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Julniar M Tasli Herman Bermawi Afifa Ramadanti
- Student must be able to understand the important of neonatal infection - Student must be able to recognize risk factor which predispose new born infant to infection - Student must be able to diagnose neonatal infection - Student must be able to implement infection control to prevent infection
- Infection is an ever present problem in the newborn - Infection is not only common, but also present in many different ways involving almost any system in the body - The Incidence f infections is approxmattely 5 per 1000 live birth and more common in premature infants
The Immature Imune System
The immature imune system develops from early in fetal life, but is not functionally fully integrated until 1 year age. Immunity : - specific - non specific
Specific Immunity :
- is mediate through lymphocytes - B cells - T cells Neonatal lymphocytes owing to a reduced production of cytokine
stimulate Β cells plasma cells produce Ig - Ig M produce at 15 week gestation - Ig G produce at 20 week gestation - At birth : Ig minimal & very low - Only Ig can cross the placenta - Maternal Ig G birth fall in months T cells : - produced in fetal bone marrow migrates to the thymus There are 3 function : - Produce citokine - Supplies the immune respon of other cells - Kill target cells
Cellular : phagocytic white cells ( neutrophile and monocytes) ingest bacteria chemical chemotactic (complement and leukotrienes) site of inflamation Humoral : .lysozyme 6 .lactoferin .complement .Non specific immunity .interferon .
Low levels of IgG : IgM & Ig A 2. Endogenous factors 1. Phagocytic action is less afective 4. IUGR infant also appear to be more susceptible 7 .Susceptibility of the neonate to infection I. Humoral activity is impaired ( complement are low ) 5. Premature infant fail to receive IgG from mother 3.
Endogenous Factors: 1. Hiperbillirubinemia reduces immune function in several differet ways 8 . Drugs may impair immune function (corticosteroids) 4. Baby is bacteriologically steril little competition existing bacterial flora 2. Breaches of the skin barrier entry of bacteria to the baby 3.II. Fat emulsion (intralipid impair the fagocytic function of white cells) 5.
Intrapartum 3.Origins of infections : 1. Postnatally 9 . In utero (congenitally) 2.
Congenitally (intrauterine) I.Second semester : syphilis .First semester : TORCH (infection) . Hepatitis B.Toxoplasmosis .histeria monocytogenes. HIV . Transplacentally .Third semester : 1.Others e. coxsachoe B. varicella. 2. HIV.Rubella . streptococcus .CMV . Viral : Varicella. haemophilus influenza pneumococcus 3.Herpes simplex type 2 .g coxsaches B virus. Protozoa : malaria 10 . Bacterial : .group B β haemolyticus. echovirus.
Herpes simples. group B streptococcus beta haemolyticus. pneumonas proteus. Klebsiella. neiserria GO. Ascending infections : after rupture of membranes Pathogens : Esch.Chlamydia trachomatis 11 . group A streptococcus. Intrapartum . staphylococcus.II.Pathogens : .Candida albicans. HIV .PROM intrapartum infection . Hepatitis B. Enterococcus fecalis. Grup B streptococcus .coli.
shigella. salmonella. adenovirus. echovirus 3. 2.Aquired In the nursery (nasochomial) : 1. staph aureus. group B streptococcus coliform. candida parapsilosis. 12 . anaerobic bacteria. rotavirus. RSV. Bacteria : coagulate_negative staphylococcus. Fungal : candida albicans. pseudomonas. Viruses : coxsachie.
Maternal factors of sepsis ( feber. purulent liquor ) 2.Risk Factor Intrapartum Infection Mathernal factor : 1. Prolonged rupture of membrane 3. WBC high. Fregment vaginal examinations 5. Duration of labour ( >12 hours ) 4. tender uterus. The present of fertal distress or birth asphyxia 13 .
Neonatal Sepsis 14 .
• Suspect the bacterial pathogens responsible for causing sepsis • Use laboratory tests appropriately to diagnose sepsis. including the use of cultures to identify the suspected organism • Decide on the appropriate specific and supportive treatment.Neonatal Sepsis: Learning Objectives • Define neonatal sepsis • Recognize the importance of neonatal sepsis as a major cause of infant mortality and morbidity in Indonesia • Recognize infants who are at increased risk of developing sepsis • Obtain a neonate’s history in order to identify risk factors and symptoms of sepsis • Perform a physical examination of a neonate to recognize signs of sepsis. 15 .
Definition of Neonatal Sepsis • Disease of infants who are younger than 1 month of age • are clinically ill and • have positive blood cultures (or positive cultures from other normally sterile sites) 16 .
5 to 8.Incidence of Neonatal Sepsis • Asia: 7.1 to 38 per 1000 live births • Africa: 6.5 .9 per 1000 live births 17 .23 per 1000 live births • South America: 3.9 per 1000 live births • United States: 6 .
State of the World’s Newborns 2001 Infections 32% Asphyxia 29% Complications of prematurity 24% Congenital anomalies 10% Other 5% 18 .Direct Causes of Neonatal Deaths World Health Organization.
Case fatality due to neonatal sepsis is 12 to 68% in developing countries Why is the case fatality so high? 19 .
or hypoxemia • Other organ damage lung.Neonatal sepsis. septic shock. limbs.morbidity in survivors • Brain damage due to meningitis. liver. joints 20 .
Neonatal Sepsis Early Onset • < 72 hours of age • Acquired around birth • Vertical transmission from mother to baby Late Onset • > 72 hours of age • Acquired from the environment • Nosocomial or hospital acquired Distinction between Early onset sepsis and Late onset sepsis not clear in developing countries: • baby born at home and brought to the hospital at 3 days of age • baby referred from another hospital 21 .
Early Onset Sepsis .risk factors • Prolonged rupture of membranes >18 h • Maternal chorioamnionitis • Foul smelling amniotic fluid • Handling by untrained midwife • Maternal urinary tract infection • Premature labor 22 .
Chorioamnionitis Maternal fever during labor 38ºC ± uterine tenderness ± leucocytosis ± fetal tachycardia High risk of neonatal sepsis 23 .
IV lines. • Not fed maternal breast milk • POOR HYGIENE in NICU Module: Neonatal Sepsis-Session 1 24 .Late Onset Sepsis risk factors • Prematurity/ LBW • In hospital • Invasive procedures. babies with infections. nurses.doctors. urine catheter. chest tube • Contact with infectious disease . central lines.ventilator.
Bacterial Pathogens Responsible for Sepsis in Developing Countries • Early onset sepsis – Gram negative bacilli • E.coli • Klebsiella • Late onset sepsis – Gram negative bacilli • Pseudomonas • Klebsiella – Enterococcus – Group B streptococcus – Staph aureus – Coagulase negative staphylococci 25 .
5% 0.Saharan Africa Americas / Caribbean 46.85 % 16 –68 % 43.30% 2.71 % 0.Organisms associated with sepsis in developing countries (Stoll BJ Clin Perinatol 1997) % Gram negative % Group B Streptococcus India / Pakistan/ SE Asia Sub .35% 26 .
Neonatal Meningitis • Organisms: Gram negative in 1st week Strep pneumoniae > 1 week 27 .
Diagnosis of Neonatal Sepsis • Clinical signs and symptoms • Laboratory tests – culture of bacterial pathogen – other laboratory indicators 28 .
90% • Apnea • Temperature instability. shock. purpura. may be subtle • Respiratory distress. temp more common • Decreased activity • Irritability • Poor feeding • Abdominal distension • Hypotension.specific.late signs 29 . seizures.Diagnosis of Neonatal Sepsis clinical signs and symptoms Clinical Signs: early signs non.
2000 • • • • • • • • • • • • • • Respiratory rate > 60 breaths per minute Severe chest indrawing Nasal flaring Any of these signs: Grunting Suspect Serious Bulging fontanelle Bacterial Infection Convulsions Pus draining from ear Redness around umbilicus extending to the skin Temperature > 37.5C (or feels cold) Lethargic or unconscious Reduced movements Not able to feed Not attaching to the breast No sucking at all 30 .Clinical Criteria for Severe Bacterial Infection WHO Handbook Integrated Management of Childhood Illnesses.7 C (or feels hot) or < 35.
Laboratory Tests • Cultures to identify bacterial pathogen – blood.reactive protein 31 . csf. other • Hematological tests – WBC count – Platelet count – Erythrocyte Sedimentation Rate (ESR) • Other tests – C. urine.
do not wait for the written report.Blood Culture Gold standard for diagnosis of bacteremia • Add at least 0.5 -1.0 ml blood obtained by sterile venipuncture to culture bottle • Most bacteria grow within 24 to 48 hours • Talk to your microbiology lab every day. 32 .
Baby has risk factors and clinical signs of sepsis but blood culture is negative Blood cultures are positive in only 2 to 25% of babies with clinically suspected sepsis. • Mother may have received antibiotics in labor • Baby may have received antibiotics before blood culture • Volume of blood taken for blood culture too small 33 .
Lumbar Puncture • Possibility of meningitis 1-10% • Babies with meningitis may not have specific symptoms • 15% of babies with meningitis will have negative blood cultures 34 .
32 wbc / mm3 Glucose concentration : 24 .119 mg / dl Protein concentration: 20 .170 mg / dl 35 .Normal CSF values in newborn WBC count: 0 .
36 .Urine culture • Useful in neonates with late onset sepsis • Sterile specimen obtained by sterile catheterization or by suprapubic bladder aspiration.
Other cultures • Surface cultures • Endotracheal cultures • Gastric aspirate cultures Poor Sensitivity and Specificity 37 .
Abnormal white blood cell count • • • • Total WBC count < 5000 /L. 000/L Absolute neutrophil count: <1500/L Immature to total neutrophil ratio > 0.2 bandform neutrophil 38 .2 Immature to mature neutrophil ratio > 0. > 25.
There is No Substitute for Clinical Acumen • WBC counts may be normal in babies with sepsis • High WBC counts at birth not very specific. asphyxia • Better Predictors of Sepsis Total WBC count < 5000 /L Absolute neutrophil count: <1500/L Abnormal IT ratio at 12 to 24 hours of age 39 .may be due to stress.
6 mg/ dl on day 1.Reactive Protein • Acute phase reactant: synthesized in 6 to 12 hours • Normal: < 1. then < 1.C. meconium aspiration.0 mg/ dl • Falsely elevated with asphyxia. PROM • May not be positive early (only 60% sensitivity) • Repeated tests more useful (up to 84% sensitivity) • Negative Predictive value: 90% 40 .
up to a maximum of 14 mm/ hr • Poor sensitivity and specificity – False positive tests with hemolysis – False negative tests with DIC 41 .Micro-ESR • Measures ESR in vertically placed capillary tube in 1 hour • Normal values increase with age (due to increasing fibrinogen and falling hematocrit) • Normal: day of life plus 3 mm/ hr.
why do we do these tests? 42 .ESR are not reliable.If WBC count. micro. CRP.
if possible) Start antibiotics immediately Module: Neonatal Sepsis-Session 1 43 .Severe Clinical Symptoms Blood culture (CSF culture.
44 . perform blood culture CSF testing and start antibiotics.Risk factors for sepsis present but baby appears well • WBC count / CRP may be useful in excluding sepsis • Baby still needs close observation for at least 48 hours • If mother had chorioamnionitis.
Coli • Ampicillin and Gentamicin Indonesia? 45 .Treatment: antibiotics Choice: tailored to organisms prevalent in region USA: • Early onset sepsis: Group B strep / E.
4 weeks PLUS • Gentamicin once daily.First line therapy in facility setting (WHO 2003) • Ampicillin 50 mg/ kg – every 12 hours in 1st week of life – every 8 hours from 2. 46 .
• Plus gentamicin 47 .Suspected Staphylococcal Infection • Use Cloxacillin or flucloxacillin instead of Ampicillin.
Baby not responding to first line antibiotics or suspected hospital acquired infection • 3rd generation cephalosporin – cefotaxime – ceftazidime • For nosocomial infection : – vancomycin plus gentamicin/ amikacin or ceftazidime 48 .
Duration of antibiotic treatment Septicemia • Gram negative septicemia: 14 days • Group B Strep septicemia: 10-14 days Repeat blood culture within 24 . 49 .48 hours of beginning treatment to document clearance of organism.
48 hours of beginning treatment Consider neuroimaging studies 50 .21 days Document negative culture within 24 .Duration of antibiotic treatment Meningitis • Gram negative meningitis: 21 days minimum • Group B Strep meningitis: 14 .
Prevention of Nosocomial Infection • • • • • • Hand washing Early feeding Maternal breast milk Decrease use of broad spectrum antibiotics Decreased use of invasive procedures Proper sterilization procedures 51 .
Localized Infections 52 .
infection around the umbilical cord in the umbilicus .Localized Infections An infections is a certain part of the baby’s body ( cord. eye. mouth ) Can spread quickly through the newborn’s small body and causes sepsis Quick & correct treatment of localized infections may prevent sepsis and possible death I.amphisillin & gentamycin 53 . Umbilical cord infections .wash the cord and stump and apply gention violet 0.5 % . skin.can easily pass through the cord sepsis is and death if treatment is delayed or not given .Treatment : .
Eye infection .Th/ : Localized : .Treatment : .5 % Serious infections : .Ampicillin 50mg/kg IM III.Etiologi : .Chemical : AgNO3 ( no treatment ) .O .O ) 54 .G.Localized or serious skin infection .clamydia .Ceftrixone 50 mg/kgBB ( max 125 mg/kg ) single doze for G.II.Bacteria : .Topical erytromycin for clamydia .wash the skin and remove all dirty and pus .Skin pustules . Skin Infection .apply gentian violet 0.
Treatment : .White patches on the mucous membrane or tongue (candida albican) .5 % 55 .000 U/ml : 1 – 2 ml into the baby’s mouth 4 x / day .IV.Gentian violet 0. Oral Trush .nystatin 600.
TERIMAKASIH 56 .
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