Neonatal

Sepsis
MODERATOR- DR. PRIYANKA
PRESENTOR- DR. CHARN SINGH
NEONATAL
SEPSIS
CLINICAL SYNDROME CHARACTERIZED BY
SIGNS AND SYMPTOMS OF INFECTION
WITH OR WITHOUT ACCOMPANYING
BACTEREMIA IN THE FIRST MONTH OF LIFE.
,
Incidence
30 per 1000 livebirths

Mortality due to NNS is about 4.1%

⚫ If diagnosed early and treated

aggressively with antibiotics & good
supportive care, most cases of neonatal
sepsis can be saved.
EARLY ONSET SEPSIS
• MAINLY DUE TO BACTERIA ACQUIRED BEFORE AND
DURING DELIVERY
I.E, BY ORGANISMS PREVALENT IN GENITAL TRACT OR IN
THE LABOR ROOM OR O.T
•MOSTLY CAUSED BY
GRAM NEGATIVE ORGANISMS(ACINOBACTOR SPP, E
COLI, KLEBSIELLA),
GRAM POSITIVE -COAGULASE NEGATIVE
STAPHYLOCOCCUS, STAPHYLOCOCCUS AUREUS,
ENTEROCOCCUS SPP
• MAJORITY MANIFEST AS RD DUE TO INTRAUTERINE
PNEUMONIA
 EONS
Intramural Neonates/in house delivery
Klebsiella pneumonia-32.5%
Staph. aureus-13.6%
Extramural Neonates/Outside delivery
Klebsiella pneumonia > Staph aureus > Pseudomonas
In delhi Neonate infection study
Acinobactor-22%
Klebsiella-17%
E.coli.-14%
 Associated Risk factors for EONS
1. SPONTANEOUS PREMATURITY
2. FOUL SMELLING LIQOR
3. RUPTURE OF MEMBRANES >24 HOURS
4. SINGLE UNCLEAN OR >3 STERILE VAGINAL EXAMINATION
DURING LABOUR
5. PROLONGED LABOR (DURATION OF 1ST AND 2ND STAGE OF
LABOR >24 HOURS)
6. PERINATAL ASPHYXIA (APGAR SCORE <4 @ 1 MIN)
OTHER- FEVER >37.5 C IN MOTHER WITH EVIDANCE OF
BACTERIAL INFECTION, CHORIOAMNIONITIS, LBW,MSL
. GENDER: MALES>FEMALE
As per NNF
Clinical Perinatal score for
EONS
Plan as per Perinatal
score
 Clinical
Features
Temperature: Hematological: Metabolic:
Hypothermia or fever Bleeding, Petechiae, purpura Metabolic acidosis,
(former more common in direct hyperbilrubinemia
preterm LBW infants)

CVS: CNS: Skin:

Brady/tachycardia , Lethargy, poor cry, refusal to Multiple pustules, abscess,
Poor perfusion, prolonged suck sclerema, mottling,
capillary refill time Bulging anterior fontanelle, umbilical discharge and
vacant stare, high pitched cry, redness
excess irritability, stupor LocaLised skin infection-
/coma, seizures, neck in FUNGAL INFECTION
retraction

RS: Abdominal: Renal:

Respiratory distress, Feed intolerance, vomiting, Acute renal failure
apnea and gasping diarrhea, abdominal distension.
respiration
 Investigations

Investigations
SEPSIS SCREEN POSITIVE WHEN 2 OR MORE PARAMETERS ARE POSITIVE
IN EONS POLYMORPHS IN GASTRIC ASPIRATE MARKER OF CHORIOAMNIONITIS,
CAN BE USED AS ADDITIONAL PARAMETER OF SEPSIS SCREEN
•THE SCREEN MUST BE REPEATED AFTER 12 HOURS.
•TWO CONSECUTIVE COMPLETELY NEGATIVE SCREENS ARE SUGGESTIVE OF
NO SEPSIS
Manroe Chart for ANC- TERM
INFANT
Mouzinho Chart-for
VLBW
 IT RATIO
• ITR is defined as
Immature neutrophils (band forms, metamyelocytes, myelocytes)
Mature + immature neutrophils

• Positive:
Term > 27%
Preterm > 20%
 CRP

• Acute phase reactant- produced by liver

• Cut-off value for quantitative assay: 10 mg/L

• Quantitative CRP (Nephelometry) >> CRP (ELISA) >>semi-
quantitative CRP (latex agglutination)
• Rises after 10-12 hours, Peaks after 24 hours, Half life of 24-
30 hours
• Because of this typical delayed response, the sensitivity of CRP
elevation at the time of evaluation for suspected sepsis is low,
particularly with EONS.
• EONS:
• A single determination of CRP at birth lacks both sensitivity and specificity for
infection.
• Can be raised in MAS, delayed transition after birth, hemolysis, tissue injury, or
surgery
• LONS:
• Serial CRP determinations at the time of blood culture, 12 to 24 hours and 48 hours
later
• Extending the interval of sampling into the second 24 hours enhances the NPV
• Length of antibiotic treatment for infants with culture-negative clinical sepsis:
• Persistently normal CRP levels correlate strongly with the absence of infection,
they may be used to determine that antibiotics may be safely discontinued
• Routine use of serial CRP measurements can be associated with longer length of
hospital stay
 Peaks after 24 hours
False positivity high in EONS as well
as LONS
Serial CRP better than single CRP
Look for biochemical
abnormalities

• Blood glucose & calcium

• Blood urea
• Serum creatinine
• TSB
• Serum electrolytes
• ABG
Diagnostic tests
Blood culture
CSF culture
Urine culture
Tracheal aspirate culture
Any body fluid culture
 Polymerase chain reaction
Latex particle agglutination test
NEWER MARKER OF NEONATAL
SEPSIS

 Procalcitonin
 Sr. Amyloid A, Hepcidin, CD64, CD11b, IL-1, IL-6, IL-8, TNF-
alfa, Soluble TNF receptor, E- selectin
 Molecular assay- PCR
 Bone Scan
 Radiology- CXR, Abdominal Xray, Neuroimaging
Procalcitonin

• Concentrations increase in the first 4 hours after exposure to bacterial

endotoxin, peaking at 6 to 8 hours and remaining high for at least 24
hours.

• PCT response is more rapid than elevation of CRP, this marker is an

attractive alternative for detection of early-onset sepsis.

• PCT cutoff value:

• 0.5 ng/mL – Negative

• 0.5-2 ng/ml – Borderline

• > 2 ng/ml - Positive

Procalcitonin- Term
baby
Procalcitonin-PreTerm
baby
Procalcitonin

• For EONS, Pooled sensitivity of 76% and a specificity of 76%

• For LONS, Pooled sensitivity of 90% and a specificity of 88%

• Marked statistical heterogeneity in the included studies

Three challenges have limited the application of PCT levels in evaluation of

newborn infants for possible sepsis:
• Need for detailed age-specific normative ranges
• Disappointing sensitivity early in the course of infection

• Lack of specificity, levels rise in response to noninfectious

inflammatory signals
CRP V/S Procalcitonin

• Bacterial Vs Viral:
• PCT has better specificity, sensitivity & predictive value than CRP

• EONS:
• Time points for the measurement of PCT (at birth,
0–12 h, 12–24 h, 24–48 h)
• Diagnostic accuracy of PCT in low-risk neonates
significantly higher than in no-risk neonates
(p<0.05)
• LONS:
• Pooled sensitivity for PCT 72% Vs 55% for CRP,
p<0.05
• Pooled specificity for PCT lower than for the CRP
77% Vs 85%, p>0.05
CRP V/S Procalcitonin

Procalcitonin better than CRP for early

detection of EONS & LONS
Blood culture

• Gold standard to diagnose sepsis

• All episodes of sepsis, prior to starting antibiotics

• BACTEC culture bottles

• Site to be prepared by cleaning with 3 separate spirit swabs

• At least 1 ml of blood required

• Immediate innoculation

• Not to be taken from indwelling central lines

Normal CSF Parameters
Management
EARLY RECOGNITION
+
APPROPRIATE ANTIBIOTICS THERAPY
+
OPTIMAL SUPPORTIVE MEASURES
 Indications of starting
Antibiotics
IN EONS
1. PRESENCE OF >3 RISK FACTORS
2. PRESENCE OF FOUL SMELLING LIQOR
3. PRESENCE OF <2 RISK FACTORS AND A POSITIVE SEPTIC
SCREEN
4. STRONG CLINICAL SUSPICION OF SEPSIS

IN LONS
1. POSITIVE SEPTIC SCREEN
2. STRONG CLINICAL SUSPICION OF SEPSIS
Duration of Antibiotics

 Culture and Sepsis Screen Negative but clinical

picture of Sepsis- 5 to 7 days
 Sepsis Screen Positive but Blood/CSF C/S
Negative- 7 to 10 Days
 Blood Culture Positive but No meningitis- 10
to 14 days
 Meningitis (irrespective culture report)- 21
days
 Arthritis, Osteomyelitis, Endocarditis- 4
weeks
 Ventriculitis- 6 weeks
EMPIRICAL ANTIBIOTICS THERAPY
AS PER PREVALENT ETIOLOGICAL AGENTS
AND ANTIBIOTICS SENSITIVITY PATTERN
AS PER ANTIBIOGRAM OF LAST 6-12
MONTHS
NEEDS TO BE REVIEWED EVERY 6-12MONTHS

FIRST LINE ANTIBIOTICS- TOGETHER

COVERS 60-70% ISOLATES
AMPICILLIN OR PENICILLIN WITH GENTAMYCIN
AMPICILLIN OR CLOXACILLIN WITH GENTAMYCIN
OR AMIKACIN
Second Line Antibiotics-
 covers 80-90%
 Piperacillin--Tazobactam with Amikacin
 Ciprofloxacin or Vancomycin with Amikacin

Reserve/Newer Antibiotics
 Aztreonam, meropenem, imipenem
 Adjunctive Therapy
 1. Double Volume exchange Transfusion
 50% reduction in sepsis related mortality
 removes toxins & harmful circulating cytokines, enhance
immunoglobulins

 2. Intravenous Immunoglobulins (IVIG)

 provide opsonic activity, activate complement & promote antibody
dependent cytotoxicity

 3. Granulocyte macrophage colony stimulating factor(GM-

CSF)
 increase neutrophils and macrophage numbers
 4. Antioidants
 selenium, melatonin
 free radicals scavengers
5. Glutamine
anabolic for dividing immune & gut cells
6. Lactoferrin
antimicrobial & anti inflammatory
7. Probotics
enhance local &systemic immunity
promote growth of beneficial bacteria in gut
8. Breast Milk
contains secretory IgA, cellular defenses, antimicrobial
proteins & peptides
fungal infection
 caused by Candida sp- mainly C. albicans, rarely
Aspergillus, Zygomycetes, Malassezia, Trichosporon
 invasive Candida infec. is inversely proportional to
Birth weight.

Incidence-
 VLBW(<1500gm)-1-2%
 ELBW(<1000gm)-2-8%
 INCREDIBLY LBW <750 gm or GESTATION <26 WKS-20%
 Amphotericin B
deoxycholate-1mg/kg/day
lipid formulation-3-5mg/kg/day
 Fluconazole 12mg/kg/day- oral or iv
 Flucytosine-25mg/kg-4 times daily
 Micafungin
THANKS