18636324 Neonatal Sepsis

8/2/2019 18636324 Neonatal Sepsis

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NeonatalSepsis

Self-LearningPacket2004Thisself-learningpacketisapprovedfor2contacthoursforthefollowingprofessionals:1.RegisteredNurses2.LicensedPracticalNurses

OrlandoRegionalHealthcare,Education&Development

Copyright2004Rev.10/31/2004


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NeonatalSepsis

TableofContentsPurpose.......................................................................................................................3Objectives...................................................................................................................3Instructions.................................................................................................................3Introduction................................................................................................................4Immunity....................................................................................................................4ImmuneSystemDevelopment...................................................................................................4ImmuneSystemPhysiology.......................................................................................................5

RiskFactors................................................................................................................7TrendsinNeonatalSepsis..........................................................................................8Frequency...................................................................................................................................8Mortality/Morbidity...................................................................................................................8Race,Sex,&Age......................

.................................................................................................8

EarlyversusLateOnsetInfections............................................................................9ClinicalSignsofSepsis...........................................................................................10DiagnosticEvaluations............................................................................................10TypesofPathogens..................................................................................................12GroupBStrep..........................................................................................................................12Staphylococcus.........................................................................................................................13EscherichiaColi........................

...............................................................................................13

Management.............................................................................................................14NursingConsiderations............................................................................................14FamilyImplications.................................................................................................15Summary..................................................................................................................16PostTest...................................................................................................................17References................................................................................................................21

OrlandoRegionalHealthcare,Education&DevelopmentCopyright2004

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NeonatalSepsis

PurposeThepurposeofthisself-learningpacketistoeducatenurseswhocareforinfantsandtosatisfythecontinuingeducationrequirementsofOrlandoRegionalHealthcareemployees.OrlandoRegionalHealthcareisanApprovedProviderofcontinuingnursingeducationbyFloridaBoardofNursing(ProviderNo.FBN2459)andtheNorthCarolinaNursesAssociation,anaccreditedapproverbytheAmericanNursesCredentialingCentersCommissiononAccreditation(AP085).

ObjectivesAftercompletingthispacket,thelearnerwillbeableto:1.Matchimmunesystemdevelopmentwithappropriateweekofgestation.2.Identifythedefinitionofneonatalsepsis.3.Labelthecorrectimmunoglobulinwithitsdefinition.4.Identifythecostofcarerelatedtoneonatalsepsis.5.Identifytheriskfactorsforneonatalinfections.6.Describetrendsinneonatalsepsis.7.Differentiatebetweencongenitalandacquiredinfections.8.Identifythesignsandsymptomsofasepticneonate.9.Describedifferenttypesofneonatalinfections.10.Matchtreatmentoptionswithappropriateinfection.11.Identifynursingconsiderationswhentakingcareofasickinfant.12.Describefamilyimplicationswhenanewbornbecomesill.

InstructionsInordertoreceive2.0contacthours,youmust:

CompletetheposttestattheendofthispacketSubmittheposttesttoEducation&DevelopmentwithyourpaymentAchievean84%ontheposttest

Besuretocompletealltheinformationatthetopoftheanswersheet.Youwillbenotifiedifyoudonotpass,andyouwillbeaskedtoretaketheposttest.


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NeonatalSepsis

IntroductionNewborninfantsareatmuchhigherriskfordevelopingsepsisthanchildrenandadultsbecauseoftheirimmatureimmunesystemespeciallyprematureinfants,where1outofevery250willbediagnosedwithsepsis.Sepsisisoneofthemajorleadingcausesofdeathinthefirstfewmonthsofanewbornslife.Infectionscancontributeupto13-15%ofalldeathsduringtheneonatalperiodwiththemortalityratereachingashighas50%forinfantswhoarenottreatedtimely.Thecombinationofanimmatureandslowrespondingimmunesystemincreasestheriskofinfectionintheneonate.Onereasonfortheincreasedriskisthatantibodies,whichhelpprotectmothersfrominfections,donotcrossthroughtheplacentatothefetusuntilapproximately30weeksofgestation.Theantibodiespresentatbirthtaketimetoreachoptimumlevels,whichalsoaffectstheprotectionprovided.Afterreadingthispacket,thelearnerwillhaveabetterunderstandingofthephysiologyoftheneonatalimmunesystem,currenttrendsinthediagnosisandtreatmentofinfections,riskfactors,signsandsymptomsofsepsis,andimplicationsfornurseswhoprovidecareforthesepticnewborn.

ImmunityImmuneSystemDevelopmentTheimmunesystembeginsveryearlyinfetaldevelopmentwiththeoriginofbloodformationinthethirdweekofgestation.Inthefourthweekofgestationthethymusforms.Thethymushelpstomatureanddevelopwhitebloodcellssothattheycanplayakeyroleinfightinginfections.Bytheeighthweekofgestation,

Tcells,Bcells,andnaturalkillercellscanallbefoundinthethymus.Tcells,whichmakeanimportantcomponentincell-mediatedimmunity,areformedsolelyinthethymus.Bcells,whicharetheprecursorsofantibodyproducingcells,arefirstproducedintheliverbutby12weeksgestationmoveintothebonemarrowwhereitremains.Naturalkillercells,whicharecytotoxiccellsthathavetheabilitytoattackviruses,matureinthethymus.Interestingly,greaterconcentrationsofnaturalkillercellsarefoundintheperipheralbloodofnewbornsandthenewbornusuallyhasadultlevelsofthesecellsatbirth,buttheydiminishrapidly.Neutrophilsarerelativelynumerousinboththetermandpre-terminfant.Aneutrophilisatypeofwhitebloodcellthatdefendsthebodyfromorganismsthatcauseinfection.Thestagesofneutrophildevelopment,fromimmaturetomature,aremyeloblast,promyelocyte,myelocyte,metamyelocte,band,andsegmentedneutrophil.Whenaninfectionispresent,theneutrophilsmigrateout

ofthecapillariesandintotheinfectedsite,wheretheyingestanddestroytheOrlandoRegionalHealthcare,Education&DevelopmentCopyright2004

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NeonatalSepsispathogenscausingtheinfection.Theamountofcirculatingneutrophilsinthenewbornpeaksaround12hoursafterbirthandthenstartstodeclinetonormallevels.Eventhoughalargenumberofcirculatingneutrophilscanbefoundinthenewborn,thebonemarrowstoragepoolofneutrophilsatbirthisonly20%to30%ofthecirculatingpoolinadults.

DifferencesinImmuneResponsesinFullandPretermInfantsImmuneSystemComponentImmunoglobulinGFullTermInfantPretermInfant

Completeplacentaltransfer,concentrationscomparabletomotherConcentrationsofTandBcellscomparabletothoseinadultswithnormalresponsetoantigens50%-75%ofconcentrationinadultElevatednumbersatbirth,withimpairedfunctionalabilityNormalnumberatbirthbuthaveimpairedchemotaxisNormalnumberatbirth

Incompleteplacentaltransfer,concentrationsdecreasedConcentrationsofTandBcellscomparabletothoseinadultswithnormalresponsetoantigensDecreasedconcentration

Lymphocytes

ImmuneSystemPhysiologyDespitetheimmunesystemandimmunesystemcomponents,earlydevelopmentduringgestationthenewbornstillremainsvulnerabletoinfectionsaftertheyarebor

nbecauseoftheimmaturityoftheirimmunesystem.

Complement

Neutrophils

Elevatednumbersatbirth,withimpairedfunctionalabilityNormalnumberatbirthbuthaveimpairedchemotaxisNormalnumberatbirth

Monocytes

Macrophages

butdecreasedfunctionbutdecreasedfunctionAnewbornhasapoorresponsetoinvadingpathogens.ThisNaturalKillerCellsConcentrationsimilartoConcentrationsimilartoimmuneresponsewillgraduallyadultlevel,buthaveadultlevel,buthaveimprovewithage.Duringthediminishedcytotoxicdiminishedcytotoxicinitialpostpartumphase,theeffectseffectsinfantreliesonmaternalantibodiesandthemothersbreastmilk,whichisrichwithimmunoglobulins.Whenapathogenicorganismovercomestheinfantsdefenses,infectionandsepsisresult.Sepsisisdefinedasthepresenceofmicroorganismsortheirtoxinsinbloodorothertissues.Newbornsepsisisstilloneofthemostsignificantcausesofneonataldisabilityanddeathtoday.

Reviewingthefunctionsoftheinfantsimmunesystemwillhelpprovideabetterunderstandingoftheinteractionbetweenthepathogenicorganismsandthenewborns

susceptibilitytoinfection.Infectionsoccurwhentheinfantcomesincontactwithapathogenicorganism.Theorganism,whetheritisavirus,fungus,orbacteria,entersintotheinfantsbodysystemandbeginstomultiply.Theinfantsimmunesystemresponsetoanorganismisdividedintothreephases.Thefirstphaseistheprimaryornonspecificphase,whichoccursimmediatelyfollowingtheinfantsinoculationwithapathogenicorganism.Duringthisphase,thereisamigrationoftheneutrophils



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NeonatalSepsistotheprimarysiteoftheinfection.Theneutrophilsenterintothecellsthroughmembranefiltersandadheretothepathogen.Ingestionanddestructionoftheinvadingorganismthentakesplace.Thenextphaseintheimmuneresponseiscalledthesecondaryphaseorthespecificresponsephase.Duringthisphase,thereisinteractionofTandBcellstohelpdevelopimmunoglobulinsorantibodiestoprotecttheinfantfromtheinfection.Therearethreemajortypesofimmunoglobulins:ImmunoglobulinG(IgG),ImmunoglobulinM(IgM),andImmunoglobulinA(IgA).ImmunoglobulinGisthemajorimmunoglobulinoftheserumandinterstitialfluid.Itprovidesimmunityagainstbothbacterialandviralpathogens.Itstartstocrosstheplacentaandenterintofetalcirculationaround30weeksgestationandcontinuesuntilthe40thweek.TerminfantshaveIgGlevelsthatareequaltoorexceedmaternallevels.SinceIgGisnottransferreduntilaroundthe30thweekofgestation,thepreterminfantdoesnothavethisprotectivebarrier.Preterminfantsarethusathigherriskforinfections.ResearchhasshownthattherearealsodecreasedlevelsofIgGinpost-termandsmallforgestationageinfants,whichsuggestthattheremaybesomeinhibitionoftransferwithplacentaldamage.ImmunoglobulinMdoesnotcrosstheplacentathus,littleornoIgMistransferredtothefetus.ThislackofIgMincreasestheinfantssusceptibilitytogramnegativeinfections.Theinfantdoeshoweverbeginsynthesisofthisimmunoglobulinveryearlyintheirfetallife.LevelsofIgMhavebeendetectedaround30weeksgestationwithhigherlevelsdetectedwhenthereisanintrauterineinfectionpresent.ImmunoglobulinAisthemostcommonimmunoglobulinfoundinthegastrointestinaltract,respiratorytract,humancolostrum,andbreastmilk.IgAdoesnotcrosstheplacenta,andintrauterinesynthesisis

minimal.LevelsofIgAareusuallynotdetecteduntiltheinfantisaround2to3weeksold.Thelastimmuneresponseisthetertiaryphase.Thisphaseprovideslong-termimmunityagainsttheorganism.Duringthesecondphase,theBcellsproducememorycellsthatrecognizetheinvadingpathogenonsubsequentexposures.Thesememorycellsrecognizetheinvadingorganismandcausethemtobeneutralized,preventingtheinfantfrombecomingsickagain.AlthoughadequatenumbersofBcellsarepresentatbirth,antibodyproductionisdiminishedintheneonateduetoalackofuterineexposuretoforeignpathogens.


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NeonatalSepsis

RiskFactorsCausesofinfectionsinnewbornscanbedividedintothreemaingroups:intrauterine,intrapartum,andpostnatalinfections.Allthreegroupsincludefactorsthatincreasetheinfantsriskofcomingincontactwithanorganismthatcancauseaninfection.SourceMaternalRiskFactorsPoorprenatalcarePoornutritionSubstanceabusePrematureruptureofmembranesMaternalfeverProlongedlaborMaternalUTI

Intrapartum

Intrauterineorfactorsthatincreasetheriskbeforebirthincludethefollowing:poorprenatalcare,poornutrition,NeonatalMalerecurrentabortions,andsubstanceBirthasphyxiaabuse.IntrauterineinfectionsoccurLowbirthweightwhenpathogenicorganismscrosstheplacentaintothefetalcirculatorysystem.Theorganisms,suchascytomegalovirus(CMV),canresideintheamnioticfluid,.Otherorganismsascendfromthevaginaltrack,infectingthemembranesandcausingthemtorupture.Thisruptureofmembranescanleadtoinfectionsoftherespiratoryandgastrointestinaltractofanewborn.Intrapartumorfactorsthatincreasetheinfantschanceofbecominginfectedduringthebirthingprocessinclude:prolongedruptureofmembranes(>12to18hours),urinarytractinfections,pretermlabor,prolongedordifficultlabor,maternalfever,colonizationwithGroupBStreptococcus(GBS),andmaternalinfections.Mostinfectionsduringthebir

thingprocessarerelatedtotheinfantcomingintounavoidablecontactwithaninfectedbirthcanal.Thebirthcanalcanhostbacteriathataninfantsimmunesystemcannotdefendagainst.Postnatalinfectionsmaybecontractedafterdelivery,asinthecasewithinfectionscontractedduringresuscitation,orasaresultofanosocomialinfectionduetoimproperhandwashing.Infectionsinthepostnatalperiodaremorecommoninthoseinfantswhorequireforeignobjectsbeintroducedintotheirsystems.Itemslikeendotrachealtubesorindwellingcathetersincreasetheriskofaninfantbecomingseptic.Thesinglemostimportantriskfactorforinfectionintheneonateisprematurity.Neonatalfactorsthatincreasetheinfantschanceofbecomingsickinclude:lowbirthweight,prematurity,birthasphyxia,meconiumstaining,andresuscitation.Thereisadirectcorrelationbetweengestationalageandtheinfantsriskforinfection.Infantsbornatlessthen32weeksgestationhavea4to25timeshigherriskofdevelopinganea

rlyonsetinfection.Reasonsforthisincludeimmatureimmunesystem,thinnerskin,andthefrequentneedforinsertionofforeignobjects.Also,prematureinfantsarelikelytodevelopchroniclungdiseaserequiringprolongedventilatorsupport.Corticosteroidsareoftenusedtohelptreattheirlungdisease,butthesedrugsmayleavetheinfantatanincreasedriskofinfection.


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NeonatalSepsisItisimportanttonotethatinanotherwisehealthy-appearing,term-gestationinfantnoneofthesefactorsbythemselvesshouldleadtoanassumptionthattheinfantwillsufferaninfection.However,acombinationoftheseriskfactorsgreatlyincreasestheinfantschanceforinfectionandthereforeshouldheightenthesuspicionofsepsis.Studieshaveshownthatincidenceofinfectionincreasestogreaterthan15%whentwoormoreriskfactorsarepresent.Aninfantwhoappearssickshouldheightenclinicalsuspicionofsepsis,andanevaluationforinfectionshouldbeperformedimmediately.

TrendsinNeonatalSepsisFrequencySepsisidentifiedbytheresultsofcultures,suchasblood,CSF,urine,occursinapproximately2outevery1000livefulltermbirths.Ofthe7-13%infantswhoundergoevaluationforsepsisonly3-8%haveculture-provensepsis.Sincetheearlysignsofsepsisareoftennonspecificahighpercentageofnewbornsaresubjectedtoasepticworkupandadministrationofantibioticsbeforethediagnosishasbeenmade.TheAmericanAcademyofPediatrics(AAP),AmericanAcademyofObstetricsandGynecology(AAOG)andtheCentersforDiseaseControlandPrevention(CDC)allhaverecommendationsforsepsisscreeningand/ortreatmentforvariousriskfactors,thusahigherpercentageofnewbornsaresubjectedtodiagnostictests.Sincethemortalityrateofuntreatedsepsisisashighas50%,mosthealthcareprovidersbelievethatthehazardofnottreatingordelayingtreatmenttowaitforpositiveculturesistoohigh,andthereforetreatmentisinitiatedwhileawaitingthetestresults.Asaresult,theannualtreatmentcostforsepsisinneonateshereintheUnitedStatesisapproximately$800million.

Mortality/MorbiditySepsisisamajorcauseofdeathduringthefirstfewmonthsoflifecausing13-15%ofallneonataldeaths.Themortalityrateofneonatalsepsiscanbeashighas50%forinfantswhoarenottreatedorwhentreatmentisnotbegunquickly.Aseriousmorbidityofneonatalsepsisisneonatalmeningitis.Researchhasshownthatneonatalmeningitisoccursin2-4per10,000infantsandofthoseinfantsdiagnosedwithneonatalmeningitistheirchanceofsurvivalsignificantlydecreases.Itisresponsiblefor4%ofallneonataldeaths.

Race,Sex,&AgeCurrentresearchhasshownthatAfrican-AmericaninfantshaveanincreasedincidenceofGroupBStrep(GBS)diseaseaswellasacquiredorlatesepsis.Tohelp

counterthismanyprofessionalhealthcaregroupshaverecommendguidelinesforcontrollingriskfactorsinthisrace.Despitethesechangesinscreeningandtreatments,African-Americaninfantsstillremainatthehighestriskforsepsis.Maleinfantshaveahigherincidenceofsepsisthantheirfemalecounterparts.Thishigherrateofsepsisisespeciallytrueforgramnegativeinfections.OrlandoRegionalHealthcare,Education&DevelopmentCopyright2004Page8


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NeonatalSepsisPrematurenewbornsalsohaveahigherrateofinfectionthanfullterminfants.Theincidenceofsepsisissignificantlyhigherininfantswithverylowbirthweight.Infantsweighinglessthan1000gareatthehighestriskforsepsis.

EarlyversusLateOnsetInfectionsNeonatalbacterialinfectionsareclassifiedintotwodifferentcategoriesdependingonthetimeoftheirpresentation.Congenitalinfectionsorearlyonsetinfectionsoccurwhenaninfantpresentswithsignsandsymptomsoftheillnesswithinthefirstweekoflife.Acquiredorlateonsetinfectionsoccuraftertheinfantisgreaterthanaweekold.CongenitalinfectionsorearlyonsetCharacteristicsofCongenitalvs.AcquiredSepsissepsisoccurswithinthefirstfewdaysoflife,andaretypicallyCharacteristicCongenitalAcquiredacquiredduringtheintrapartumperiod,oftenfromorganismsinthematernalgenitaltract.Eighty-fiveTimeofOnset:Birth-4Days>7DayspercentofnewbornswithearlyonsetsepsisbegintoshowOBComplications:FrequentUnusualsymptomswithinthefirst24hoursoflife,5%havesymptomsbetweenSource:MothersPostnatal24and48hours,averysmallGenitalTractEnvironmentpercentageofinfantsshowClinicalMultisystemFocalsymptomsbetween48hoursand6Presentation:daysoflife.Prematureinfantshavethemostrapidonset.AsuddenMortalityRate5-502-6onsetandrapidprogressiontoseptic(%):shockoftencharacterizetheseUsualGroupBStrepStaphEpiinfections.ThemainclinicalfeatureOrganisms:E.ColiCandidaofanewbornwithearlyonsetsepsisisrespiratorydistress,whichoftenpresentsasmildnasalflaringandtachypnea.Therespiratorydistresscanqu

icklyprogresstomultisystemfailureandshockifnotcaughtearly.Withearlyonsetsepsis,thereisahighmortalityrateof15%to50%.ThemostcommonorganismforearlyonsetbacterialinfectionisGroupBStrep(GBS).InadditiontoGBS,EscherichiaColi,Enterococcus,andChlamydiaarealsocommoncausesofcongenitalinfectionsinthenewborn.Acquiredorlateonsetinfectionscanoccuranywherefrom7daysto2monthsfollowingbirth.Theseinfectionsarenormallyseenafterthefirstweekoflifeandusuallyarecontractedfromorganismsinthepostnatalenvironment.Theclinicalmanifestationsmaybeacutephysiologicaldeteriorationormanifestationsofamorelocalizedinfectionthathasprogressedtosepsis.Acquiredinfectionshavesloweronsetsandhaveadecreasedmortalityrateofaround10%to20%.CommonpathogensresponsibleforlateonsetinfectionsincludeCandidaAlbicans,CoagulaseNegativeStaphylococci,Serratia,GBS,andPseudomonas.


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ClinicalSignsofSepsisFewneonatalinfectionsareeasytorecognize.Sinceinfantsareunabletospeakandvocalizewhentheyarenotfeelingwell,itisimportantforthestaffcaringfortheinfanttobeobservantofsignsandsymptomsofsepsis.Thesesignsrangefrommildsymptomstoarapidlydeterioratinginfant,whomayneedresuscitation.Earlyonsetinfectionsoftenpresentwithnonspecific,vaguesymptomsbecauseofneonatesinabilitytomountaninflammatoryresponse.Oftentheonlysignisthattheinfantdoesnotlookright.Seetheboxtotherightforalistofthesignsandsymptoms.SignsofSepsis

Signsofinfectionmaybeexhibitedevenasearlyasthemotherslabor.Ofteninfantsdemonstrateprofoundtachycardiabeforebirth,ortheymayshowdecreasedbeat-to-beatvariabilityonafetalmonitoringstrip.Newbornswhohavecongenitalinfectionsmaybedepressedatdelivery,havelowapgars,and/orrequireresuscitation.

PallorPoortemperaturecontrolGruntingFlaringApnea&BradycardiaLethargyHypoglycemiaPoorfeedingAbdominaldistention

Commonnonspecific,earlysignsofinfectionseenmostofteninclude:hypothermia,accompaniedbyachangeintheinfantscolor,tone,activity,and/orfeedingb

ehavior.Duringthistime,theremayalsobesuddenepisodesofapnea.Gastrointestinalsymptomsincludefeedingintoleranceoralackofinterestinfeeding.Becausethesenonspecificsignsofsepsisalsocharacterizetheonsetofnumerousnoninfectiousprocesses,itmakesthediagnosisdifficult.

DiagnosticEvaluationsSincesepsiscanbeeasilyconfusedwithotherneonatalconditionssuchashypoglycemiaorCNSdisorders,laboratoryandradiographictestsareperformed.Thesetestscanhelpconfirmwhenaninfantistrulyseptic.Septicwork-upswillusuallybeperformedonthoseinfantswhoaredisplayingsignsofsepsis.Work-upsmayincludeaperipheralbloodculture,completebloodcellcount(CBC)withdifferential,chestx-ray,urineculture,andlumbarpuncturewithbloodbeingtheprinciplefluidassessedforsuspectedsepsis.Ideally,allculturesshouldbeo

btainedbeforeantibioticsarestarted.However,20%to30%ofwomeninlaborreceiveantibioticsbeforedeliveryoftheinfant,andthereforetheinfantmayhavealreadybeenexposedtotheantimicrobials,whichmayaffecttheresultsofthebloodcultures.PositiveCSF,urine,andbacterialbloodculturesarelabresultsthatconfirmtheinfanthasaninfection.Otherabnormalresultstoobserveinaninfantsuspectedofsepsisarehypoglycemia,


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NeonatalSepsishyperglycemia,metabolicacidosis,thrombocytopenia,orhyperbilirubinemia.ThebloodcultureandCBCarethemosthelpfulteststoidentifyaninfectionandwhichpathogenisthecausativeorganism.CBCfindingsthatindicateaninfectionispresentinclude:anelevatedordecreasedwhitebloodcount(WBC),alowplateletcount,andahighI:Tratio.TheI:TratioisacalculationwhichisdonetoshowthepercentageofimmaturetototalI:TRatioCalculationwhitebloodcells.WhentheI:Tratioisgreaterthan0.2,thisindicatesthatthereisaleftshift.ImmaturecellsThisleftshiftmeansthattherearemoreimmatureI:Tratio=Total(mature+immature)neutrophilsthanmatureneutrophilscirculatingaroundinthebloodstream.Aneutrophilisatypeofwhitebloodcellthatdefendsthebodyagainstorganismsthatcauseinfection.Wheninfectionispresenttheneutrophilsmigrateoutofthecapillariesandintotheinfectedsite,wheretheyingestanddestroythepathogenscausingtheinfection.Whenthedemandfortheneutrophilsexceedsthesupplyincirculation,immatureneutrophilsarereleasedintothebloodtohelpfightofftheinfection.Thisislabeledaleftshiftandindicatesthataninfectionmaybepresent.Astheinfectiondiminishesandneutrophilsarereplenished,ashifttotherightoccurs,indicatingthateverythingisbacktonormal.


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NeonatalSepsis

TypesofPathogensOverthepast70years,therehavebeenchangesinthepredominantbacteriathatcausebothearlyonsetandlateonsetinfections.Thefluctuatingpatternisduetothedevelopmentanduseofnewdrugs,themobilepopulationoffamilies,andtheprolongedsurvivalofinfantswhowouldhavediedpreviously.Inthe1930smostneonatalinfectionsweretheresultsofGroupABetaHemolyticStreptococci.Thispathogencontinuedtobethecauseofmostinfectionsuntilthe1950swhenmostinfectionswerethencausedbythepathogenStaphylococcusAureus.From1966to1978,eitherEscherichiaColiorGroupBStrepcausedthemajorityofinfections.GroupBStrepremainsoneofthemajorcausesofinfectionstoday.

GroupBStrep(GBS)Althoughanypathogenicorganismcancauseseriousproblemsforthenewborn,GBSisbyfarthemostseriouscauseofneonatalinfectionandmortality.GBSisanormalflorafoundinthevaginaandgastrointestinaltractof15%to20%ofwomen.Itisnotasexuallytransmitteddiseaseandnormallydoesnotcauseanyproblemsforthewomenwhoarecolonizedwithit.Forinfantsthough,GBScancauseserioushealthproblemsandevendeath.Ofthe20%ofwomencolonizedwithGBS,50%ofthemgivebirthtoinfantscolonizedwithGBS.1%to2%ofthoseinfantsbecomeclinicallyillwithaGBSinfection.OneriskfactorforwomenwhoarecolonizedwithGBSisthattheyhaveahigherchanceforprematurelaborbecauseoftheelevatedamnioticfluidlevelofphospholipaseA2.Thisphospholipasepro

ducesprostaglandin,whichisapotentlaborstimulatant.OtherriskfactorsthatincreasetheinfantschanceofbecominginfectedwithGBSincludematernaltemperature>38Celsius(100.4F),prolongedruptureofmembranes,prematuredelivery,multiplebirths,andaprevioussiblingwithaGBSinfection.BecauseoftheseverityofaGBSinfectioninthenewborn,treatmentguidelineshavebeenestablishedbythegoverningbodiesinvolvedinnewbornhealth.ThemainfocusoftheguidelinesistopromoteGBSscreeningofallpregnantwomenlateintheirpregnancy.Thisispartlyduetothefactthatupwardsof25%ofGBSinfectionsoccurinterminfantswhoareborntomotherswithoutanyriskfactors.WhenthepregnantwomanistestedandispositiveforcolonizationofGBS,sheshouldbetreatedwithantibioticsduringlabor.GBSinfectionscaneitherbeanearlyorlateonsetinfection.TheearlyonsetinfectionisaresultoftransmissionoftheGBSbacteriafromthemothertothefetus,usuallyduringdelivery.Theinfant

willbegintopresentsymptomsduringthefirst24-48hoursoflife.Atfirst,thesymptomsmaybeverysubtleandnonspecific.Theinfantmaypresentwithpallor,tachypnea,tachycardia,ordecreasedactivity.Ifthesefirstsymptomsgoundetected,theinfantwillprogresstosignsofinfectionthataremoreobvious.Thesemayincludetemperatureinstabilityand/orrespiratorydistress,suchasgrunting,nasalflaring,retractions,andapnea.GBSinfectionsareprogressiveandthesymptomsworseniftreatmentisnotinitiated.Withinhours,aninfantcandeterioratefromgruntingwithslightretractionstosepticshockanddeath.Themortalityrateininfantslessthen36weeksofgestationis30%to50%.


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NeonatalSepsisLateonsetGBSinfectionscanoccuranywhereafterthefirstweekoflifeupto2monthsofage.Lateonsetinfectionsseemtobecausedbynosocomialtransmissionratherthanmaternaltransmission.ThisformofGBSinfectioncanbelessseverethantheearlyonsetformbutstillcarriesamortalityrateof25%.Infantswiththislateformwilloftenpresentwithmeningitisastheirmainsymptom.TreatmentofGBSoftenbeginswhenthemotherisinlabor.Forwomenwhotestpositive,ampicillinisneededatleast4hoursbeforedeliveryforthetreatmenttobesuccessful.Ifthemotherdoesnotreceivetheampicillin,theinfantmayhavetoundergobloodteststoruleoutthepresenceoftheGBSbacteria.ForthosenewbornswhodoacquireaGBSinfection,treatmentstartswithsupportivecare.Thisincludesantibiotics,suchasampicillinandgentamicin,fluidandvolumesupport,andrespiratorysupport,usuallyintheformofaventilator.Treatmentagainstmeningitis-inducedseizureactivitymayalsoberequired.LongtermoutcomesforinfantswithGBSinfectionsaredependentuponthetypeofinfection,whetheritisearlyonsetorlateonset,andhowsoontreatmentwasstarted.NeonateswhopresentwithearlyonsetGBSandreceivetreatmentquicklyhaveabetterprognosisthenthosewhoacquirelateonsetGBSinfectionswhere25%to50%ofthoseinfantsmayhavepermanentneurologicaldamage.

StaphylococcusStaphylococcalpathogenscancausemildtosevereinfections.Transmissionmayresultinalocalizedinfectionfromascalpelectrode,tomorewidespreadinfectionssuchasosteomyelitisresultinginoverwhelmingsepsis.Themajorsourceofthisinfectionfromstaphylococcuscomesfromimproperhandwashingbythehosp

italstaff.Itisalsoassociatedwithinfectionsarisingfromumbilicalcatheters,endotrachealtubes,andcentrallines.Othercausesofnosocomialinfectionsareimproperstaffing,lackofspacebetweeninfants,andlackofsteriletechniquewhencaringforinvasivecatheters.Colonizationofthepathogenoccursin40%to90%ofinfants,usuallybythefifthdayoflife.Itismostoftentreatedwithvancomycin.

EscherichiaColiE.ColiisthemostcommoncauseofgramnegativeneonatalinfectionintheUnitedStates.Thispathogeninfects1to2outofevery1,000livebirthsandisresponsibleforupto45%ofneonatalinfections.Thisbacteriumisfoundinthemothersgenitaltractwithahighincidenceofcolonizationintheneonate.Thepathogencancausesevereinfectionsthatmayleadtorespiratorydistress,cardio

vascularcollapse,meningitis,multiorganfailure,andevendeath.E.Coliisusuallytreatedwithgentamicin.


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NeonatalSepsis

ManagementToincreasetheinfantschanceofsurvival,earlyrecognitionofsignsandsymptomsofsepsisisimperative.Oftenthediagnosisofsepsisisbaseduponsuspicionofthepresentingclinicalsignsandsymptoms.Antibiotictherapyisusuallystartedbeforelabresultsconfirmandidentifythepathogencausingtheinfection.Inadditiontoantibiotictreatment,therapyconsistsofcirculatory,respiratory,nutritional,anddevelopmentalsupport.Treatmentbeginswithcarefulmonitoringoftheinfantsvitalsignsandregulationofthethermalenvironment.Supportivetherapyforasepticinfantstartswiththeadministrationofoxygenwhenrespiratorydistressorhypoxiabecomespresent.Theinfantmayalsoneedmoreinvasiverespiratorysupportsuchascontinuouspositiveairwaypressure(CPAP)ortobeplacedonaventilatoriftheyaresufferingfromapneicepisodes.Infantswhoaresickmayalsodevelopelectrolyteabnormalities.Theseinfantswillneedcareful,ongoingmonitoringandadjustmentofthefluidandelectrolytebalance,especiallywhentheinfantsareNPO.Antibiotictherapyiscontinuedfor7to21daysiftheculturesarepositive,oritisdiscontinuedin3daysifculturesarenegative.Theinfantsoutcomeisvariable.Beforetheavailabilityofantibiotics,mortalityratesforinfectedinfantsweregreaterthan95%.Inthe1970sand1980s,themortalityratedecreasedto20%to40%.Today,withtheuseofantibioticsalongwithearlyrecognitionandsupportivecare,mortalityhasreducedto13%to45%,dependingonthecausativeagent.However,approximately1,500neonatesintheUnitedStatesstilldieannuallyfromsystemicinfections.

NursingConsiderationsNursingcarefortheinfantwithsepsisinvolvesskilledobservationandongoingassessments.Recognitionofaproblemisparamountinimportance.Itismostoftenthenursewhoobservesandidentifiesthatsomethingjustisntrightwiththeinfant.Thisisduetothefactthatthenursemaintainsconstantassessmentanddocumentationofsubtlechangesintheinfantsvitalsigns,physicalassessments,feedingtolerance,responsiveness,and/orgeneralbehavior.Awarenessofthepotentialroutesfortransmissionofinfectiouspathogenswillalsohelpidentifythoseinfantsatriskfordevelopingsepsis.Muchofthecareforinfantswithinfectionsinvolvesthemedicaltreatmentoftheillness.Nursesmustbeawareofthesideeffectsofthespecificantibioticsandtheproperadministrationguidelines.Prolongedantibiotictherapyposesadditionalhazardsforaffectedinfan

ts.Antibioticspredisposetheinfanttogrowthofresistantorganismsandsuperinfectionsfromfungalagentssuchascandida.Thenursemustbealertforsignsofsuchcomplications.


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NeonatalSepsisAnotherchallengeincaringforasickinfantisstartingandmaintainingIVaccessfordrugtherapy.Commonsitesintheinfantincludethehandandarm,aswellastheveinsfoundinthescalpandfoot.Iftheinfantisgoingtorequireextensiveantibiotictherapy,aperipherallyinsertedcentralcatheter(PICC)maybeconsidered.Totalcareofinfantswithsepsisinvolvesdecreasinganyadditionalphysiologicand/orenvironmentalstress.Thisincludesprovidinganoptimumthermoregulatedenvironmentandanticipatingpotentialproblems,suchasdehydrationorhypoxia.Precautionsneedtobeimplementedtopreventthespreadofinfectionstoothernewborns.Tobeeffective,precautionsmustbecarriedoutbyallcaregiversthatcomeincontactwiththesickinfant.Properhandwashing,useofdisposableequipment,disposingofexcretions,andadequatehousekeepingoftheenvironmentandequipmentareessential.Sincenursesarethemostconstantcaregiversinvolvedwithsickinfants,itisusuallytheirresponsibilitytooverseethateveryonemaintainsallphasesofisolation.

FamilyImplicationsMaternalattachmentisacumulativeprocessthatbeginsbeforeconception.Itisstrengthenedbysignificanteventsduringpregnancy,andmaturesthroughmaternal-infantcontactduringtheneonatalperiod.Whenaninfantbecomessick,thenecessaryphysicalseparationappearstobeaccompaniedbyanemotionaldetachmentonthepartoftheparents,whichmayseriouslydamagethecapacityforparentingtheirinfant.Duringpregnancy,andsometimesevenbeforeconceptionoccurs,mothersdevelopanidealorfantasyimageoftheirunbornchild.Tothemother,theunbornchildhasanimaginedappearance,patternofbehavior,andexpected

accomplishments.Anythingthataltersthisimagecanalterthebondingbetweenthemotherandhernewchild.Thereforenursingcaredoesnotstopwithprovidingmedicalcaretoasickinfant.Thenurseneedstoencourageandfacilitateparentalinvolvement,ratherthanisolatingtheparentsfromtheirinfantandassociatedcare.Nursesshouldbecognitiveofthefactthattheparentsworryassociatedwithasickinfantcangowaybeyondtheinfantsactualstateofillness.Oftenparentsaskthemselves,CanIcareforthisinfant?Thenurseneedstoprovideconstantteachingandsupplythefamilywithcontinualupdatesontheinfantsconditiontohelpthemthroughthisfrighteningtime.Itisimportantforthenursetousesimpleandbasicvocabulary.Whenmedicallanguageisused,itincreasestheparentsanxietylevel,andteachingiflesseffective.Somemothersfeelguiltythattheymayhavedonesomethingtocausetheinfantscondition.Thenursingstaffneedstoprovideconstantreassurancethatthisisacommonfeelingandth

atshedidnotcausetheinfanttobecomeill.The


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NeonatalSepsisnurseneedstorememberthegoalsofhis/hercare.Goalscannotbeonlypatientorientated,butneedtobefamilyorientatedaswell.Itisimportanttorememberthatitistheinfanttowhoweprovidecare,butitisthefamilywhowilltakethebabyhome.Thenurseneedstoprovidethefamilywiththeknowledgeandskillstheyneedtotakecareoftheirinfantoncethebabyisdischargedfromthehospital.

SummaryDespitethemajoradvancesinneonatalmedicine,manyinfantsstilldeveloplife-threateninginfectionsduringthefirstmonthoflife.Identifyingandcaringforaninfantwithapossibleinfectionstartswithaskillednursewhoisproficientinperformingneonatalassessments.Theassessmentbeginswithanursesinnateknowledgeofthemanydifferentriskfactorsfornewborninfection.Thenurseneedstobeobservantforanysignthatmayindicatesepsis.Itcannotbeoveremphasizedthatpromptrecognition,earlydiagnosis,andimmediatetreatmentofsepsiscandramaticallyimprovetheinfantsoutcomeandlimitanypotentialdisability.Oncesepsishasbeenidentified,treatmentmustbeinitiatedpromptly,andtheinfantreassessedfortheirresponsetothetherapy.Hourscanmakethedifferenceofaninfantsurvivingtheinfection,orsuccumbingtoitssystemicdevastation.Becauseofthenonspecificmanifestationsofimpendingsepsis,anychangesinthephysicaland/orbehavioralstateofaninfantshouldraisethesuspicionofsepsis.Aboveallelse,nursingassessmentandinterventionsarethemostimportanttoolintheprevention,promptrecognition,andeffectivemanagementofnewborninfections.


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NeonatalSepsisEducation&DevelopmentAnswerSheetOrlandoRegionalHealthcareEmployee:()No()YesEmployee#LastNameStreetAddressFirstNameCityDate

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Darkenthecorrectcircle,youmayusepencilorblackink1.2.3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20.21.22.23.24.25.AOOOOOOOOOOOOOOOOOOOOOOOOOBOOOOOOOOOOOOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOOOOOOOOOOODOOOOOOOOOOOOOOOOOOOOOOOOOEOOOOOOOOOOOOOOOOOOOOOOOOO

26.27.28.29.30.31.32.33.34.35.36.37.38.39.40.41.42.43.44.45.46.47.48.49.50.

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NeonatalSepsis

PostTestDirections:DoNOTwriteonthistest.Completethistestusingthebubblesheetprovided.1.AllofthefollowingdefinesepsisinthenewbornEXCEPT:A.ThepathogenovercomestheinfantsdefensesB.ThepresenceofmicroorganismsintheinfantsbloodC.ThepresenceofthepathogenintheinfantsstoolD.ThepresenceofmicroorganismsintheinfantstissuesWhichofthefollowingarematernalriskfactorsfordevelopingneonatalinfections?A.RegularwellnesscheckupsB.PoornutritionC.MultiplebirthsD.FirstpregnancyTCellsarefirstfoundinthefetusatwhatweekgestation?A.4weeksB.6weeksC.8weeksD.10weeksTheannualcostoftreatmentofneonatalsepsisintheUnitedStatesis__________.A.$600millionB.$700millionC.$800millionD.$900millionInfantsthathaveahigherriskfordevelopinginfectionareA.MaleinfantsB.FemaleinfantsC.FullterminfantsD.PostterminfantsAninfantis6hoursoldandisstartingtoshowsignsofrespiratorydistresssuchasgruntingandretraction.Whichofthefollowingaccuratelydescribesthetypeofinfectiontheinfanthas?A.AcquiredB.CongenitalC.NosocomialD.Periodic

2.

3.

4.

5.

6.


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NeonatalSepsis7.Amotherbringsinher2-week-oldinfanttothedoctorandreportsthattheinfanthasbeenlethargicandnoteatingverywell.Whichofthefollowingaccuratelydescribesthetypeofinfectiontheinfanthas?A.AcquiredB.CongenitalC.IntrapartumD.MaternalThemostcommontypeoforganismthatcausesacongenitalbacterialinfectionis:A.CandidaAlbicansB.PseudomonasC.GroupbetastrepD.SerratiaAllofthefollowingaresignsofinfectioninthenewbornEXCEPT:A.PallorB.ApneaC.HypoglycemiaD.ChokingWhichstatementbestdescribessignsandsymptomsofaninfantwithsuspectedsepsis?A.Infantswithinfectionswillhaveafever.B.Theinfantsappetiteisunaffectedbysepsis.C.Infantswithinfectionsareeasytorecognizebecauseoftheobvioussymptoms.D.Infantswithinfectionsarehardtorecognizebecauseofthevaguesymptoms.Whentakingcareofasickinfantthenurseshould:A.DecreaseanyphysiologicorenvironmentalstressB.HavebloodorderedandwaitingC.PerformfrequentlinenchangesD.PerformfrequentlabdrawsIngeneralwhenassistingthefamilywithcopingwiththehospitalizedinfant,thenurseshouldrecognizethat:A.Mothersoftenfeelcapableandreadytojumpinandhelpwiththecareofthesickinfant.B.Fathersoftenarereadytojumpinandhelpwiththecareofthesickinfant.C.Mothersoftenfeelguiltywhentheirinfantbecomessick,blamingthemselvesfortheinfantsillness.D.Parentalinvolvementisalowpriorityinthecareofaninfant.

8.

9.

10.

11.

12.


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NeonatalSepsisMatchthecorrectimmunoglobulinwithitsdescription13.Doesnotcrosstheplacenta,levelsarehigherwhenaninfectionispresent.Mostcommonimmunoglobulinfoundinthegastrointestinaltract.Levelsnotdetecteduntiltheinfantis2-3weeksold.Crossestheplacentaandentersintofetalcirculationaround30weeksofgestation.

A.ImmunoglobulinAB.ImmunoglobulinGC.ImmunoglobulinM

14.

15.

Matchthecorrectpathogenwithitsdescription16.Thispathogenisamajorsourceofinfectionfromhospitalpersonnelwithimproperhandwashing.Mostcommoncauseofgramnegativeinfections.Infectioncanbeeitherearlyorlateinitsonsetandisoneofthemostseriouscausesofmortalityinthenewborn.A.EscherichiaColiB.GroupBStrepC.Staphylococcus

17.18.

Matchthecorrectpathogenwithitscommontreatment19.20.21.EscherichiaColiGroupBStrepStaphylococcusA.AmpicillinB.GentamicinC.Vancomycin


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NeonatalSepsis

ReferencesBellig,L.(2004,June23).Neonatalsepsis.Emedicine.RetrievedJuly12,2004fromhttp://www.emedicine.com/ped.topic2630.htmCDC.GroupBStrep.RetrievedJuly23,2004,fromhttp://www.cdc.gov/ncidod/dbmd/gbs/Deacon,J.&ONeill,P.(1999).CoreCurriculumforNeonatalIntensiveCareNursing(2nded.).Philadelphia,PA:W.B.SaundersCompany.Gardner,S.&Merenstein,G.(2002).HandbookofNeonatalIntensiveCare(5thed.).St.Louis,MI:Mosby.Haw,P.(2003).CareoftheSickNeonate:AQuickReferenceforHealthCareProviders.NewYork,NY:LippincottWilliams&Wilkins.Huether,E.S.&McCance,L.K.(2000)UnderstandingPathophysiology(2nded.).St.Louis,MI:Mosby.Ladewig,P.,London,M.,Moberly,S.,&Olds,S.(2001).ContemporaryMaternal-NewbornNursingCare(5thed.).NewYork,NY:PrenticeHall.Lowdermilk,L.D.,Perry,E.S.,&Bobak,M.(2000).Maternity&WomensHealthCare(7thed.).St.Louis,MI:Mosby.McKenney,W.M.(2001,December).Neonatalnursing.Understandingtheneonatalimmunesystem:highriskforinfection.CriticalCareNurse,21(6),35-47.Mullaney.D.(2001).GroupBstreptococcalinfectionsinnewborns.JOGNN,30(6),649-658.NeonatologyontheWeb.NeonatalInfections.RetrievedJuly14,2004,fromhttp://www.neonatology.org/syllabus/sepsis/index.htmOddie,S.&Emblrton,N.(2002).RiskfactorsforearlyonsetneonatalgroupBstreptococcalsepsis:casecontrolstudy.BritishMedicalJournal,325(7539),308-311.Polinski,C.(1996,October).Thevalueofthewhitebloodcellcountanddifferentialinthepredictionofneonatalsepsis.NeonatalNetwork,15(7),13-22.Sater,J.K.(1998,September/October

).Treatmentofsepsisintheneonate.TheJournalofIntravenousNursing,21(5),275-281.Sinha,A,Yokoe,D.&PlattR.(2003).IntrapartumantibioticsandneonatalinvasiveinfectionscausedbyorganismsotherthangroupBstreptococcus.TheJournalofPediatrics,145(5),492-497.Wong,J.D.(2003).Whaley&WongsNursingCareofInfantsandChildren(7thed.).St.Louis,MI:Mosby.


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NeonatalSepsis

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