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Ophthalmia Neonatorum

Ophthalmia Neonatorum

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Ophthalmia Neonatorum (Newborn Conjunctivitis, Neonatal Conjunctivitis

Ophthalmia neonatorum is conjunctivitis that occurs in the newborn. Conjunctivitis is an inflammation of the surface or covering of the eye because of infectious or non-infectious causes. Any eye infection that occurs in the first month of a baby’s life can be classified as ophthalmia neonatorum. While an infection has the potential to damage the delicate eye of an infant, there are a number of ways these infections can be prevented.

“ Neonatal conjunctivitis is defined as conjunctivitis presenting before 1 month of age Generally it can be divided into noninfectious and infectious categories”.

The most common noninfectious cause is a chemical conjunctivitis induced by silver nitrate solution used for prophylaxis against infectious conjunctivitis. Bacterial, chlamydial, and viral infections are major causes of infectious neonatal conjunctivitis; chlamydia is the most common. Other infectious agents that the infant may acquire as it passes through the birth canal during include, Streptococcus spp., Staphylococcus spp., Escherichia coli, Haemophilus spp., Neisseria gonorrhea, and herpes simplex .The time of onset of the conjunctivitis as well conjunctival scraping can aid in the diagnosis of the specific etiology of the neonatal conjunctivitis If an infection does occur, effective treatment is available for infants who develop an eye infection. If you suspect your baby may be at risk for an infection, or may have an eye infection, you should contact your doctor immediately.

The cause of the conjunctivitis may be simply an irritation in the eye, or a blocked tear duct. However, bacteria can also cause an infection in the eye. The most common types of bacteria that cause infection in the infants eye come from the mothers birth canal, and are passed to the infant during delivery. These infections can include:

 

Sexually transmitted diseases (STDs)The most common bacteria passed to infants during delivery are due to STDs from the mothers birth canal. If untreated, many of these infections can cause serious damage to the infants eye. STDs that can cause eye damage include: o Chlamydia aureus o Gonorrhea o The virus that causes oral and genital herpes Skin bacteria such as Staphylococcus Bacteria from the mothers gastrointestinal tract, such as Pseudomonas

since hospitals today have such effective prevention measures. If your baby has this or any of the other symptoms described below. it is important to call your baby’s doctor as soon as possible to receive prompt treatment. see your pediatrician. Silver nitrate. Irritation Ophthalmia neonatorum due to irritation usually resolves on its own in a few days. the doctor may recommend warm compresses and gentle massage to the area to help unclog the duct. The doctor will look at your baby’s eyes to check for anything that may be irritating the eye. the irritation may be due to the antibiotic given after delivery. orally. In addition.Risk Factors The biggest risk factor for developing ophthalmia neonatorum is a maternal infection or STD at the time of delivery. with some infections. Antibiotic treatment is very effective and generally. And when they do occur. Symptoms :  Redness and swelling of the conjunctiva in the newborn. bacterial cases of ophthalmia neonatorum are rare. Many hospitals now use other types of antibiotics to avoid this irritation. the eye may be irrigated to remove the discharge. You and your doctor can develop a plan to protect your baby from infections during delivery. the infection resolves rapidly. which was often used in the past to prevent eye infection. it is standard treatment in US hospitals to give infants antibiotic eye drops or ointment immediately following delivery. In cases where conjunctivitis does develop. baby's Some of the other symptoms of ophthalmia neonatorum include:  Drainage and discharge from the eye. The doctor may also want to take a sample of any discharge to determine what type of bacteria or virus is causing the infection. Treatment: Since the potential for serious eye damage to the infant is so great. This helps prevent the development of an eye infection even if the mother shows no symptoms of infection. a cesarean section can prevent the infant from getting the infection. it may be watery or thick and pus-like. In some cases. An open. If you are pregnant. effective treatment of the mother before the time of delivery can prevent the transmission of infection to the newborn. or had in the past. Diagnosis: If your baby’s pediatrician suspects ophthalmia neonatorum your physician will first perform an eye examination. they are usually identified quickly.  Swollen eyelids . For mothers with active genital herpes lesions at the time of delivery. honest relationship with your doctor is . If you suspect that your infant may have an infection in the eye. and to see if any damage has occurred. can cause irritation in the baby’s eye. In most cases. Prevention: The best prevention of ophthalmia neonatorum is treatment of any sexually transmitted diseases in the mother prior to labor and delivery. These antibiotics may be given as topical drops or ointments. Bacteria Infants that have an eye infection due to bacteria are given antibiotics. The doctor may look at the baby’s tear ducts to see if they are blocked. Fortunately. it is important to discuss any STDs that you have. the treatment of ophthalmia neonatorum depends on the cause: Blocked Tear Duct In cases of ophthalmia neonatorum that are due to a blocked tear duct. the mother may not have any symptoms during delivery and still be able to transmit the infection. or as an injection. Unfortunately.

1. Time of Onset (Days after Birth) 0–2 2–7 Etiology (Clinical Presentation) Chemical (mild lid edema with watery discharge) Gonococcal (severe lid swelling with purulent discharge) Chlamydial (variable lid swelling with serous or purulent discharge) Bacteria (Staphylococcus. Fig. gonorrhoeae should be obtained as well as blood agar for other bacteria. TABLE 1. Disclosure of your full medical history can help protect your baby from infection Table 1. gram stain may reveal multinucleate giant cells or Papanicolaou smear may show eosinophilic intranuclear inclusions in epithelial cells. Culture for herpes simplex virus also can be indicated if a corneal epithelial defect is present or the diagnosis cannot be made on ocular examination . In herpetic conjunctivitis. Neonatal conjunctivitis. Initial culture on chocolate agar or a Thayer-Martin test for N.important during your pregnancy. Chlamydial infection can be ruled out with a conjunctival scraping Giemsa stain for intracytoplasmic inclusion bodies or direct immunofluorescent antibody assay. Streptococcus. Haemophilus purulent discharge) Herpes simples virus (serous discharge with dendritic keratitis or geographic ulcers) Conjunctival Scraping Minimal reactive cells to few PMN Many reactive cells with gram negative intracellular diplococci Many reactive cells with Giemsa stain for basophilic cytoplasmic inclusion bodies or direct immunofluorescent assay Gram stain for bacteria 3–10 4–7 3–14 Variable reactive cells with multinucleated giant cells Laboratory studies: Laboratory studies for neonatal conjunctivitis are essential for proper management and diagnosis.

Treatment includes both topical erythromycin ointment and oral erythromycin 30 to 50 mg/kg per day divided in four doses. after which the treatment can be altered based on laboratory results. with spontaneous resolution in 2 to 3 days. 2. the treatment of choice for this organism is a systemic. and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea and chlamydial ophthalmia in newborn infants. Specific treatment for infectious neonatal conjunctivitis is based on the clinical picture and the findings on Gram. gentamicin or tobramycin drops for gramnegative organisms. up to 30% . or bacitracin ointment for gram-positive organisms. Typical treatment lasts for 2 weeks to prevent recurrence and secondary pneumonitis. which has high sensitivity and specificity. Because of the prevalence of penicillin-resistant N. 0.5% erythromycin. Most bacterial conjunctivitis respond quickly to topical antibiotic treatment. A pediatrician should be consulted for possible extraocular involvement. The mother and her sexual contacts also should be treated. Gonococcal conjunctivitis. Irrigation of the affected eyes with saline until discharge is eliminated may be useful. and fortified topical antibiotics for Pseudomonas. Acute neonatal conjunctivitis should be treated as gonococcal conjunctivitis until culture results become available. Giemsa. third-generation cephalosporin such as ceftriaxone 30 to 50 mg/kg per day in divided doses IV or IM.alone with presence of vesicular lesions. It is much more indolent and less severe. cephalosporin Treatment before laboratory results should include topical erythromycin ointment and penicillin G intravenous (IV) or intramuscular (IM) thirdgeneration. erythromycin. It presents with severe purulent conjunctivitis with lid edema and chemosis This organism can penetrate intact corneal epithelium and cause rapid ulceration and perforation. and Papanicolaou stains.5% povidone-iodine solution also may be effective in preventing neonatal ophthalmia and appears to cause less chemical conjunctivitis as compared with either silver nitrate or erythromycin. Fig. gonorrhoeae. Most cases of herpetic conjunctivitis are type II. Medical treatement: Topical 1% silver nitrate. not to exceed 125 mg. Diagnosis is made by observing intracytoplasmic inclusion bodies by Giemsa stain or direct immune fluorescent assay. Gonococcal conjunctivitis can progress rapidly. Chlamydial conjunctivitis has a later onset than gonococcal conjunctivitis typically from 3 to 10 days after birth.7 Specific treatment for chemical conjunctivitis is not necessary. however. In addition. Herpetic conjunctivitis can be the sole manifestation of a neonate infected with herpes simplex. Recent studies indicate that 2. a single dose of cefotaxime 100 mg/kg IM is an alternative treatment. Both parents also should be treated for chlamydia even if they are asymptomatic.

or meningitis).. septicemia. Neonatal sepsis . Treatment consists of topical trifluorothymidine 1% drops every 2 hour or 3% vidarabine ointment. Most present with later onset conjunctivitis with corneal keratitis usually presenting as microdendrites or small geographic ulcers.g. In cases with systemic involvement (e. pneumonitis. systemic acyclovir should be used.can be type I.

or gastroenteritis) in the setting of fever. Neonatal sepsis is divided into two categories: Early Onset Sepsis (EOS) and Late Onset Sepsis (LOS). Earlyonset infections are caused by organisms prevalent in the maternal genital tract or in the delivery area. pneumonia. neonatal sepsis specifically refers to the presence of a bacterial blood stream infection (BSI) (such as meningitis. EOS refers to sepsis presenting in the first 7 days of life (although some refer to EOS as within the first 72 hours of life). . late sepsis Neonatal sepsis can be classified into two sub-types depending upon whether the onset of symptoms is before 72 hours of life (early onset) or later (late onset). When pathogenic bacteria gain access into the blood stream. they may cause overwhelming infection without much localization (septicemia) or may get predominantly localized to the lung (pneumonia) or the meninges (meningitis). Etiology Most cases of neonatal sepsis in the community are caused by Escherichia coli and Staphylococcus aureus. it is possible to save most cases of neonatal sepsis. Early-onset sepsis is seen in the first week of life. Late-onset sepsis occurs between days 8 and 89. with LOS referring to presentation of sepsis after 7 days (or 72 hours. Attempts have been made to see whether it is possible to risk stratify newborns in order to decide if a newborn can be safely monitored at home without treatment despite having a fever. depending on the system used). It is difficult to clinically exclude sepsis in newborns less than 90 days old that have fever (defined as a temperature > 38°C (100. Importance : Neonatal sepsis is the single most important cause of neonatal deaths in the community. In common clinical usage. One such attempt is the Rochester criteria. the current practice in newborns less than 30 days old is to perform a complete workup including complete blood count with differential. blood culture. The associated factors for early-onset sepsis include low birth weight. Definition: Neonatal sepsis is defined as a clinical syndrome of bacteremia with systemic signs and symptoms of infection in the first 4 weeks of life. Klebsiella pneumoniae is also a common organism Early vs.Introduction Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days old. Except in the case of obvious acute viral bronchiolitis. accounting for over half of them. Older textbooks may refer to neonatal sepsis as "Sepsis neonatorum". pyelonephritis. In hospitals. If diagnosed early and treated aggressively with antibiotics and good supportive care. Criteria with regards to hemodynamic compromise or respiratory failure are not useful clinically because these symptoms often do not arise in neonates until death is imminent and unpreventable. urinalysis. urine culture.4°F). and cerebrospinal fluid(CSF) studies and CSF culture. and treat empirically for serious bacterial infection for at least 48 hours until cultures are demonstrated to show no growth. admit the newborn to the hospital.

multiple per vaginum examinations. . foul smelling liquor.prolonged rupture of membranes.

inactive or unresponsive and refuses to suckle. chest retractions. vomiting and abdominal distension may occur. neck retraction. the skin may become tight giving a hide-bound feel (sclerema) and the perfusion . Early onset sepsis manifests frequently as pneumonia and less commonly as septicemia or meningitis. a blank look. The baby. who had been active and sucking well.  Clinical signs of neonatal sepsis The signs of sepsis are non-specific and include: lethargy. In sick neonates. this tachycardia can present up to 24 hours before the onset of other signs. The most common and characteristic manifestation is an alteration in the established feeding behavior in late onset sepsis and respiratory distress in early onset sepsis. poor feeding. seizures. Diarrhea. Hypothermia is a common manifestation of sepsis. bulging fontanelle and seizures. grunt. gradually or suddenly. aspiration of feeds. umbilical sepsis). lack of breastfeeding. Late-onset septicemia is caused by the organisms thriving in the external environment of the home or the hospital. a poor cry. fever. cyanosis. superficial infections (pyoderma. A heart rate above 160 can also be an indicator of sepsis. high pitched cry. becomes lethargic. Episodes of apneic spells or gasping may be the only manifestation of septicemia. sclerema. whilst fever is infrequent. poor weight gain.difficult or prolonged labour and aspiration of meconium. apnea/gasping. renal failure. excessive crying/irritability. Symptoms Infants with neonatal sepsis may have the following symptoms:             Body temperature changes Breathing problems Diarrhea Low blood sugar Reduced movements Reduced sucking Seizures Slow heart rate Swollen belly area Vomiting Yellow skin and whites of the eyes (jaundice) Clinical features The manifestations of neonatal septicemia are often vague and therefore demand a high index of suspicion for early diagnosis (Table I). The onset of symptoms is usually delayed beyond 72 hours after birth and the presentation is that of septicemia. tachypnea. poor perfusion. disruption of skin integrity with needle pricks and use of intravenous fluids. jaundice. These factors enhance the chances of entry of organisms into the blood stream of the neonates whose immune defences are poor as compared to older children and adults. The associated factors of late-onset sepsis include: low birth weight. The infection is often transmitted through the hands of the care-providers. fever. pneumonia or meningitis.

early cyanosis and apneic spells in addition to inactivity and poor feeding.contributory. seizures. Cough is unusual. showed that infants ≤ 60 days old meeting the following criteria were at low-risk for having a serious bacterial illness:   generally well-appearing previously healthy . comatosed Abdominal distension Diarrhea Vomiting Hypothermia Poor perfusion Sclerema Poor weight gain Shock Bleeding Renal failure Cyanosis* Tachypnea* Chest retractions* Grunt* Apnea/gasping* + Fever + Seizures + Blank look + High pitched cry Excessive + crying/irritability + Neck retraction + Bulging fontanel The additional features of pneumonia or meningitis may be present depending upon the localization of infection in different systems and organs of the body. H/o of convulsions Risk factors: A study performed at Strong Memorial Hospital in Rochester. Grunting 8. New York. blank look. Cyanosis may appear. grunting.becomes poor (capillary refill time of over 3 seconds). Cyanosis 9. : Clinical manifestations of neonatal sepsis: Lethargy Refusal to suckle Poor cry Not arousable. A critical neonate may develop shock. Resp rate > 60/minute 7. the clinical picture being dominated by manifestations of associated septicemia. A large WHO study published in 2003 identified nine clinical features which predict severe bacterial illness in young infants . Feeding ability reduced 2. neck retraction or bulging anterior fontanel are highly suggestive of meningitis. No spontaneous movement 3. Findings on auscultation of the chest are nonspecific and non. 1. The evidence of pneumonia includes tachypnea. bleeding and renal failure. Temperature >38 C 4. However. Meningitis is often silent. Lower chest wall in drawing 6. Prolonged capillary refill time 5. chest retractions. fever. the appearance of excessive or high-pitched crying.

coli). soft tissue. or with a single dose of intramuscular antibiotics.500/mm3 urine WBC count ≤ 10 per high power field (hpf) stool WBC count ≤ 5 per high power field (hpf) only in infants with diarrhea o o o o o o o Those meeting these criteria likely do not require a lumbar puncture. including Escherichia coli (E. The following increases an infant's risk of early-onset sepsis:     Group B streptococcus infection during pregnancy Preterm delivery Water breaking (rupture of membranes) that lasts longer than 24 hours before birth Infection of the placenta tissues and amniotic fluid (chorioamnionitis) Babies with late-onset neonatal sepsis get infected after delivery. but will still require close outpatient follow-up. joint. One risk for GBS infection is Preterm rupture of membranes. micro ESR (Erythrocyte Sedimentation Rate) titer > 55mm. Cause: A number of different bacteria. 3. Listeria. 2. .000/mm3 absolute band count ≤ 1. and are felt to be safe for discharge home without antibiotic treatment. Screening women for GBS (via vaginal and rectal swabbing) and treating culture positive women with intra partum chemoprophylaxis is reducing the number of neonatal sepsis caused by GBS. DLC showing increased numbers of polymorphs. or ear infection WBC count 5. The baby gets the infection from the mother before or during delivery. and certain strains of streptococcus. DLC: band cells > 20%.     full term (at ≥37 weeks gestation) no antibiotics perinatally no unexplained hyperbilirubinemia that required treatment no antibiotics since discharge no hospitalizations no chronic illness discharged at the same time or before the mother no evidence of skin. The following increase an infant's risk of sepsis after delivery:   Having a catheter in a blood vessel for a long time Staying in the hospital for an extended period of time Diagnosis: Neonatal sepsis screening: 1. increased haptoglobins. bone. Early-onset neonatal sepsis most often appears within 24 hours of birth.000-15. may cause neonatal sepsis. 4.

There are a variety of other tests which can be used to predict sepsis but it may be difficult to perform them at all places and hence the clinical acumen remains crucial. gastric aspirate showing > 5 polymorphs per high power field. is the gold standard test for definitive diagnosis of neonatal sepsis. pleural fluid or pus is diagnostic.000 per cmm. newborn CSF (CerebroSpinal Fluid) screen: showing increased cells and proteins. shock. to fight infection. suggestive history of chorioamnionitis.20 means that immature neutrophils are over 20 percent of the total neutrophils because bone marrow pushes even the premature cells into circulation. Direct method: Isolation of microorganisms from blood. urine. This can give false negatives due to the low sensitivity of culture methods and because of concomitant antibiotic therapy. CSF. birth asphyxia and periventricular hemorrhage. Indirect method: There are a variety of tests which are helpful for screening of neonates with sepsis. An absolute neutrophil count of < 1800 per cmm is an indicator of infection. toxic granules on peripheral smear and gastric aspirate smears showing more than 5 leucocytes per high power field are also useful indirect evidences of infection. A practical positive "sepsis screen" takes into account two . The most useful and widely used is the white blood cell count and differential count.. 7. 6. Neutropenia is more predictive of neonatal sepsis than neutrophilia but it may be present in maternal hypertension. Culturing for microorganisms from a sample of CSF. etc. which warrants an antibiotic with a high CSF penetration. PROM (Premature Rupture Of Membranes). meconium aspiration and prolonged rupture of membranes.5.. The micro-ESR may be elevated with sepsis and fall of > 15 mm during first hour indicates infection. The most widely used is C-reactive protein (CRP) which has a high degree of sensitivity for neonatal sepsis. The CRP can be affected by asphyxia. Immature neutrophils (Band cells + myelocytes + metamyelocytes) to total neutrophils ratio (l/T) > 0. Lumbar punctures should be done when possible as 10-15% presenting with sepsis also have meningitis. Platelet count of less than 100. Acute phase reactants are also frequently used in predicting neonatal sepsis. blood or urine.

They may be relatively asymptomatic until hemodynamic and respiratory collapse is imminent. Although uncommon. clindamycin is often added. Neutropenia (ANC <1800/cmm) 3. Exams and Tests: Laboratory tests can help diagnose neonatal sepsis and identify the bacteria that is causing the infection. they are frequently treated with antibiotics empirically until cultures are sufficiently proven to be negative. while GM-CSF corrects neutropenia if present. administered parenterally throughout.or more positive tests as given below: 1. so. neonates are also vulnerable to other common pathogens that can cause meningitis and bacteremia such as Streptococcus pneumoniae and Neisseria meningitidis. In addition to fluid resuscitation and supportive care. if anaerobic species are suspected (such as in cases where necrotizing enterocolitis or intestinal perforation is a concern.(This is the main rationale for using ampicillin versus other beta-lactams. Micro ESR (> 15mm 1st hour) 5. Escherichia coli.) The organisms which are targeted are species that predominate in the female genitourinary tract and to which neonates are especially vulnerable to. sepsis is difficult to diagnose clinically. Immature neutrophil to total neutrophil (I/T) ratio (> 0. if there is even a remote suspicion of sepsis. Blood tests may include:    Blood culture C-reactive protein Complete blood count (CBC) A lumbar puncture (spinal tap) will be done to examine the cerebrospinal fluid for bacteria. Leukopenia (TLC <5000/cmm) 2. specifically Group B Streptococcus. however a recent study found that.2) 4.) Of course. At a small hospital. one may only depend on the CSF cells. If the baby has a cough or problems breathing. a common antibiotic regimen in infants with suspected sepsis is a beta-lactam antibiotic (usually ampicillin) in combination with an aminoglycoside (usually gentamicin) or a third-generation cephalosporin (usually cefotaxime—ceftriaxone is generally avoided in neonates due to the theoretical risk of kernicterus. a chest x-ray will be taken. and Listeria monocytogenes . it has no effect on reducing sepsis or improving survival. lumbar puncture should be done in all cases of late onset (>72 hours) and symptomatic early onset sepsis because 10-15 percent of them may have associated meningitis. The implications of detecting meningitis in the setting of septicemia include: the need for using antibiotics with a high CSF penetration and provision of antibiotic treatment for at least 3 weeks. CRP +ve If possible. Treatment: Note that. in neonates. Granulocyte-macrophage colony stimulating factor (GM-CSF) is often used in neonatal sepsis. .

Preventing and treating infections in mothers. where possible. many babies with these bacterial infections will recover completely with no remaining problems. Older babies may not be given antibiotics if all lab results are within normal limits. Outlook (Prognosis): With prompt treatment. neonatal sepsis is a leading cause of infant death.) This practice has saved many lives. Treatment: Babies in the hospital and those younger than 4 weeks old are started on antibiotics before lab results are back.infant . Possible Complications:   Disability Death When to Contact a Medical Professional Seek immediate medical help if your infant shows symptoms of neonatal sepsis. or who have previously given birth to an infant with sepsis due to the bacteria. Neonatal septicemia. the child may be followed closely on an outpatient basis. and delivering the baby within 24 hours of rupture of membranes. the better the outcome. (Lab results may take 24-72 hours. Group B strep.Urine culture tests are done in babies older than several days. can all help lower the chance of neonatal sepsis. Alternative Names Sepsis neonatorum. Babies who do require treatment will be admitted to the hospital for monitoring. Prevention Preventative antibiotics may be given to pregnant women who have chorioamnionitis. Nevertheless. The more quickly an infant receives treatment. Sepsis . providing a clean birth environment. Instead.

8. If perfusion is poor as indicated by a capillary refill time of more than 3 seconds. A dextrose bolus will help correct hypoglycemia which is often present in septic infants. Infuse glucose (10 percent) 2 ml/kg stat. Oxygen should be provided if the infant is having retractions. stabilize the cardiopulmonary status. 5. Start intravenous line. Provide warmth. Start oxygen by hood or mask. Antibiotic therapy Antibiotic therapy should cover the common causative bacteria. Consider use of dopamine if perfusion is persistently poor. TABLE -II: Supportive care of a septic neonate 1. correct hypoglycemia and prevent bleeding tendency (Table-II). In neonates with sclerema. The septic neonate should be nursed in a thermo neutral environment. 9. grunt or cyanosis. 6. Provide gentle physical stimulation. 4. if required. if perfusion continues to be poor. Staphylococcus aureus and Klebsiella pneumoniae. An intravenous line should be established. Provide bag and mask ventilation with oxygen if breathing is inadequate. Avoid enteral feed if very sick. Apneic neonates should be given physical stimulation and bag-mask ventilation.Supportive care : The purpose of supportive care is to normalize the temperature. give maintenance fluids intravenously 10. Table III shows detailed guidelines about antibiotic therapy. ensure consistently normal temperature 2. 3. normal saline bolus should be infused immediately. Consider exchange transfusion if there is sclerema. cefotaxime should be used along with an aminoglycoside. There is no role of intravenous immunoglobulin therapy in neonatal sepsis. A combination of ampicillin and gentamicin is recommended for treatment of sepsis and pneumonia. Inject Vitamin K 1 mg intramuscularly. namely. exchange transfusion with fresh whole blood may be contemplated. . 11. the temperature should be raised using a heat source. Infuse normal saline 10 ml/kg over 5-10 minutes. Escherichia coli. Vitamin K should be given to prevent bleeding. Appropriate maintenance intravenous fluids are administered. 7. In cases of suspected meningitis. Enteral feeds are avoided if infant is very sick or has abdominal distension. if cyanosed or grunting. if apneic. if perfusion is poor as evidenced by capillary refill time (CRT) of more than 3 seconds. If hypothermic. Repeat the same dose 1-2 times over the next 30-45 minutes.

Usually staphylococci and Gram negative bacilli (Pseudomonas.IM 8 hrly 8 hrly 8 hrly IV IV.5 mg/kg/dose 7. Septicemia or Pneumonia Antibiotic <7 days age Inj Ampicillin or Inj cloxacillin AND Inj Gentamicin or Inj Amikacin TABLE III: Antibiotic therapy of neonatal sepsis Each dose Frequency Route Duration > 7 days age 8 hrly IV. IM 50 mg/kg/dose 50 mg/kg/ dose 2. Klebsiella) should be covered using aminoglycoside (gentamicin or amikacin) and a third . first line of antibiotics may comprise of cloxacillin 100 mg per kg per day and an aminoglycoside (gentamicin or amikacin). IM IV. antibiotic sensitivity pattern of organisms responsible for nursery infection should be known and the antibiotic therapy should be started accordingly.I. In nosocomial sepsis.5 mg/kg/dose 12 hrly 12 hrly 12 hrly 12 hrly 7-10 days 7-10 days 7-10 days 7-10 days In late-onset sepsis to cover nosocomial staphylococcal infection.

II.5 12 hrly 8 hrly IV mg/kg/ dose 3 weeks 3 weeks 3 weeks 3 weeks . Meningitis Antibiotic <7 days age (1) Each dose Frequency Route Duration Inj Gentamicin OR (2) Inj Gentamicin > 7 days age Inj 100 12 hrly 8 hrly IV Ampicilli mg/kg/ n dose and 2.5 mg/ 12 hrly 8 hrly IV kg/dose Inj 50 12 hrly 8 hrly IV Cefotaxi mg/kg/ me and dose 2.

A good antenatal care goes a long way in decreasing the incidence.generation cephalosporin (cefotaxime). Deep-seated infections (osteomyelitis) and meningitis may require therapy for 3-6 weeks. Superficial infections must be adequately managed. Cord should be kept clean and dry. Rinse thoroughly with running water. appropriate antibiotics are used singly or in combination. For resistant staphylococcal infection. if a baby appears ill even though the cultures are negative. All persons taking care of the baby should strictly follow hand washing policies before touching any baby. Purulent conjunctivitis can be treated with neosporin or chloramphenicol ophthalmic drops. site of infection and the clinical response of the baby. Pustules can be punctured with sterile needles and cleaned with spirit or betadine. antibiotic therapy should be continued for 7 to 10 days as bacterial infection can occur with negative cultures. However. The duration of antibiotic therapy in sepsis depends upon the pathogen. Oral thrush responds to local application of clotrimazole or nystatin (200. Rings. these may be stopped after 3 days. Babies should be fed early and exclusively with expressed breast milk (or breastfed) without any prelacteal feeds. if baby is clinically well and the culture is negative. Unnecessary interventions should be avoided. All types of infections should be diagnosed early and treated vigorously in pregnant mothers. if neglected they can lead to sepsis or even an epidemic. Superficial infections Superficial infections can be treated with local application of antimicrobial agents. All mothers should be immunized against tetanus.000 units per ml) and hygienic precautions. Wash hands up to the wrist for 20 seconds in between patients. papers etc. Hands should be rewashed after touching contaminated material like one’s face. The sleeves should be rolled above the elbows. On confirmation of sensitivity pattern. It is preferable to use bar soaps rather than liquid soaps as the latter tend to harbor organisms after storage. This is the simplest and the most effective method for control of infection in the hospital. watches and jewellery should be removed. vancomycin (30 mg per kg per day) should be used. In emergency situations bactericidal and Prevention of infections Hand washing . In a baby in whom the antibiotics were started on low suspicion. Dry hands with sterile hand towel/paper towel. hair. morbidity and mortality from neonatal sepsis. 7-10 days therapy is required for soft tissue infections or pneumonia. Wash hands up to elbows with a thorough scrub for 2 minutes with soap and water taking care to cover all areas including the under surface of well trimmed nails.

A high index of suspicion with or without lab evidences of infection is the key for early diagnosis. Stock solutions for rinsing should be avoided. Most of the times a scrupulous reinforcement of general control measures may be sufficient to stop the outbreak. disinfection and sterilization of nursery and assessment of the need for additional measures.virucidal solutions like Sterillium can be used to clean hands before touching babies. cleaning of cots and incubators should be ensured and these policy guidelines should be available in the form of a manual in the nursery. review of protocols. cohorting of infants in nursery and a review of antibiotic policy may be necessary. The nursery temperature should be maintained between 30+2°C. Control of outbreak Conclusion In conclusion. . The use of prophylactic antibiotics for prevention of nosocomial infections is strongly condemned. probes. There should be no compromise in the use of disposables. Linen and cotton should be washed thoroughly. manifestations of neonatal sepsis are non-specific. Every baby must have separate thermometer and stethoscope and all barrier nursing measures must be followed. elbow. cannulae. dried and autoclaved. General measures for the control of an outbreak include detailed epidemiological investigations. bacillocid spray for 1-2 hours may be used. procedures and techniques. The nursery may be fumigated using formalin 40% and potassium permanganate (70 gms of KMNO4 with 170 ml of formalin for 1000 cubic feet area).Strict house-keeping routines for washing. disinfection. Prevention of infection in hospital The nursery environment should be clean and dry with 24 hour water supply and electricity. chest tubes etc. Alternatively. culture surveys of susceptible patients. Depending upon the pathogen and type of outbreak. Use of disposable items for invasive and non. Prompt institution of antibiotic therapy and supportive care will save most of the cases of neonatal sepsis. Overcrowding should be avoided. Surgical. increased emphasis on hand washing. They are not only useless but also dangerous because of the potential risk of emergence of resistant strains of bacteria.invasive interventions (catheters. There should be adequate ventilation and lighting. Unnecessary invasive interventions such as needle pricks and setting up of intravenous lines should be kept to the barest minimum. reduces the risk of infection. All procedures should be performed after wearing mask and gloves.) though costly.operated taps should be used in the hospitals for hand washing.

Stoll et al . Pediatrics 2011: 127:817-826. Morbidity and Mortality Weekly Report.References Verani JR. 2010. Schrag S. 59(RR-10): 1-36. coli disease continues. Revised Guidelines from CDC. Prevention of Perinatal Group B Streptococcal Disease. 2010. . Early onset neonatal sepsis: the burden of group B streptococcal and E. McGee L.

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