neonatology: neonatal septicemia. lecture points morbidity and mortality the compromised host of the...
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Neonatology:
Neonatal Septicemia
Lecture points
• Morbidity and mortality• The compromised host of the neonates in immunology• Pathogens for clinical consideration• Clinical manifestation• Clinical Management
Incidence
• 1% ~ 10%, in live birth
• 15-20%, in VLBW
Incidence
0
5
10
15
20
25
‰
0
5
10
15
20
25
‰
Gross incidence Comparison: US and developing countries
Neonatal Septicemia
5.30%
10.30%
3.10%
0%
3%
6%
9%
12%
15%
USA Preterm Full
Death rate: US
Neonatal Septicemia
Death rate : developing countries
0%
2%
4%
6%
8%
LONS 7.5%
0%
5%
10%
15%
20%
death rate: 9.8%~12%
• Immature development in body defense
• Imperfect function
• Less experience of exposure to environment and pathogens
• Affected by maternal antibodies
Immunological features in neonates
Non-specific Immune: • Poor barriers function• Undeveloped complement activation capacity • Relative fewer neutrophil, Immature Functio
n• Lower ILs, lower level of cytokines
Immunological features in Neonates
Specific Immune: • Quantities and quality of Ig G, A, M• T, B cell: quantities, quality and their function
Immunological features in Neonates
Pathogens
• Domestic:– Staphylococcus: most commonly seen– Escherichia coli, etc. – G- bacillus
• US:– GBS: the leading pathogen during 1970’s– Escherichia coli: the leading pathogen
during 1990’s
Pathogenic Changes
0
1
2
3
4
5
6
7
8
GBS
E.coli.
‰
EONS: Changes by G+ vs. G-
Early 1990’s Late 1990’s
0%
5%
10%
15%
20%
91-93 96-00
year
any
G+
G-GBS
E.coli
Pathogenic Changes
Relevant factors of pathogenic changes
• Change of colonized pathogens in maternal birth canal • GBS Screening • Preventive antibiotic therapy used during pre partum
• Ampicilline for the mother with GBS positive : pre partum and Intro-partum GBS Septicemia Efficacy : around 70% ( vs. control P < 0.0001 )
Pathogens based on the types in developed country
• EONS :– E. coli– Listeria monocytoge
nes, Pseudomonas– Meningococcus– Enterococcus and G
BS
• LONS :– Coagulase-negative
Staphylococcus– Haemophilus influen
za bacillus– Other pathogens
Pathogens based on the types in developed country
E.coli. 27%
Staph 40%
Klebsiella 15%
GBS <10%
Others >8%
LONS (48 hours after birth) Mainly: G+ Coagulase-negative Staphylococcus Partly reported : Staphylococcus epidermidis, GBS and E. coli
EONS (within 24-48 hours after birth)G+ = G-
G+ : mainly Klebsiella pneumoniae and E. coliG- : Enterococcus commonly seen
VEONS (within 24 hours after birth)Klebsiella 、 E. coli 、 Enterococcus
Pathogens based on the types in developing country
VEONS42%
EONS40%
LONS7% Others
11%
Early onset dominant Related with the maternal and the intro-partum high risk factors
Pathogens based on the types in developing country
Pathogens isolated in China
0
5
10
15
20
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30
35
40
45
0-3d(671) 4-7d(458) 8-28d(1849)
CNS金葡菌E.col i肠杆菌假单胞菌
main isolates from blood culture bsed on the ages: n=671/458/1849
临床儿科杂志: 2002-2 浙江大学附属儿童医院资料
Pathogens isolated in China
0
5
10
15
20
25
30
表葡 腐生葡 E. col i 金葡菌 克雷伯 不动杆菌
中华儿科杂志 01-6 ;重庆儿科医院资料
Domestic data : main isolates: n=815
main isolates account for during different periods: n=436
0%10%20%30%40%50%60%70%80%90%
100%
92-94 95-96 99-00
G+
staph
Staphylococcusepidermidisother CNS
临床儿科杂志 02-5 :深圳市人民医院儿科资料
Pathogens isolated in China
Pathogens isolated in China
0%10%20%30%40%50%60%70%80%90%
100%
92-94 95-96 99-00
G-其它不动杆菌假单胞菌克雷白杆菌沙门氏菌E. col i
HF
G+其它链球菌肠球菌
CNS其它表葡菌金葡菌
临床儿科杂志 02-5 :深圳市人民医院儿科资料
main isolates account for during different periods: n=436
Pathogens isolated in China
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
1989-1991 1999-2001
肠杆菌棒壮杆菌Ecol i芽胞杆菌CNS金葡菌
main isolates account for during different periods: n=606/475
临床儿科杂志: 2002-2 哈尔滨儿童医院资料
The path of Infection
Path:1. Intrauterine infection
2. Intro-partum infection
3. Post delivering infection
• Maternal intro-partum fever (OR=4.1 CI=1.2-13.4)
• Repeated Vaginal examinations (OR=2.9 CI=1.1-8.0)
• Among GBS Sepsis, Dystocia and maternal fever account for 49%
• Prolonged membrane rupture ≥18 hour ( 79% )• Prematures and LBW
• Later onset sepsis: PDA, Long time of Intravascular catheter, various of invasive procedure, BPD
Risk factors of sepsis occurrence
Clinical manifestations
General :– Anorexia– Less Crying– Fewer physical activi
ties– Lower temperature
or fever – Poor weighting gain– Persistent Jaundice
Focal:– Omphalitis
– Skin infection
– Blepharitis (eyes)
– Otitis media
– Paronychia (nails)
Clinical manifestations
Toxic:– Shock– Hepatosplenomegaly– Skin deposition point– Distension– Anemia
Complication:– Meningitis– Pneumonia – Peritonitis– Urinary Tract Infectio
n– Scleredema– DIC– Toxic myocarditis
Laboratories and investigation aids
• Peripheral whole blood test• Blood culture • Others:
– CRP/ PCT– Smear of WBC: check bacterial – CSF– Urine
• CXR
Clinical Management
Antibiotic therapy• Selection based on the pathogen isolated
• Early, Adequate dose, IV
• Duration: – 2 weeks for G+, 3 weeks for G-. – Longer duration for meningitis and severe
Supportive therapy
– Dehydration– Correct metabolic acidosis– Maintenance of electrolyte and Acid-base
balance– Enough energy supply– Keep warm– Correct hypoxemia– Immunological therapy: IVIG
Clinical Management
Complication treatment– Shock– DIC– Scleredema– Respiratory failure – Conversion
– Jaundice– Focal lesion
Clinical Management
Thanks for listening
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