newborn fever 100512

Neonatal Fever

2010-5-12

李浩遠醫師林口長庚醫院兒童內科

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Reliable Temperature Measurementn All measurements are estimates of the body’s

true core temp—central circulation=aorta and pulmonary artery.

n RECTAL—gold standardn Esophageal—accurate but impracticaln Tactile and axillary—inaccurate, varies

considerably with environmental temperaturen Tympanic—inaccurate in age <3 years




Some Definitions

n Infant - <1 year

n Neonate - < I month

n “early onset” - < 7 days




Small/premature =

n Poor antibody responsen Poor neutrophil responsen Poor complement activationn Impaired macrophage activityn Poor T cell functionn Reduced placental IgG




Three Barriers to Infection

NORMALFLORA

SKIN ANDMUCOUS

MEMBRANES

IMMUNITY




Impaired Barriers

n Thin skin

n Raw umbilicus

n Invasive devices




A Hazardous Journey

n The uterus: Listeria monocytogenesn The birth canal: group B streptococcusn E colin The unit: Acinetobacter baumaniin Devices: CNSn The attendants: Staph aureus




Fever Source of Neonates

n The majority of febrile neonates presenting to the ED have a nonspecific viral illness

n 12% have serious bacterial infections (SBI)n Infected by more virulent bacterian More likely to develop serious sequelae from viral

infectionsn GBS is associated with high rates of meningitis(39%),

non-meningeal foci(10%), and sepsis(7%)n The most common bacterial infections are UTI and

occult bacteremia




Clinical Presentations

n Not breathing welln Not feeding welln Not looking well

lethargic irritable mottledn Fever and tachycardia n Seizures AND NOT A BLOOD TEST OR X-RAY!




Neonatal PEn PE is felt to be unreliable in detecting many serious

bacterial infections. n Meningitis should always be considered—up to 10%

appear well, only 15% have a bulging fontanelle, and 10-15% have nuchal rigidity. So, a high index of suspicion is important!!! ~20% will not have fever initially.– Hyperthermia or hypothermia– Lethargy or irritability– Poor feeding or vomiting– Apnea– Dyspnea– Jaundice– Hypotension– Diarrhea or abdominal distension– Bulging fontanelle– seizures




Risk Factors

n Risk Factors– Preterm– Membrane rupture: before labor onset or

prolonged>12 hours– Chorioamnionitis or maternal peripartum fever– UTI– Multiple pregnancy– Hypoxia or Apgar score <6– Poverty or age <20

n 1/3-1/2 neonatal sepsis will have no risk factors!




Diagnosis and Treatmentn if <28 days of age and rectal temp> 38ºC

– Admit– Blood Culture– Urine Culture—cath specimen– Lumbar Puncture

• Cell count, protein, glucose, culture, PCR– Parenteral Antibiotics

• Ampicillin + Gentamicin(Cefotaxime), consider Acyclovir(primary maternal infxn, esp if delivered vaginally, PROM, fetal scalp electrodes, skin eye or mouth lesions, seizures, CSF pleocytosis)




Early Onset GBS Disease

n 376 cases in 2001n 39 died

Important because:n Identified risk factorsn Preventable




Risk Factors

n Previous baby affected by GBSn GBS in urine at any time this pregnancyn Preterm labourn Prolonged ROMn Fever in labour

(RCOG guidelines 2003)




Screening Based Strategy

n 27% carry it (rectal plus vaginal swabs)

n Antibiotic prophylaxis 86% reduction




The Disease

n Early onsetn Low apgarn Sepsisn Pneumonia

n GBS causes 70% early onset sepsisn Low birth weight




Devices

n Initial responsen Getting worse

n Central line in situn ?CNS




Coagulase negative staphylococci

n Gram positive coccin Normal skin floran Low grade pathogen in normal hostn Hydrophobic cell surface (adheres)n Polysaccharide production - biofilmn Neonatal infections




Neonatal Unit B/C

n CNS 234n Stau 17n E.coli 19n GNB’s 32n GBS 18




Attendants

n Staph aureusn Phage type 3A/3Cn Exfoliative toxin A




Outbreak Control

n Swabs of all staff handling newbornsn Check all hands

n One individual handled 17/18 affectedn Epidemic strain from nose, axillan All other staff negativen Treatment of carrier ended outbreak




Staphylococcus aureus

n Looks like CNS and..n Normal flora (30% adults) but..n Highly pathogenicn Exfoliative toxin A - SSSSn Potential for cross infection

n Treated with flucloxacillin




Control Measures

Wash hands

and

check hands




Conclusions

n Infection: significant hazard to neonaten Bacteria for every occasion

n Smaller is frailern Never give up on a neonate




newborn fever 100512

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