Neonatal Sepsis

Neonatal Sepsis

A clinical phenomenon known as neonatal sepsis is characterized by infection-related signs and symptoms in the first month of life, either with or without bacteremia. It covers a range of infant systemic diseases, including septicemia, meningitis, pneumonia, osteomyelitis, arthritis, and urinary tract infections.

Typically, conjunctivitis and oral thrush are not included in the definition of newborn sepsis.

Causes:

• Escherichia coli, klebsiella, at hospital and staphylococcus aureus at a community.

Types:

Neonatal sepsis can be classified into two major categories depending up on the onset of symptoms:

• Early-onset sepsis (EOS): It presents within the first 72 hours of life. In severe cases, the neonate may be symptomatic at birth. Infants with EOS usually present with respiratory distress and pneumonia. The source of infection is generally the maternal genital tract. Some maternal/ perinatal conditions have been associated with an increased risk of EOS. Knowledge about these potential risk factors would help in early diagnosis of sepsis.
  A presence of foul smelling liquor or three of the above-mentioned risk factors warrants initiation of antibiotic treatment. Infants with two risk factors should be investigated and then treated accordingly.
  Based on the studies, the following risk factors seem to be associated with an increased risk of early-onset sepsis:
  • Low birth weight 
  • Febrile illness in the mother with evidence of bacterial infection within 2 weeks prior to delivery
  • Foul smelling and/or meconium stained liquor
  • Rupture of membranes >24 hours
  • Single unclean or > 3 sterile vaginal examination(s) during labor
  • Prolonged labor (sum of 1st and 2nd stage of labor > 24 hrs)
  • Perinatal asphyxia (Apgar score)
• Late-onset sepsis (LOS): It typically shows about 72 hours after birth. Neonatals typically present with septicemia, pneumonia, or meningitis in LOS, and the source of infection is either nosocomial (hospital-acquired) or community-acquired. Various factors that enhance the likelihood of nosocomial sepsis include:
  • Low birth weight,
  • Prematurity,
  • Admission in intensive care unit,
  • Mechanical ventilation
  • Invasive procedures,
  • Administration of parenteral fluids, and use of stock solutions.
  • Factors that might increase the risk of community-acquired LOS include poor hygiene, poor cord care, bottle-feeding, and pre-lacteal feeds. In contrast, breastfeeding helps in prevention of infections.

Pathophysiology:

• Baby with bottle feeding
• Contamination of bottle due to hands of care provider
• Organism enter into gastrointestinal tract
• Colonization of organization
• Organism enter into blood stream causes systematic bacterial infection
• Septicemias

Clinical features:

• Non-specific features: The earliest signs of sepsis are often subtle and nonspecific; indeed, a high index of suspicion is needed for early diagnosis. Neonates with sepsis may present with one or more of the following symptoms and signs:
  • Hypothermia or fever (formerly is more common in preterm low birth weight infants)
  • Lethargy, poor cry, refusal to suck
  • Poor perfusion prolonged capillary refill time
  • Hypotonia, absent neonatal reflexes
  • Brady/tachycardia
  • Respiratory distress, apnea and gasping respiration
  • Hypo/hyperglycemia
  • Metabolic acidosis.
• Specific features related to a various system:
• Central nervous system (CNS): Bulging anterior fontanelle, vacant stare, high-pitched cry, excess irritability, stupor/coma, seizures, neck retraction. Presence of these features should raise a clinical suspicion of meningitis
• Cardiac: Hypotension, poor perfusion, shock
• Gastrointestinal: Feed intolerance, vomiting, diarrhea, abdominal distension, paralytic ileus, necrotizing enterocolitis (NEC)
• Hepatic: Hepatomegaly, direct hyperbilirubinemia (especially with urinary tract infections)
• Renal: Acute renal failure
• Hematological: Bleeding, petechiae, purpura
• Skin changes: Multiple pustules, abscess, sclerema, mottling, umbilical redness, and discharge.

Diagnosis:

• History: Maternal condition, feeling to child, delivery history
• Physical examination
• Blood tests: total count, differential count, culture, blood glucose, hemoglobin, peripheral smear
• Lumber puncture

Management:

• Admit the baby in a hospital.
• Provide warmth, weight the baby.
• Establish IV line and give fluid at maintenance volume according to the baby’s age for the first 12 hours. Infuse 10% glucose at dose pf 2ml/kg start.
• Obtains sample for blood count, blood sugar, peripheral smear, blood culture and hemoglobin examination.
• Look ay capillary refill time by pressing at the sternum for 3 seconds and observe for refilling of the blanched area. The refill time should be 3 second
  • If the refill time is delayed indicate poor perfusion or shock then infuse normal saline 10ml/kg Over 5-10 minutes. Repeat the same dose, if perfusion continues to be poor.
  • If capillary refill time is normal, start on maintenance fluid 10% dextrose 
• Inject vitamin K intramuscular 1mg if not given earlier.
• Insert nasogastric tube and keep the baby nil per orally.
• Start oxygen therapy by hood or mask if cyanosis present.
• Provide gentle physical stimulation if apnea is present.
• Obtain chest x-ray.
• Start antibiotic with ampicillin and gentamycin and if the child condition worsens or meningitis is suspected treat with ceftriaxone along with amikacin. Modify treatment as per blood culture report.

Assess baby’s condition over six hours for improvement:

If the condition is improved after 3 days of treatment, continue treatment for 10 days to complete dose. If the baby is having convulsions and suspected meningitis then:

• Correct hypoglycemia.
• For convulsion:
  • Phenobarbital 20mg/kg body weight through IV slowly over five minutes or 20mg/kg single intramuscular injection if IV line not opens
  • If convulsion does not stop within 30 minutes, give 19 mg/kg phenobarbitone IV slowly over 5 minutes and repeat one more time after another 30 minutes if necessary.
  • If convulsion continues or reoccurs within six hours, give phenytoin 20mg/kg body weight IV.
  • Mix the phenytoin in 15ml of normal saline and infuse at the rate of 0.5 ml per minute over 30 minutes. (do not use other fluid to infuse phenytoin it causes phenytoin to crystalize).
• Suspected meningitis:
  • Perform lumber puncture and send CSF for cell count, gram stain, culture, and sensitivity.
  • Treat baby with ceftriaxone and gentamicin and modify treatment as per culture report.
  • Measure hemoglobin every three days during hospitalization and again at discharge. If HB is less than 11gm/dl give a blood transfusion.
  • Observe the baby for 24 hours after discontinuing antibiotics.
• If signs of sepsis reoccur, repeat the culture and treat with additional antibiotics.

Nursing care of baby with sepsis

• Assess the baby's status right away, paying attention to things like color, movement or convulsions, heart rate, respiration, temperature, weight, bleeding, and shock symptoms.
• Place the infant in a hospital and begin immediate intervention.
• Preserve the thermal environment.
• Monitoring and oxygen administration.
• Open the IV line and administer fluids to maintain and stop hypoglycemia.
• The early detection of complications
• Specific handling of the problem.
• Proper medication as directed by a doctor.
• Adopt measures to prevent infection.
• Parental psychological assistance.