NEONATAL SEPSIS AND JAUNDICEBY

DR.MANGO TAMBA KEZIAH{NOTORIOUS PhD}

OBJECTIVES• Review use of common drugs• Review treatment of jaundice• Severe newborn infections• Diagnosis• Treatment

SEPSIS AND JAUNDICE• DEFINITION; Systemic response to infection in the newborn.

• The term should be reserved for documented infection in a newborn who has systemic illness for which non-infectious causes have been excluded.

SEPSIS• ETIOLOGY; Bacteria……common all gestation

Fungi……esp VLBW

Viruses…..usually as TORCHES

Protozoa…TORCHES or malaria

BACTERIAL• Gram negative organisms • Klebsiella, Escherichia coli, • Pseudomonas, and Salmonella.• Gram positive less common• Staphylococcus Aureus• Coagulase negative staphylococci (CONS)• Streptococcus pneumoniae, and Streptococcus pyogenes• Group B streptococcus (GBS) is rare CANDIDA…esp.VLBW preceded by oral colonisation

can be cultured from blood ?contamination in more mature

infants.

• VIRUSES…..Herpes simplex common Veriscella

Torches group.E.g rubella,syphilis.

HIV (neonatal dx)

PROTOZOA….Malaria Toxoplasmosis

PATHOGENESIS• Exposure during delivery….commonest

• Inhalation of infected amniotic fluid..rare

• Trans-placental infection possible (esp. preterm deliveries).

• Severe sepsis– Sepsis with one or more signs of organ dysfunction•E. g CVS, Renal, Respiratory, Hematology, Metabolic acidosis

• Septic Shock– Sepsis with hypotension-

•systolic BP < 90 mmHg•Or 40 mmHg below the normal for at least one hour with adequate hydration

PATHOPHYSIOLOGY• 3 BROAD GROUPS• (1) Early onset….onset within 1st 3 daysbacteria acquired before and during delivery• (2) Late onset…..onset after 3rd day of life• bacteria acquired after delivery • (3) Nosocomial….hospital acquired usually long stay babies

can be multi-drug resistant

PREDISPOSITION• Why are newborns so prone to infection ?

• (1) Innefficient immune mechanisms; (a) cellular immunity is compromised.

Polymorph function is ↓vis adherance,chemotaxis,phagocytosis

(b) humoral immunity is deficient IgG crosses placental barrier in 3rd

trimester…preterms have very little.

IgG usefull defence against gram +ves

IMMUNITY• IgM….Doesnt cross placental barrier

important defence against gram –ve

hence newborns prone to gram-ve

sepsis. IgA…..Doesnt cross placental barrier

production starts at age 2-5 weeks

present in breast-milk

responsible for mucosal immunity

IMMUNITY• Physical barriers……SKIN thin and friable-

easily breached.

…….Mucous membranes

breached by many

invasive procedures

have no IgA.

RISK FACTORS• Males > Females• PROM =Premature or Prolonged• Maternal chorio-amnionitis(esp with fetal tachycardia)

• Maternal GBS colonisation• > 6 digital vaginal exams during labor with PROM

• Prematurity itself

• Low APGAR score = Asphyxia• Maternal fever>38.3°c• Maternal UTI• Poor or no ANC• Poor maternal nutrition/socio-economic status

• LBW• Difficult delivery

Neonatal Infection – Is it severe?

CLINICAL FEATURES• History of feeding difficulty• History of convulsions• Temperature ≥37.50C or <35.50C• Fast breathing / respiratory rate ≥ 60 bpm

• Severe chest indrawing• Grunting• Change in level of activity

• Jaundice• Prolonged capillary refill• Pallor• Bulging fontanelle• feed intolarance,abd distention,hepato/splenomegally,vomiting,diarrhoea.

• RS……respiratory disstress,cyanosis,apnoec attacks,

• CNS….lethargy, abnormal moros , xsive crying, irritability,convulsions,bulging fontanelless,

• CVS….delayed cappilary re-fill,tachycardia or bradycardia.

• OTHERS…jaundice, petechiae, purpura,bleeding.

VIT K• Babies are all mildly deficient with coagulation indices < adults.

• ~ 1 in 1,000 infants may have a severe deficiency, this can result in:– Haemorrhage from incisions– GI haemorrhage– Intra-cranial bleeding.– Death

• 1mg Vitamin K im given at birth prevents this (

TX OF CONVULSIONS/BIRTH ASPHYXIA

• Diazepam is dangerous in babies < 1 month

• First line treatment is Phenobarbitone 20 mg/kg im

• Maintenance usually 5mg/kg im, oral or ngt every 24 hours.

Phenobarbitone for a fitting baby weighing 3.1kg?

• Stat phenobarbitone:– 60 mg im– NOT as an iv bolus.

• If the child continues to convulse after 30 minutes a further 5 - 10 mg / kg im can be given BUT continuous monitoring for respiratory depression is required.

• Then no more phenobarbitone for 24 hours unless directed by a consultant.

ANTI-PYRETICS• Febrile fits only occur at ages ≥ 6 months

• Fever can be effectively treated by removing covers / clothes in the first weeks of life.

• So fever should first be investigated and treated with simple measures.

• Anti-pyretics may have side effects and there is no routine indication for drugs to reduce temperature– Use them when simple measures fail

• Pain is a separate consideration

Investigations• Blood culture…..gold standard 0.5-1ml is optimal sample. Taken aseptically usually aerobic culture alone is adequete but may take anaerobic culture if suspected.

• Heamogram/FBC….very usefull in resource poor setting.Important to interprate it appropriately. INCLUDE I/T RATIO.

• CSF(7% yield),URINE (2% yield) –cultures• Swab of infected cord or skin lesion• Antigen detection tests on urine,CSF,serum.

• CXR..to determine cause of respiratory disstress.

• CRP..good maker of infection and success of treatment

• Other supportive investigations such as UEs LFTs etc as required.

TX• SUPPORTIVE;- ensures hydration/electrolyte balance.

• Thermal-neutral environment.• Ensure nutrition (parenteral if indicated)

• Isolate/barrier nursing.• Remove all indwelling cathetars.

• DEFINITIVE;- Broad spectrum antibiotics parentrally before culture report.

xpen/gentamicin

Can substitute ampicillin for xpen. Or 3rd generation cephalosporin e.g ceftazdine.

• Antibiotic change should be guided by culture and sensitivity report.

• If no culture report,then change antibiotic if no improvement in condition after 48 hrs on treatment.

• Choice of antibiotic should be guided by the known spectrum of bacteria in your nursery and known antibiotic sensitivities.

p/s cephalosporins are good but resistance developes very fast to them.

• Give antibiotics intravenuosly.• Treat for 7-10 days if response is immediate and good.

• OR treat for additional 5-7 days after clinical response.

• In case of meningitis, treat for 2-3 weeks.

PREVENTION• Good antenatal care.• Good delivery suite practices e.g aggressively treat chorio-amnionitis with rapid delivery of the infant.

• Prevent nosocomial infections by observing infection control strategies such as hand washing between infants, reduce over crowding,good umbilical stump care.

COMPLICATIONS• Shock,ciculatory collapse,DIC,severe jaundice,NEC.

• Long term…..due to meningitis/ mental retardation and other neurological disorders.

……due to NEC / short bowel syndrome following resection of non-viable gut.

JAUNDICE• Day 1 Jaundice:

– estigate if possible (Hb, DCT)– Refer for possible exchange transfusion– Start phototherapy immediately even if jaundice mild

• Day 2+ – Investigate and treat based on tables and: – Gestation, – Post-natal age,– Bilirubin Level

• Day 2+ and unable to measure bilirubin?– Treat based on clinical signs

• Start treatment early in preterm babies

MENINGITIS• You will never know unless you do an LP!– < 30% proven cases in young infants have a bulging fontanelle / stiff neck / convulsions

• Treatment - Minimum of 2 weeks if Gram +ve and 3 weeks iv or im treatment if Gram –ve if you don’t know the organism then 3 weeks.

APPROACH• Prevent acquired infection - Hand washing / effective cleaning and sterilisation

• treatment with Penicillin (or ampicillin) & Gentamicin

• Cephalosporins remain 2nd line therapy for treatment failure unless:– Local bacteriology results direct policy– Meningitis confirmed by LP–Note Ceftriaxone not recommended if jaundice

Current WHO & recommendations 4 GENT.

• Babies <2kg, <7 days old-3 mg/kg/day OD

• Babies ≥2kg, <7 days old-5 mg/kg/day OD

• Age > 7 days-7.5 mg/kg/day OD• Age > 10 years-6 mg/kg/day OD