Neonatal Sepsis

Nancy Roberto,CNP

Children’s Hospital Medical Center

Immune System

Specific Nonspecific

MonocytesMacrophagesNeutrophils

Skin and mucous membranesChemical barrierInflammatory responseInterferonPhagocytosis

Cell mediated Humoral

T-lymphocytes Complement B-lymphocytes

AntibodiesDeath of antigenT helperTsuppressorT cytotoxic

Lymphokines

Viral, fungal, protzoan, and some bacterial protectionGraft rejectionSkin hypersensitivityImmune surveillance

IgAViralProtection

IgDFunction unknown

IgEAllergy &ParasiticInfestation

IgGBacterialprotection

IgMBacterial protection

Definition of Neonatal Sepsis

A clinical syndrome of systemic illness accompanied by bacteremia occurring in the first month of life (Gomella,Cunningham and Eyal, 1994)

Pathogenesis of Neonatal Sepsis

Early onset infection: usually multisystem, fulminant illness with prominent respiratory symptoms

Late onset infection: usually has an identifiable focus, most often meningitis, in addition to sepsis

Nosocomial infection: horizontal transmission from NICU environment

Causative Organisms

Primary Sepsis: usually vaginal flora, GBS, gram-negative enteric organisms (E Coli), Listeria monocytogenes, Staphylococcus, Streptococci (including enterococci), anaerobes, and Haemophilus influenzae

Nosocomial Sepsis: Staphylococci (S. Epidermidis and S.Aureus), gram negative rods (Pseudomonas, Klebsiella, Serratia, Proteus) and fungal organisms.

Risk Factors for Sepsis

Maternal Poor PNC and/or nutrition Multiple gestation Low socioeconomic status Recurrent AB Substance abuse Prolonged ROM (>24 hours) Maternal fever/infection Meconium stained or foul-smelling

amniotic fluid Prolonged or difficult labor

Neonatal Prematurity LBW Birth asphyxia Meconium staining Resuscitation Invasive procedures Congenital anomalies (spinal

and abdominal wall defects) Immune defects, asplenia

Clinical Presentation

Thermoregulation Neurologic Skin Gastrointestinal Cardiac Respiratory Metabolic Hematologic

Bacteremia

Thermoregulation

Normal temperature ranges (degrees Celsius)

Skin=36.0-36.5 Rectal=36.5-37.5 Axillary=0.5-1.0 degrees lower

than skin temperature Hypothermia Hyperthermia Temperature instability

Neurologic Symptoms

Lethargy Irritability Decreased muscle

tone Increased muscle

tone Poor feeding Seizures

Skin

Poor peripheral perfusion

Cyanosis Mottling Pallor Petechiae Rashes Jaundice

Hematologic

WBC values

Neutropenia

Thrombocytopenia - Fungal and

G-Negative organisms associated with

lower PLT and more prolonged low PLT

count (Guida, et al 2003 Pediatrics)

Anemia

Disseminated intravascular

coagulation

Cardiac

Tachycardia Bradycardia Hypotension Prolonged capillary

refill Weak peripheral

pulses Cyanosis

Respiratory

Tachypnea Grunting Flaring Retractions Apnea Cyanosis/desaturation Poor air movement Increasing oxygen

requirement

Gastrointestinal

Poor feeding Emesis Gastric residuals Abdominal distention Visible or palpable

bowel loops Diarrhea or bloody

stools

Metabolic

Hyperglygemia Hypoglycemia Hyponatremia Metabolic acidosis

Diagnostic Work-up

CBC with differential Cultures (Blood, Urine,

CSF, tracheal aspirate) X-rays Blood gases Urinalysis PT, PTT, Fibrinogen,

FSP or D-dimer

Bacterial Infection

Blood (Septicemia) CSF (Meningitis) Pneumonia Urinary tract infection Ophthalmia Otitis media Necrotizing enterocolitis

Fungal Infection

Thrush Cutaneous candidiasis Acute disseminated (systemic)

candidiasis

Viral Infection

Rubella Cytomegalovirus (CMV) - Breastmilk main source of perinatally

acquired CMV. More concern in ELBW infants (Yasuda et al, 2003, Pediatrics)

Herpes simplex virus (HSV) Hepatitis B virus Hepatitis C virus AIDS (Human immunodeficiency virus-HIV)

Acronym for Microorganisms Responsible for Infection of the Fetus

(Remington & Klein, 2001) TORCHES To= Toxoplasma gondii R= Rubella virus C= Cytomegalovirus H= Herpes simplex virus E= Enteroviruses S= Syphilis (Treponema

pallidum

CLAP C= Chickenpox (varicella-

zoster virus) L= Lyme disease (Borrelia

burgdorferi) A= AIDS (human

imunodeficiency virus) P= Parvovirus B19

Management of Sepsis

Universal precautions Initial therapy: Broad

spectrum antibiotic coverage

Continuing therapy: Based on culture and sensitivity

Isolation

Complications & Supportive Therapy Respiratory Cardiovascular Hematologic CNS Metabolic Family

Case Study #1

Risk Factors in Neonatal Sepsis

Case Study #2

Clinical Presentation in Neonatal Sepsis