Perinatology Division Department of Child Health Medical School Sumatera Utara University

Direct Causes of Neonatal Deaths

World Health Organization. State of the Worlds Newborns 2001

Infections 32%

Asphyxia 29% Complications of prematurity 24% Congenital anomalies 10% Other 5%

Definition
Neonatal sepsis is a clinical syndrome Of systemic illness accompanied by bacteremia occurring in the first month of life

Early Onset < 72 hours of age Acquired around birth Vertical transmission from mother to baby

Late Onset > 72 hours of age Acquired from the environment Nosocomial or hospital acquired

Distinction between Early onset sepsis and Late onset sepsis not clear in developing countries: baby born at home and brought to the hospital at 3 days of age baby referred from another hospital
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Early Onset Sepsis - risk factors

Prolonged

rupture of membranes >18 h Maternal chorioamnionitis Foul smelling amniotic fluid Handling by untrained midwife Maternal urinary tract infection Premature labor

Late Onset Sepsis risk factors

Prematurity/ In

LBW

hospital Invasive procedures- ventilator, IV lines, central lines, urine catheter, chest tube Contact with infectious disease - doctors, nurses, babies with infections, Not fed maternal breast milk POOR HYGIENE in NICU
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Bacterial Pathogens Responsible for Sepsis in Developing Countries

Early

onset sepsis
negative

Late

onset sepsis
negative

Gram

Gram

bacilli
E.coli

bacilli
Pseudomonas Klebsiella

Klebsiella

Enterococcus Group

Staph

B streptococcus

aureus Coagulase negative staphylococci

Diagnosis of Neonatal Sepsis

Clinical

signs and symptoms Laboratory tests culture of bacterial pathogen other laboratory indicators

Diagnosis of Neonatal Sepsis clinical signs and symptoms

Clinical Signs: early signs non- specific, may be subtle Respiratory distress- 90% Apnea Temperature instability- temp more common Decreased activity Irritability Poor feeding Abdominal distension Hypotension, shock, purpura, seizures- late signs
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Purpura

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Pseudomonas sepsis with DIC

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Laboratory Tests
Cultures
blood,

to identify bacterial pathogen tests

csf, urine, other

Hematological
WBC

count Platelet count Erythrocyte Sedimentation Rate (ESR)

Other
C-

tests

reactive protein
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Abnormal white blood cell count

Total WBC count < 5000 /L, > 25, 000/L Absolute neutrophil count: <1500/L Immature to total neutrophil ratio > 0.2 Immature to mature neutrophil ratio > 0.2

bandform

neutrophil

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Chest X Ray

Group

B streptococcal sepsis: diffuse ground glass opacity indistinguishable from HMD Persistent focal parenchymal lung findings

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Group B Strep Pneumonia

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First line therapy in facility setting

(WHO 2003)

Ampicillin

50 mg/ kg every 12 hours in 1st week of life every 8 hours from 2- 4 weeks PLUS Gentamicin > usia kehamilan 35 minggu: 4 mg / kg setiap 24 jam usia kehamilan 30 - 34 minggu: 0 - 7 hari: 4.5 mg/kg setiap 36 jam > 8 hari: 4 mg/kg setiap 24 jam
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Suspected Staphylococcal Infection

Use

Cloxacillin or flucloxacillin instead of Ampicillin. Plus gentamicin

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Baby not responding to first line antibiotics or suspected hospital acquired infection
3rd

generation cephalosporin cefotaxime ceftazidime nosocomial infection : vancomycin plus gentamicin/ amikacin or ceftazidime

For

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Treatment of Fungal Infection

Amphotericin

B Intravenous infusion for 14 to 21 days

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Duration of antibiotic treatment

Septicemia
Gram

negative septicemia: 14 days Group B Strep septicemia: 10-14 days Repeat blood culture within 24 - 48 hours of beginning treatment to document clearance of organism.

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Duration of antibiotic treatment Meningitis

Gram

negative meningitis: 21 days minimum Group B Strep meningitis: 14 - 21 days Document negative culture within 24 - 48 hours of beginning treatment Consider neuroimaging studies

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Supportive Care
Temperature GI

support support

support - vomiting, ileus

hypoxia, apnea, shock

Cardiorespiratory

Hematological

support: anemia, thrombocytopenia, DIC support- seizures

Neurological

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Prevention of Nosocomial Infection

Hand

washing Early feeding Maternal breast milk Decrease use of broad spectrum antibiotics Decreased use of invasive procedures Proper sterilization procedures

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Prevention of Sepsis

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