Nov 2007 ACoRN © 2005-07 Infection Sequence. Nov 2007ACoRN © 2005-07.

Nov 2007Nov 2007ACoRN © 2005-ACoRN © 2005-

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Infection SequenceInfection Sequence


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5Problem List

8Support

Respiratory

Surgical Conditions

Thermoregulation

Fluid & Glucose Management

Neurology

Cardiovascular

1Baby at-

risk

Sequences

2 Resuscitation

3PrimarySurvey

4Infection

Consider transport

6

7


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AA lerting signslerting signs

CC ore stepsore steps

OO rganization of rganization of carecareRR esponseesponse

NN ext ext stepssteps

SS pecific pecific managementmanagement

SS pecific pecific diagnosisdiagnosis



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Alerting SignsAlerting Signs


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Risk factors for infectionRisk factors for infection

• AntepartumAntepartum– previous baby with GBSprevious baby with GBS– positive maternal GBS screenpositive maternal GBS screen– GBS bacteriuriaGBS bacteriuria– maternal infectionmaternal infection– previous unexplained stillborn at termprevious unexplained stillborn at term


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Risk factors for infectionRisk factors for infection

• IntrapartumIntrapartum– preterm labor preterm labor – PPROM < 37 weeksPPROM < 37 weeks– rupture of membranes > 18 hoursrupture of membranes > 18 hours– maternal temperature maternal temperature ≥≥ 38 38ooCC– signs and symptoms of chorioamnionitissigns and symptoms of chorioamnionitis

• NeonatalNeonatal– need for resuscitation or invasive proceduresneed for resuscitation or invasive procedures– prematurityprematurity


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Infection Risk FactorsInfection Risk Factors

0

1

2

3

4

5

6

7

Lik

elyh

oo

d (

nu

mb

er X

)

PROM

Prematurity

Maternal Chorio

Perinatal Asphyxia

Male

Recent Colonization withGBS, HSV

Multiple Gestation

Foul Smelling at birth


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Respiratory Laboured respiration* Respiratory rate > 60/min* Receiving respiratory support*

Surgical Conditions Anterior abdominal wall defect Vomiting or inability to swallow Abdominal distension Delayed passage of meconium or imperforate anus

Thermoregulation T < 36.3 or > 37.2ºC axillary* Increased risk for temperature instability

Fluid & Glucose Management Blood glucose < 2.6 mmol/L At risk for hypoglycemia Not feeding or should not be fed

Neurology Abnormal tone* Jitteriness Seizures*

Cardiovascular Pale, mottled, or grey* Weak pulses or low BP* Cyanosis unresponsive to O2

Heart rate > 220 bpm


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Clinical signs of infectionClinical signs of infection

• Signs of infection are non-specific.Signs of infection are non-specific.

• Newborns have poor immunity. Infection Newborns have poor immunity. Infection can lead to rapid dissemination and can lead to rapid dissemination and deterioration.deterioration.


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Core StepsCore Steps


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Organization of CareOrganization of Care


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ResponseResponse


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Next StepsNext Steps


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Specific DiagnosisSpecific Diagnosis

• Sepsis without a focusSepsis without a focus

• Sepsis with one or more fociSepsis with one or more foci– pneumoniapneumonia– meningitismeningitis– urinary tract infectionurinary tract infection


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OrganismsOrganisms

• Early onsetEarly onset

GBSGBSE. E.

ColiColiListeriaListeria

H. FluH. FluStrep A Strep A

and Dand D

• Late onsetLate onset

Staph epi Staph epi aureausaureaus Gram NegGram Neg

CandidaCandidaGBSGBS


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PresentationPresentation

• Early onsetEarly onsetFirst 72 hours of ageFirst 72 hours of age

Pneumonia / sepsisPneumonia / sepsisHigh mortality rateHigh mortality rate

• Late onsetLate onsetMore frequently after one week of ageMore frequently after one week of ageFrequently associated with meningitisFrequently associated with meningitisSignificant neurological morbiditySignificant neurological morbidity


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Specific ManagementSpecific Management


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Specific ManagementSpecific Management• Modify antibiotic choices to optimize coverage

– dependent on site of infection– dependent on isolated organism from cultures– dependent on antibiotic sensitivity

• Therapeutic drug monitoring to optimize treatment

• Duration of antibiotic therapy• Need for additional tests and interventions

– surgical consultation and intervention– consultation with Infectious Disease specialist


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Specific ManagementSpecific Management

• Observe for and treat complications of Observe for and treat complications of infection:infection:– shockshock– hypoglycemiahypoglycemia– thrombocytopenia and coagulopathythrombocytopenia and coagulopathy

• Repeat Primary Survey at regular Repeat Primary Survey at regular intervals.intervals.


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TreatmentTreatment

• ANTIBIOTICSANTIBIOTICS

• Supportive CareSupportive Care– Ventilation, oxygenVentilation, oxygen– IV fluids, volume, pressorIV fluids, volume, pressor– Transfusion if indicatedTransfusion if indicated– Thermal regulationThermal regulation– NPO or NG suction if neededNPO or NG suction if needed– FFP/ Cryo if clotting disordersFFP/ Cryo if clotting disorders


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Other conditions that may Other conditions that may present like severe sepsispresent like severe sepsis

• Ductal dependent CHDDuctal dependent CHD

• Congenital adrenal hyperplasiaCongenital adrenal hyperplasia

• Inborn errors of metabolismInborn errors of metabolism

• Abdominal catastrophesAbdominal catastrophes


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AA lerting signslerting signs

CC ore stepsore steps

OO rganization of rganization of carecareRR esponseesponse

NN ext ext stepssteps

SS pecific pecific managementmanagement

SS pecific pecific diagnosisdiagnosis



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Questions?Questions?


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What about What about the CBC?the CBC?


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IndicationsIndications

• Complete blood count (CBC) with white Complete blood count (CBC) with white count and differential count and differential – Is infection suspected? Is infection suspected?

• Platelet countPlatelet count– Infection? Infection? Maternal ITP?Maternal ITP?– Alloimmunization? Alloimmunization? TORCH?TORCH?


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White blood cellsWhite blood cells

http://www.mcl.tulane.edu/classware/pathology/Krause/Blood/Band(k).JPG

http://www.mcl.tulane.edu/classware/pathology/Krause/Blood/Neutrophil(k).JPG






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• Variable WBC countVariable WBC count

• Stress Stress neutrophil demargination neutrophil demargination

• Limited storage pool Limited storage pool neutropenia neutropenia

• Immature formsImmature forms

http://www.mcl.tulane.edu/classware/pathology/Krause/Blood/Band(k).JPG






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• WBC is insensitive and nonspecificWBC is insensitive and nonspecific– normal in 50% proven sepsisnormal in 50% proven sepsis

• Low neutrophil count or increased Low neutrophil count or increased band count is more usefulband count is more useful



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• sometimes expressed as immature/total sometimes expressed as immature/total (I/T) ratio (I/T) ratio

• > 0.25 suggestive of sepsis> 0.25 suggestive of sepsis

bands (immature)bands (immature)

segmented + band (total)segmented + band (total)

Mature vs. ImmatureMature vs. Immature


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• Infection?Infection?• WBC < 5.000 WBC < 5.000 • Neutrophils < 1.750 Neutrophils < 1.750 • Bands > 2.000 Bands > 2.000 • I/T > 0.25I/T > 0.25

Caution!Caution!• Decision to treat sepsis in sick babies is a Decision to treat sepsis in sick babies is a

clinical one.clinical one.• Do not delay antibiotic treatment while waiting Do not delay antibiotic treatment while waiting

for results.for results.


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KevinKevin

• 34 weeks’ gestation34 weeks’ gestation

• PPROM – leaking for 5 daysPPROM – leaking for 5 days

• SVD two hours agoSVD two hours ago

• Apgars 5Apgars 511, 7, 755

• Birth weight 2400 gramsBirth weight 2400 grams

• Grunting and requiring oxygenGrunting and requiring oxygen

• CPAP startedCPAP started


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CBC resultCBC result

WBCWBC

HgbHgb

HctHct

PlateletsPlatelets

Segmented neutrophilsSegmented neutrophils

Band neutrophilsBand neutrophils

MonocytesMonocytes

NormalNormal

4.0 x 104.0 x 1099/L/L (5.0-25.0) (5.0-25.0)

145 g/L145 g/L (135-195) (135-195)

0.0. 4747 (0.45- (0.45-0.66)0.66)

180 x 10180 x 1099/L/L (150-450) (150-450)

0.9 x 100.9 x 1099/L/L (5.0-25.0) (5.0-25.0)

0.6 x 100.6 x 1099/L/L (<1.20) (<1.20)

1.5 x 101.5 x 1099/L/L (0.5-1.8) (0.5-1.8)


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• What is Kevin’s IT What is Kevin’s IT ratio?ratio?

bands (immature)bands (immature)

segmented + band (total)segmented + band (total)

0.60.6

(0.9 + 0.6)(0.9 + 0.6)

IT ratioIT ratio = 0.4= 0.4

KevinKevin


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KevinKevin

• Blood culture results at Blood culture results at 12 hours:12 hours:– Gram positive cocci in Gram positive cocci in

chainschains

• Next dayNext day– Streptococcus group B Streptococcus group B

(GBS)(GBS)


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Questions?Questions?

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