 20 hrs)
  • Home or contaminated delivery
  • “Chocolate-colored”/foul smelling amniotic fluid
  • Persistent fetal tachycardia
  • SYMPTOMATIC INFANT
    • treat immediately (in DR if possible)
gbs s epsis23
GBS SEPSIS

SEPSIS SCREEN

  • CBC with differential
  • Platelet count
  • Blood culture x 1 (ideally 1 ml)
  • Chest X-ray &/or LP if symptomatic
  • Close observation and frequent clinical evaluation
  • Role of CRP
slide24

Algorithm for Neonate whose MotherReceivedIntrapartum Antibiotics

Maternal Rx for GBS?

Maternal antibiotics

for suspected

chorioamnionitis?

Signs of neonatal sepsis?

Full diagnostic evaluation *

Empiric therapy++

Gestational age

<35 weeks?

Limited evaluation$ &

Observe ≥ 48 hours

If sepsis is suspected, full

diagnostic evaluation and

empiric therapy ++

Duration of IAP

before delivery

< 4 hours #

No evaluation

No therapy

Observe ≥ 48 hours**

YES

YES

YES

NO

NO

* CBC, blood cx, & CXR if resp sx. If ill consider LP.

++ Duration of therapy may be 48 hrs if no sx.

$ CBC with differential and blood culture

# Applies only to penicillin, Ampicillin, or cefazolin.

** If healthy & ≥ 38 wks & mother got ≥ 4 hours IAP, may D/C at 24 hrs.

NO

slide25

Careful Observation

&

Immediate Antibiotics

Careful Observation pending review of screen

  • Symptomatic INFANT
  • Maternal intrapartum fever > 38.6o
  • “Chocolate” or foul smelling fluid
  • Ill mother
  • Fetal tachycardia
  • Home delivery
  • Maternal fever < 38.6o
  • PROM
  • Mat GBS with < 2 dose abx

(-) Screen(+) Screen(-) Screen(+) Screen

Cont abx until bld cx neg for 48o if asympt. Use clini-cal judgement for cessation of abx if pt is/was sympt

d/c abx; careful obs and monit bld cx until d/c

Careful obs and monit bld cx until d/c

Initiate abx & cont until bl cx (-) for 48o. Clinical judgement for cessation of abx if pt sympt

Blood Culture Positive

Initiate, resume or continue abx therapy and treat for 7-10 days for gram pos organism or longer if gram neg organism cultured. LP may be performed at the discretion of attending, especially in seriously symptomatic pt

s epsis26
SEPSIS

SIGNS and SYMPTOMS

  • temp instability • lethargy
  • poor feeding/residuals • resp distress
  • glucose instability • poor perfusion
  • hypotension • bloody stools
  • abdominal distention • bilious emesis
  • apnea • tachycardia
  • skin/joint findings
s epsis27
SEPSIS

LABORATORY EVALUATION

  • Provide added value when results are normal
    • high negative predictive value
    • low positive predictive value
      • abnl results could be due to other reasons and not infection
  • IT < 0.3, ANC > 1,500 (normal) do not start abx, or d/c abx if started, if pt remains clinically stable
  • IT > 0.3, ANC < 1,500 consider initiation of abx pending bldcx in “at-risk” pt who was not already begun on antibiotics for other factors
s epsis28
SEPSIS

LABORATORY EVALUATION

  • Positive screen
    • total WBC < 5,000 – I/T > 0.3
    • ANC < 1,500 – platelets < 100,000
  • Additional work-up
    • CXR, urine cx, and LP as clinically indicated
  • CRP
    • no added value for diagnosis of early onset sepsis
    • best for negativepredicativevalue or when used serially
    • not to be used to decide about rx, duration of rx or need for LP
    • positive results for a single value obtained at 24 hrs ranges > 4.0 - 10.0 mg/dL
s epsis29
SEPSIS

TREATMENT

  • Review protocol
  • Antibiotics
    • Ampicillin 100 mg/kg/dose IV q 12 hours
    • Gentamicin 3.5 mg/kg/dose IV q 24 hours
      • IM route may be used in asymptomatic pt on whom abx are initiated for maternal risk factors or to avoid delays when there is difficulty obtaining IV
    • For meningitis: Ampicillin 200-300 mg/kg/d
  • Symptomatic management
    • respiratory, cardiovascular, fluid support
prognosis
Prognosis
  • Fatality rate 2-4 times higher in LBW than in term neonates
  • Overall mortality rate 15-40%
  • Survival less likely if also granulocytopenic (I:T > 0.80 correlates with death and may justify granulocyte transfusion).