Dr Dickson Adomako Kissi
Obstetric and Gynecology Department, VRAMarch 24, 2016
Neonatal SepsisDefinitionEtiologyClassificationPathophysiologySymptoms and SignsLaboratoryTreatmentConclusion
DefinitionAs children develop physiologically and emotionally, it is
useful to define certain age based groups. Neonate or new born is birth to 1 month, infant is 1 month to 1 year and young child is 1 year to 4 years whiles older child is 5 years to 10 years.
Neonatal sepsis is invasive infection, usually bacterial, occurring during the neonatal period (0 to 1 month).
Neonatal sepsis occurs in 0.5 to 8.0 per 1000 births. The highest rates occur in low-birth weight (LBW) infants,
those with depressed respiratory function at birth, those with maternal perinatal risk factors, males and those with congenital anomalies.
DefinitionRoutine care for babies and children aims to promote healthy
development through education, vaccination, and early detection and treatment of disease.
Immediately at delivery, the neonate’s respiratory effort, heart rate, color, tone, and reflex, irritability should be assessed; all are key components of Apgar score assigned at 1 minute and 5 minutes after birth.
Apgar score assigns 0 to 2 points for each of the 5 measures of neonatal health ( appearance, pulse, grimace, activity, respiration)
Neonatal sepsis can be early onset (within 7 days of birth) or late onset (after 7 days)
Early onset: Early onset sepsis usually results from organisms acquired intrapartum. Most infants have symptoms within 6 hours of birth, and almost all cases occur within 72 hours.
Group B streptococcus (GBS) and gram negative enteric organisms (predominantly Escherichia coli) account for most cases of early onset sepsis.
Vaginal or rectal cultures of women at term may show GBS colonization rates of up to 30%. At least 35% of their infants also become colonized.
Nontypeable Haemophilus influenza sepsis has been increasingly identified in neonates, especially premature neonates.
ClassificationOther gram negative enteric bacilli ( eg, klebsiella sp) and
gram-positive organisms – Listeria monocytogenes, enterococci, group D streptococci, and staphylococci account for other cases.
Steptococcus pneumonia, H, influenza type b, and less commonly, Neisseria meningitides have been isolated.
Asymptomatic gonorrhea occurs in pregnancy, so Neisseria gonorrhea may be a pathogen.
ClassificationLate onset: Late onset sepsis is usually acquired from the
environment. Staphylococci account for 30 to 60% of late onset cases and
most frequently due to intravascular devices. E. coli is also becoming increasingly recognized as a
significant cause of late onset sepsis, especially in very LBW infants.
Classification Isolation of Enterobacter cloacae or E. sakazakii from blood
CSF suggests contaminated feedings. Group B streptococcus can also cause late onset sepsis.
Anaerobes particularly Bacteroides fragilis may also account for sepsis. Candida is increasingly important, occurring in 12 to 13% of very LBW infants.
Certain viral infections may manifest as early or late onset sepsis.
PathophysiologyEarly onset: Certain maternal perinatal and obstetric factors
increase riskPremature rupture of membranesMaternal bleeding (e.g., placenta previa, abruption
placentae)PreeclampsiaPrecipitous deliveryMaternal infection (particularly of the urine tract or
endometrium, most commonly manifest as maternal fever shortly before or during delivery)
Preterm deliveryHeavy colonization with GBS
PathophysiologyHematogenous and transplacental dissemination of
maternal infection occurs in the transmission of certain viral (eg, rubella, cytomegalovirus), protozoal (eg, Toxoplasma gondii), and treponemal (eg, Treponema pallidum)pathogens.
A few bacterial pathogens (eg, L.monocytogenes, Mycobacterium tuberculosis) may reach the fetus transplacentally, but most are acquired by the ascending route in utero or as fetus passes through the colonized birth canal.
PathophysiologyAmniotic fluid contaminated with meconium or vernix
caseosa promotes growth of GBS and E.coli. Hence, the few organisms in the vaginal vault are able to proliferate rapidly after PROM, possibly contributing to this paradox.
PathophysiologyLate onset: The most important risk factor in late onset
sepsis is preterm delivery, prolonged hospitalization, contaminated equipments or IV or enteral solutions.
Gram-positive organisms (eg, coagulase negative staphylococci and staphylococcus aureus) may be introduced from the environment or the patient’s skin.
PathophysiologyGram negative enteric bacteria are usually derived from the
patient’s endogenous flora. Initial foci of infection can be in the
urinary tract, paranasal sinuses, middle ear, lungs, or GI tract, and may later disseminate to
meninges, kidneys, bones, joints, peritoneum, and skin.
Symptoms and signs
Early signs are frequently nonspecific and subtle and do not distinguish among organisms including viral.
Diminished spontaneous activityLess vigorous suckingApnea, respiratory distressBradycardiaTemperature instability (hypothermia or hyperthermia)Seizures Jitterness JaundiceVomiting, diarrheaAbdominal distentionFoul-smelling amniotic fluid at birth
Symptoms and Signs Vital signs are reviewed, noting abnormalities in
temperature and respiratory rate.Temperature should be measured orally for accuracy. Fever
is present in only 10 to 15% but, when sustained for more than 1hour, generally indicates infection.
Any infant with cough, tachypnea, or labored breathing requires pulse oximetry.
The infants overall appearance and response to examination are important.
Symptoms and signsThe febrile baby who looks quite ill, especially when the
temperature has come down, is of great concern and requires in-depth evaluation and continued observation.
Although serious illness does not always cause high grade fever, and many high fevers result from self-limited viral infections, a temperature of more than 39 Celsius in a baby indicates higher risk of occult bacteremia.
Symptoms and signsPeriumbilical erythema, discharge, or bleeding without a
hemorrhagic diathesis suggest omphalitisComa, seizures, or a bulging fontanelle suggests meningitis,
encephalitis or brain abscess.Decreased spontaneous movement of an extremity and
swelling, warmth, erythema or tenderness over a joint indicates osteomyelitis or pyogenic arthritis.
Complete blood count with differentialsRadiographyBlood cultureUrine cultureLumbar punctureUltra sound scan ESR (C reactive protein is also considered) it is elevated in
sepsisUltimately testing should be directed by history and
examination findings IL-6 and other inflammatory cytokines are being
investigated as markers for sepsis.
LaboratoryThe normal WBC count in neonates varies and the absolute
band count is not sensitive enough to predict sepsis, but a ratio of immature: total polymorphonuclear leukocytes of less than 0.2 has a high negative predictive value.
The platelet count may fall hours to days before the onset of clinical sepsis but more often remains elevated until a day or so after the neonate becomes ill.
LaboratoryUmbilical vessels are frequently contaminated by organisms
on the umbilical stamp, so blood culture results may not be reliable.
Urine sample should be obtained by catheterization or suprapubic aspiration. Absence of pyuria does not rule out UTI.
Antibiotic therapySupportive therapy IV immune globulin given at birth may prevent sepsis in
certain high-risk LBW infants but does not help in established infections.
Treatment is directed at the underlying cause of the infection.
TreatmentBecause sepsis may manifest with nonspecific clinical signs
and its effects may be devastating, rapid empiric antibiotic therapy is recommended: drugs are later adjusted according to sensitivities and the site of infection.
General supportive measures, including respiratory and hemodynamic management are combined with antibiotic treatment.
Ampicillin or penicillin G plus gentamicinCefotaxime, Clindamycin and Metronidazole can also be
used.Ampotericin B therapy for candida can be initiated before
culture results are received.
Quote !!!Do not talk about giftedness, inborn talents! One can name
great men of all kinds who were very little gifted. They acquired greatness, became “geniuses” (as we put it), through qualities the lack of which no one who knew what they were would boast of: they all possessed that seriousness of the efficient workman which first learns to construct the parts properly before it ventures to fashion a great whole; they allowed themselves time for it, because they took more pleasure in making the little, secondary things well than in the effect of a dazzling whole.
• FRIEDRICH NIETZSCHE
Thanks for VRA Obs and Gynecology Department, Dr T, Valmont, Clinical Cordinator Dr. Arhinful and the entire VRA staff and team.