ILOH, KENECHUKWU
NEONATAL
SEPSIS
Introduction
• Neonatal sepsis refers to an infection involving bloodstream in
newborn infants less than 28 days old.
• It is divided into 2 groups based on the time of presentation after
birth:
• early-onset sepsis (EOS)
• late-onset sepsis (LOS).
• EOS refers to sepsis in neonates at or before 72 hours of life
• LOS is defined as sepsis occurring at or after 72 hours of life
Introduction…
• Newborn infants have immature
immune systems
• Have just been colonised with
bacteria during their recent
delivery.
• They are therefore prone to
infections which are likely to cross
barriers, for example
• between the lungs and blood,
• the gut and blood and
meninges.
Introduction…
• Many newborn infections can be
prevented by
• good hygiene at the time of
birth,
• early and exclusive
breastfeeding,
• appropriate umbilical cord care,
• appropriate eye care,
• using KMC and
• avoiding separation of the
mother and infant.
• Common systemic bacterial infections
in young infants include
• sepsis,
• pneumonia,
• urinary tract infection,
Introduction • and meningitis
… • and all these may present alike.
• Sepsis is a clinical syndrome of
systemic illness accompanied by
septicaemia (bacteria in the blood).
• It is also called bacteraemia.
EARLY ONSET NEONATAL SEPSIS:
INFECTION IN FIRST 72 HOURS OF LIFE
a) Risk factors for EO infection
Preterm births
Suspected or confirmed rupture of
membranes for >18 hrs
Intrapartum fever >38°C
confirmed/ suspected chorioamnionitis
Mother given parenteral antibiotics for
confirmed or suspected invasive
bacterial infection (such as septicaemia)
at any time during labour, or in the 48 hr
periods before and after the birth
Suspected or confirmed infection in a
co-twin
Very low birth weight
Invasive group B streptococcal infection
in a previous baby
Maternal group B streptococcal
colonisation, bacteriuria or infection
during pregnancy
Clinical indicators suggestive of EOS Sepsis
• Signs of sepsis can be very non-specific, and they include:
Fever
o Temperature of 38 °C on one occasion
o Temperature > 37.5 °C on two occasions separated by at least one hour
o If the Infant has a fever > 37.5°C but less than 38 °C and looks well,
unwrap the infant put in the coolest part of the room – DO NOT give
paracetamol.
• Recheck the temperature in 4 hours if the fever is >38 °C treat as
neonatal sepsis
Clinical indicators suggestive
of EOS Sepsis…
Hypothermia
• Temperature <36.5 °C
•
Shock
o Cold hands and feet
o Capillary refill time >3secs
o Tachycardic
Unexplained excessive bleeding,
thrombocytopenia or abnormal
coagulation
Oliguria persisting aged >24 hr
Hypo/ hyperglycaemia
Metabolic acidosis (Base excess ≥10)
Clinical indicators suggestive of EOS Sepsis…
Respiratory distress
o Tachypnoeic (Respiratory Rate > 60/min)
o Chest indrawing
o Tracheal Tug
o Sternal recession
o Head bobbing
o Nasal flaring
o Grunting
o Cyanosis or Sp02 <90% on air
•
Apnoeas and slow breathing
o No breaths for 20 seconds; especially in a
term baby or previously well preterm baby
• Respiratory rate <20/min
Clinical indicators suggestive of EOS Sepsis…
Gastrointestinal
o Abdominal distension
o Bilious vomiting
o Bilious aspirates from NGT
Feeding difficulties (e.g. inability
to suck and poor suck)
•
Neurological
o Lethargy or not waking for feeds
o Reduced activity
o Seizures
o Abnormal posture i.e. opisthotonus
o Floppy
Clinical indicators
suggestive of EOS
Sepsis…
• Jaundice
• Yellow skin, sclera
or mucous
membranes
Clinical indicators suggestive of EOS
Sepsis…
•
a) Clinical features of Meningitis
• Meningitis is inflammation of the meninges.
• Symptoms and Signs
Suspect meningitis in a newborn with sepsis or if they present with
the following clinical symptoms or signs:
Drowsy, lethargy or unconscious
Persistent irritability
High pitched cry
Apnoeic episode
Convulsion
Bulging fontanelle
Note: Infants often do not have neck stiffness
A lumbar puncture must be done once meningitis is suspected
Figure 21.1: Showing bulging fontanelle
Table 21.1: Red flag signs
Red flag signs and clinical indicators suggestive of neonatal infection
Systemic antibiotics given to mother for suspected bacterial infection during labour or within 48
hr either side of birth
Suspected or confirmed infection in a co-twin
Respiratory distress starting >4 hr after birth
Seizures
Signs of shock
Need for mechanical ventilation in a term baby
Suspected or confirmed rupture of membranes for >18 hr
confirmed/ suspected chorioamnionitis
Lethargy, altered behaviour or responsiveness
Feed intolerance (e.g. abdominal distension, vomiting, excessive gastric aspirates)
Unexplained excessive bleeding, thrombocytopenia or abnormal coagulation
Actions if red flag signs are present
1.If there is any red flag sign, take samples for
investigations for complete sepsis work- up and
start antibiotics.
2.If there are no red flag signs but there are 2 or
more other risk factors or clinical indicators take
samples for investigations for complete sepsis
work-up and start antibiotics.
1. If there are no red flag signs or clinical indicators but there is 1 risk
factor, use clinical judgement and consider withholding antibiotics.
However, take samples for investigations including complete sepsis
work-up, and be guided by the laboratory investigation results.
2. Monitor baby for clinical indicators of possible infection. Monitoring
should be done at 1 hr, 2hr and then 2-hrly for 10 hrs.
3. If further clinical concerns, perform investigations including blood
cultures and start antibiotics.
Figure 21.2: Peri-umbilical flare in umbilical sepsis
Investigations before starting antibiotics
Blood culture
Lumbar puncture for CSF
analysis maintaining asepsis
if thought safe to do, but do
not delay antibiotics for LP
Measure C-Reactive Protein
at presentation and 18–24 hr
after.
Complete blood count and
micro ESR
Procalcitonin
• Take swabs when there is local
infection
a) Choice of antibiotics
Use Penicillin and an
aminoglycoside (gentamicin
or amikacin) as first choice for
empirical treatment of
neonatal sepsis. (local
antibiotics susceptibility
pattern should also be a
guide)
Second line can be
cefotaxime (or ceftazidime)
and amikacin
• Review antibiotics treatment based
on culture results
Investigations during antibiotic
treatment
CRP: If possible, measure before
starting antibiotics and 18–24
hrs after the first CRP test
Consider LP if:
o positive blood culture
o CRP >10 mg/L
baby does not respond
satisfactorily to antibiotics
• Procalcitonin can be done if available
• Review treatment at 36 hrs
Stop antibiotics if laboratory results and
clinical examination are not suggestive
of sepsis.
If positive blood culture or clinical
suggestion of infection treat for 7 -
10 days
Continue treatment beyond 10
Usual duration days if:
of treatment
obaby not fully recovered or
oExpert microbiological advice
based on blood culture result.
Meningitis
If meningitis suspected but Gram stain is uninformative, use
ampicillin, gentamycin and cefotaxime
Review treatment decisions taking CSF results into account
If CSF Gram stain suggests GBS, give benzylpenicillin 100
mg/kg 12-hrly and gentamicin 5 mg/kg/day
If CSF culture confirms GBS, continue benzylpenicillin for at
least 14 days and gentamicin for 5 days
If CSF culture or Gram stain confirms Gram-negative
infection, review antibiotics based on culture result.
• This refers to infection after first 72
hrs of life. Common organism
implicated in LOS include
coagulase-negative staphylococci
(CoNS), Klebsiella, Serratia,
LATE ONSET Enterobacter, Pseudomonas, E. coli
NEONATAL and Acinetobacter).
SEPSIS (LOS) A.Risk factors
Risk factors include need for
invasive interventions e.g.
prolonged ventilation, central
venous access and parenteral
nutrition, prolonged hospital
stay.
•
Clinical features
Can be vague and non-specific
Respiratory distress
Apnoea/ bradycardia
Cyanosis or poor colour
Poor perfusion (CRT >3 sec; toe-core temperature gap >2°C; mottling)
Hypotension
Tachycardia
Temperature instability (high or low)
Glucose instability
Hypotonia
Irritability
Lethargy/ inactivity
Poor feeding and poor suck
Jaundice
Seizures
Vomiting
Abdominal distension
• Look for:
Systemic signs of sepsis such as tachycardia, poor
perfusion, reduced tone, reduced activity, lethargy,
unsettled and crying/moaning
Tachypnoea and intercostal and/or subcostal recession
Bulging of the fontanelle suggesting raised intracranial
Clinical Signs pressure
Abdominal distension and tenderness
auscultate for bowel sounds; reduced or abse nt
with infection (as a result of paralytic ileus) or NEC
inspect stool for visible blood
petechiae, bleeding diathesis
Septic spots in eyes, umbilicus, nails and skin
Reluctance to move or tenderness in joints and limbs
Swabs for culture
o Swab any suspicious lesion
(e.g. skin, umbilicus or nails)
Blood cultures
o Asepsis for sample
collection is very
important to reduce risk
of culturing CoNS skin
contaminants
Full blood count
o A neutrophil count <2 or
>15x109/L
o Platelet count of <100
x109/L
o Toxic granulation in
neutrophils [or if
Investigations (Aim to perform measured, an
immature:total (I:T)
before starting antibiotics) neutrophil ratio >
0.2]
Investigations Clotting profile
o If evidence of bleeding
diathesis or in severe
infection/ septicaemia
CRP
o Acute phase protein
synthesised in the
liver in response to
inflammatory
cytokines
o Generally, a delay of
24 hr between onset
of symptoms and
rise in serum CRP
o Mini-ESR
o Procalcitonin
Urine microscopy, culture and sensitivity
o Clean-catch or supra-pubic aspiration (SPA). Use
ultrasound scan to check urine in bladder before SPA.
o Do not send urine collected in a bag for bacterial
culture.
•
Investigations Lumbar puncture (LP)
o If baby unstable, deranged clotting or
thrombocytopenia (inform the managing consultant)
(Aim to perform o Send CSF for urgent Gram-stain and culture (MC&S),
protein and glucose
before starting o PCR for bacteria and viruses if available
o In critically ill baby, consider PCR for HSV, especially
antibiotics) •
in term babies
Others
o Chest X-ray
o If abdominal distension noted, abdominal X-ray
Documentation
o Always document symptoms and signs of infection
at the time of taking blood culture, CSF cultures and
abdominal radiographs
Do not use oral antibiotics to treat
infection in babies
Consult local microbiology department
for current recommendations. These
may differ between units according to
local resident flora
Empirical •
b) Antibiotics Late onset sepsis
treatment If decision made to give antibiotics,
aim to start immediately.
First line: empirical flucloxacillin and
gentamicin unless microbiology
isolates dictate otherwise
Second line: vancomycin + gentamicin
or amikacin
Third line: meropenem +/-
vancomycin
PREVENTION OF SEPSIS
Health workers in the neonatal unit to be bare below elbow,
wear short sleeves
Remove jewellery including wedding rings, watches, bracelets
Strict hand washing with liquid soap and strict hand hygiene
(refer to section on hand washing) starting from the entrance
of the SCBU
Minimize frequency of opening incubator doors or touching
any part of baby’s cots
Do not lean on incubators or other patient equipment
Wear apron and sterile gloves when
carrying out any procedure on a baby
e.g. heel prick, re-siting IV cannula
Health workers MUST not wear same
pair of gloves for feeding and vitals of
more than one baby. Use washed hands.
Initiate enteral feeds with maternal
PREVENTION breast milk within 24 hr of birth
Aim to initiate skin -skin with mother
OF SEPSIS /KMC within 24 hours of birth for all
babies
Institute buccal colostrum swabbing
within 6hours of birth for the ill small
newborns if breastfeeds not yet feasible
Remove all IV cannulae for the baby once
no more needed
Do not use phones in the neonatal unit
Thank
you
