Neonatal Sepsis - Pediatrics - Lecture Slides, Slides for Pediatrics. Anna University
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devaku21 December 2012

Neonatal Sepsis - Pediatrics - Lecture Slides, Slides for Pediatrics. Anna University

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Neonatal Sepsis, Neonatal Infections, Presentations of Neonatal Sepsis, Serious Bacterial Infection, Occult Bacteremia, Gbs Prophylaxis, Neonatal Physiology, Definition of Fever are some key points from this lecture. I w...
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Neonatal Sepsis

Neonatal Sepsis

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Objectives

• Review of terminologies associated with neonatal infections

• Review risk factors for neonatal infections • Review presentations of neonatal sepsis • Review most common organisms and treatments • We will concentrate on the child <3 months of age

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Cases

• You are on-call tonight when the ER calls with two kids

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Cases

• Kid 1 – 9 week old, term baby – 100.6 temp – Looks well – CBC WNL – UA clean – Everyone at home with

colds

• Kid 2 – 12 day old, term baby – Fever to 101 – Jaundiced – Seizures – WBC of 3.2 K – PLT of 89

Do you treat these kids the same or different and why?

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Terminologies

• Rule out sepsis • Neonate with fever • Neonatal fever • Neonatal sepsis • Serious Bacterial Infection (SBI) • Occult Bacteremia • Neonate- the first month 28days of life • Infant- up to one year

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Back When I was an Intern…..

• Any kid 3 months or less with fever got admitted

• Kids stayed longer • If it sneezed, writhed, wiggled or wheezed, it

got an LP • Kids had to crawl seven miles through the

snow, up hill both ways, to daycare…..

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Age Groups

• Currently ages 0-28 days automatically admitted by most clinicians

• 1-3 months is a grey zone guided by clinical opinion

• Greater than three months generally not admitted

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Why Have Recommendations Changed?

• GBS prophylaxis • Immunizations

– HIB, Pneumococcus • Better understanding of neonatal physiology • Better laboratory techniques • Better understanding of the disease • Different antibiotics

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Definition of Fever

• “Gold Standard” is generally thought of as 100.4 (38.0) rectally with a glass mercury thermometer

• Lots of ways to take a baby’s temperature – I recommend using a quality thermometer – When in doubt, let the pros sort it out – In Newborn Nursery, need to counsel parents

about significance of fever in neonate

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Why the Worry?

• Neonatal immune system immature • Perinatal exposure to pathogens via birth canal • High rate of infection in kids less than 3 months with

fevers – >4% age 0-28 days with bacteremia or meningitis (drops to

1% by 3 months) – Almost 10% with UTI – Rates increase with degree of fever

• 39C with >10% rate of bacteremia

• Well appearing infant may have an infection

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Why not admit everybody?

• Not without risk of hospital acquired infection • Cost • Lost time to parents at work • Family stress • etc

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What data supports our practice?

• Rochester criteria • Philadelphia criteria • Boston criteria • Etc

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Risk Factors

• Prematurity and low birth weight • Maternal GBS • Prolonged rupture of membranes • Maternal chorioamnionitis • Sibling with sepsis • Meconium at delivery • Need for resuscitation • Male child • Multiple gestation

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“Early” Pathogens (first week) • Group B Strep (GBS)

– Incidence used to be 4-6/1000 live births (0.4%) – Now <0.1% after prenatal screening guidelines

• E. coli – Every few decades flips back and forth with GBS as most

common cause • Gram negative rods (esp. in urine)

– Occasional Salmonella sepsis • Listeria monocytogenes • Herpes Simplex • Enterovirus

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“Late” Pathogens (~1-2 weeks)

• GBS or group A strep • Enterics/Enterococcus in urine • HSV • Enterovirus, RSV, Flu

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Community Acquired (after 4-6 weeks)

• Pneumococcus • Meningococcus • GABHS • Haemophilus influenzae (HIB) not really a

problem anymore

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Signs/Symptoms

• Temperature irregularity – Fever – Hypothermia

• Tone and Behavior – Poor tone – Weak suck – Shrill cry – Weak cry – Irritability

• Skin – Poor perfusion – Cyanosis – Mottling – Pallor – Petechiae – Unexplained jaundice

Most by themselves mean little, but three (or two) strikes and you are Out!

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Signs/Symptoms

• Feeding Problems – Vomiting – Diarrhea – Abdominal

distension – Hypo or

Hyperglycemia

• Cardiopulmonary – Tachypnea – Retractions – Tachycardia for age – Bradycardia in first

few days of life – Hypotension for

age – Low PO2

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Signs/Symptoms

• Sunken fontanelle • Bulging or pulsating fontanelle • Neck stiffness CAN NOT be used • Babies can be bacteremic but look well • Presence of a “cold” does not change anything

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PIDJ April 2005

• Study in India found that any two of these signs had an almost 100% sensitivity for sepsis and over 90% mortality

• Reduced sucking • Weak cry • Cool extremities • Vomiting • Poor tone • Retractions

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Labs

• Normal WBC (5-15K) is better than high WBC is better than very high WBC (over 35K) which is better than very low WBC (<5K)

• Less than 28 days- blood, urine, CSF cultures +/- stool – Get urine culture, even if UA WNL

• >28 days see handout • CXR if respiratory symptoms

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Lab Dilemmas- Urine collection

• Don’t use bag urines! – A negative culture on a bag urine is negative – A positive means nothing

• Cath or Suprapubic aspirate? – SPA- any growth is considered a positive – Cath

• Can have false positives, especially if uncirc’d male • New debates on what constitutes a positive culture • Most references use >10K CFU’s as positive, some use as little as

1K (equals one plaque) • Microbiologists feel we should use 100K on all samples regardless

of source

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The Bloody Tap

• No right answer • Results can vary based on the amount of

blood in amount of CSF, what is the HCT, what is the peripheral WBC count etc. Some use CBC to CSF ratios.

• Sometimes seems like too many WBC’s or seems OK

• Sometimes just need to re-tap

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Treatment

• Age 0 to ~4-6 weeks – Ampicillin/Aminoglycoside – Ampicillin/Cefotaxime

• Amp kills GBS and Listeria • Gent and Cefotaxime for GNR’s

– Ceftriaxone not used- causes neonatal hepatitis and biliary sludging

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Aminoglycosides

• Disadvantages – Ototoxicity – Nephrotoxicity – Need for levels

• Advantages – Little resistance – Cheap (30 cents or so a

dose) – Highly concentrated in

urine – No need for levels if

QD dosing in a 48 hour admission

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Treatment

• After 4-6 weeks, ampicillin and a 3rd generation cephalosporin – Offers better coverage for community acquired

organisms – At 4-8 weeks, switch to cephalosporin alone.

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What About Herpes? • Some clinicians begin acyclovir on all neonatal

admissions for fever • We use the guideline of “Fever Plus”

– HSV is rare & tends to present in certain ways – Fever in addition to

• Hepatitis/jaundice • Meningitis • Seizures • Thrombocytopenia • Vesicles • Rash/purpera

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HSV Risk Factors

• Maternal history- only present in – Maternal primary infection- as many as 50% of

babies infected • Active lesions • ROM > 4-6 hours • Fetal scalp electrode • Prematurity • Caregiver with cold sore/fever blister

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HSV in Neonate

• Three types – SEM (Skin, Eye, Mucous membranes)- 15% – Isolated CNS- 35% – Disseminated (+/- CNS)- 50%

– 75% HSV-2 25% HSV-1 – Incidence 1:1K-5K births

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HSV timing

• SEM (Skin, Eye, Mucous membranes)- can be early

• Isolated CNS- 2-3 weeks • Disseminated (+/- CNS, +/-SEM)- ~1 week

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HSV Labs- three points

• CSF PCR alone DOES NOT rule out HSV • CSF PCR alone DOES NOT rule out HSV • CSF PCR alone DOES NOT rule out HSV

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HSV Labs- if do it, do it right

• CSF for PCR (>98% sensitive, >95% specific) and/or culture (30-50%)

• CSF tends to be “bloody”– 100-200 RBC with elevated WBC

• Mucous membrane cultures – Eyes, ears, anus, mouth, nose, vesicles if present,

some add urine – In nursery, wait 24 hours after birth to culture

(indicates active infection)

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HSV Labs cont. • LFT’s

– I now get for any R/O SBI kid that I am worried enough about to get a BMP

• Serial CBC’s – Thrombocytopenia – Leukopenia

• Tzank smear of lesions(~40% sensitive, not specific) • DFA or EIA of lesions (80% sensitive) • Serology NOT useful

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Imaging

• Classic CT/MRI - temporal lobe lesion but may have many presentations to include hydrocephalus

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HSV treatment

• Acyclovir 20mg/kg/dose Q8 hrs – SEM only- 14 days – Disseminated (no CNS)- 21 days – CNS- at least 21 days (PCR must clear)

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Cases

• Kid 1 – 9 week old, term baby – 100.6 temp – Looks well – CBC WNL – UA clean – Everyone at home with

colds

• Kid 2 – 12 day old, term baby – Fever to 101 – Jaundiced – Seizures – WBC of 3.2 K – PLT of 89

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