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NEONATAL SEPSIS:

Definition:
A clinical syndrome of systemic illness accompanied by
bacteremia occurring in the first month of life, especially
among premature & V.L.B.W. Infants. - It usually presents
as septicemia, pneumonia, meningitis, arthritis,
osteomyelitis & U.T.I., and it is the commonest cause of
neonatal mortality.

SOURCE OF INFECTIONS:

- Intra -amniotic infection
(CHORIOAMNIONITIS) by ascending route is
the commonest source for neonatal sepsis.
The primary sites of infection are the skin,
nasopharynx, oropharynx conjunctiva, &
umbilicus.
- Some infections are transmitted
transplacentally (CONGENITAL or TORCH INFECTIONS) .

Neonates are more liable to get infections because

:
1 . Immaturity of the immune system.
• 2 . They have low level of complements.
• 3 . Impaired function of neutrophils,
monocytes, & macrophages.
• 4 . K -cells (killer cells) have diminished
cytotoxic effect.
• 5 . IgM & IgA do not cross the placenta.

TYPES OF SEPSIS: 1 .Early

O nset Sepsis :
• - Usually occurs in the first wk. of life,
characterized by multisystem, fulminant
illness with p rominent respiratory
symptoms caused by group B
Streptococci (G.B.S.), Listeria
monocytogenes, & viruses e.g. CMV.
• - 90 % of cases presents in the first 24 hr. as
respiratory distress which proceeds to
respiratory failure.
• - Pneumonia is commonest disease .

2 .Late Onset Sepsis:

• - It usually presents after the first wk.
• - Commonly presents as meningitis.
• - G.B.S. is the commonest organism
but Listeria monocytogenes
accounts for up to 20 %.

3 .Nosocomial Infection :

• - Usually occurs in the N.I.C.U. & in ill
infants.
• - It depends on N.I.C.U. environment,
invasive monitoring and techniques.
• - Common organisms are staphylococcus
epidermidis, Gram – ve bacteria (e.g.
E.coli, Pseudomonas, Klebsiella , Proteus)
& fungi.

Risk factors for neonatal sepsis:

• 1 . Prematurity.
• 2 . Prolonged rupture of membranes (>
24 hr.).
3 . Maternal fever (> 38 c).
• 4 . Maternal U.T.I. or genital infection.
• 5 . Meconium stained or foul smelling
amniotic fluid.
• 6 . Multiple gestation .

CLINICAL PRESENTATION :

• 1 . Reluctance to feed.
• 2 . Respiratory distress, grunting & apnea.
• 3 . Lethargy, decreased or absent
movements & neonatal reflexes.
• 4 . Hypo or hyperthermia (only 50 % of
infected neonates have high temp.).
• 5 . Vomiting, diarrhea, abdominal distension.

6 . S kin rash, petechiae , purpura, skin

mottling (cutis marmorata ),
ecthyma gangrenosum (deep ulcers with
ecchymotic margins commonly seen in
mpetigo, cellulitis, i infection), klebsiella
omphalitis.


• 7 . Hypoglycemia.

• 8 . Sclerema , Edema.
9 . Hepatosplenomegaly, jaundice.

• 10 . Convulsions, bulging anterior fontanel.
(Sclerema means hardening of skin &
subcutaneous tissue)

Differential Diagnosis:

1 . R.D.S.
• 2 . Perinatal asphyxia.
• 3 . Intracranial hemorrhage.
• 4 . Severe congenital heart disease.
• 5 . Inborn errors of metabolism.
So a high index of suspicion is the corner
stone for diagnosis of sepsis because
clinical symptoms are non - specific.

LAB STUDIES:

1 .Complete Blood Picture:
a) Low platelet count( < 100.000 /c.mm).The presence of
large platelets has poor prognosis.
b) Total WBC count is increased or decreased.
Neutropenia(< 1500 ) is common. The immature to total
neutrophil ratio (I:T) is increased > 0.2 (normally it is up to
0.16 ). 2 . Elevated ESR & CRP (C -reactive
protein). 3 . Blood Culture ( for aerobic & anaerobic
cultures) is + ve in < 30 % of cases. 4 . CSF Culture
(because meningitis occurs in 1 / 3 rd . of cases).

5 . P.C.R.

• 6 . Imaging studies ( CXR, ultrasound, CT,
MRI).
• 7 .Elevated IgM level (in congenital
infections).

Indications of L umbar P uncture :

1 . Infants with + ve blood culture.
2 . Clinical & Lab. data suggestive of
bacteremia.
3 . No response or deterioration while on
antimicrobial tratment.

TREATMENT:

• - Early treatment is very
important .
- No delay is made waiting for
lab. r esults.

BUT REMEMBER THAT:

• Prolonged empirical Rx (≥ 5 days) with broad -
spectrum antibiotics for preterm neonates is
associated with higher risks of N.E.C. & death .
So antimicrobial therapy should be discontinued at
48 hours if clinical probability of sepsis is low & CRP
remains normal.

TREATMENT :

• 1 . Antibiotics:
should be given by intravenous route.
• Duration of Rx:
Clinical sepsis (based on clinical
suspicion) : 7 - 10 days.
Pneumonia: 10 - 14 days.
Meningitis: 2 - 3 weeks.
Osteomyelitis: 4 - 6 weeks.

CHOICE OF ANTIBIOTICS:

• - A combination of ampicillin & an aminoglycoside
(e.g. gentamicin ) or ampicillin & 3 rd . generation
cephalosporin ( e.g. cephotaxim ) is generally used
against Gm+ve , Gm -ve & Listeria.
• -Ceftriaxone is contraindicated in neonates
because it is highly protein bound and may
displace bilirubin, leading to a risk of kernicterus.
-Metronidazole for anaerobic infections (for 7 -
10 days).

• 2 . Supportive care (incubator, O 2 , i.v.fluid &

electrolytes, dopamine, TPN, IPPV, vit.K ,
blood & blood products).
• 3 . I.V.Immunoglobulin : which promotes
host defences by multiple mechanisms.
4 . Granulocyte transfusion.

COMPLICATIONS:

1. Septic emboli.
2 . Abscesses.
3 .Septic shock.
4 .DIC.
5 .Mortality is about 50 % .


رفعت المحاضرة من قبل: Ahmed monther Aljial
المشاهدات: لقد قام عضو واحد فقط و 65 زائراً بقراءة هذه المحاضرة






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