Ophthalmia Neonatorum (Newborn Conjunctivitis, Neonatal Conjunctivitis

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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.

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

Causes
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:

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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

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

Streptococcus. gram stain may reveal multinucleate giant cells or Papanicolaou smear may show eosinophilic intranuclear inclusions in epithelial cells. 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. 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 . 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. gonorrhoeae should be obtained as well as blood agar for other bacteria. 1. Disclosure of your full medical history can help protect your baby from infection Table 1. Neonatal conjunctivitis. Chlamydial infection can be ruled out with a conjunctival scraping Giemsa stain for intracytoplasmic inclusion bodies or direct immunofluorescent antibody assay. Initial culture on chocolate agar or a Thayer-Martin test for N. TABLE 1.important during your pregnancy. In herpetic conjunctivitis. Fig.

Acute neonatal conjunctivitis should be treated as gonococcal conjunctivitis until culture results become available.7 Specific treatment for chemical conjunctivitis is not necessary. third-generation cephalosporin such as ceftriaxone 30 to 50 mg/kg per day in divided doses IV or IM. The mother and her sexual contacts also should be treated. which has high sensitivity and specificity. Diagnosis is made by observing intracytoplasmic inclusion bodies by Giemsa stain or direct immune fluorescent assay. not to exceed 125 mg. and fortified topical antibiotics for Pseudomonas. Herpetic conjunctivitis can be the sole manifestation of a neonate infected with herpes simplex. It presents with severe purulent conjunctivitis with lid edema and chemosis This organism can penetrate intact corneal epithelium and cause rapid ulceration and perforation. with spontaneous resolution in 2 to 3 days. however. Chlamydial conjunctivitis has a later onset than gonococcal conjunctivitis typically from 3 to 10 days after birth.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. In addition. erythromycin. after which the treatment can be altered based on laboratory results. the treatment of choice for this organism is a systemic. Gonococcal conjunctivitis. Irrigation of the affected eyes with saline until discharge is eliminated may be useful. 0. Most cases of herpetic conjunctivitis are type II. or bacitracin ointment for gram-positive organisms. up to 30% . and Papanicolaou stains. Medical treatement: Topical 1% silver nitrate. It is much more indolent and less severe. Because of the prevalence of penicillin-resistant N. a single dose of cefotaxime 100 mg/kg IM is an alternative treatment. gonorrhoeae. and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea and chlamydial ophthalmia in newborn infants. A pediatrician should be consulted for possible extraocular involvement. Recent studies indicate that 2. Specific treatment for infectious neonatal conjunctivitis is based on the clinical picture and the findings on Gram. Most bacterial conjunctivitis respond quickly to topical antibiotic treatment. 2. Fig. Giemsa.alone with presence of vesicular lesions. cephalosporin Treatment before laboratory results should include topical erythromycin ointment and penicillin G intravenous (IV) or intramuscular (IM) thirdgeneration. Both parents also should be treated for chlamydia even if they are asymptomatic. Typical treatment lasts for 2 weeks to prevent recurrence and secondary pneumonitis. Treatment includes both topical erythromycin ointment and oral erythromycin 30 to 50 mg/kg per day divided in four doses. Gonococcal conjunctivitis can progress rapidly. gentamicin or tobramycin drops for gramnegative organisms.5% erythromycin.

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

the current practice in newborns less than 30 days old is to perform a complete workup including complete blood count with differential. pneumonia. In hospitals. urine culture. they may cause overwhelming infection without much localization (septicemia) or may get predominantly localized to the lung (pneumonia) or the meninges (meningitis). 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). it is possible to save most cases of neonatal sepsis. Earlyonset infections are caused by organisms prevalent in the maternal genital tract or in the delivery area. The associated factors for early-onset sepsis include low birth weight. and treat empirically for serious bacterial infection for at least 48 hours until cultures are demonstrated to show no growth. Late-onset sepsis occurs between days 8 and 89. 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).4°F). 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. blood culture. In common clinical usage. It is difficult to clinically exclude sepsis in newborns less than 90 days old that have fever (defined as a temperature > 38°C (100. 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. Except in the case of obvious acute viral bronchiolitis. Etiology Most cases of neonatal sepsis in the community are caused by Escherichia coli and Staphylococcus aureus. Early-onset sepsis is seen in the first week of life. accounting for over half of them.Introduction Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days old. 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. or gastroenteritis) in the setting of fever. Importance : Neonatal sepsis is the single most important cause of neonatal deaths in the community. neonatal sepsis specifically refers to the presence of a bacterial blood stream infection (BSI) (such as meningitis. with LOS referring to presentation of sepsis after 7 days (or 72 hours. . Neonatal sepsis is divided into two categories: Early Onset Sepsis (EOS) and Late Onset Sepsis (LOS). One such attempt is the Rochester criteria. pyelonephritis. Older textbooks may refer to neonatal sepsis as "Sepsis neonatorum". depending on the system used). If diagnosed early and treated aggressively with antibiotics and good supportive care. urinalysis. and cerebrospinal fluid(CSF) studies and CSF culture. Klebsiella pneumoniae is also a common organism Early vs. When pathogenic bacteria gain access into the blood stream. admit the newborn to the hospital.

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

a poor cry. excessive crying/irritability. chest retractions. 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).difficult or prolonged labour and aspiration of meconium. The associated factors of late-onset sepsis include: low birth weight. Early onset sepsis manifests frequently as pneumonia and less commonly as septicemia or meningitis. becomes lethargic. apnea/gasping. pneumonia or meningitis. grunt. lack of breastfeeding. vomiting and abdominal distension may occur. Diarrhea. fever. 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. disruption of skin integrity with needle pricks and use of intravenous fluids. umbilical sepsis). poor weight gain. aspiration of feeds. this tachycardia can present up to 24 hours before the onset of other signs. bulging fontanelle and seizures. The onset of symptoms is usually delayed beyond 72 hours after birth and the presentation is that of septicemia. gradually or suddenly.  Clinical signs of neonatal sepsis The signs of sepsis are non-specific and include: lethargy. 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. inactive or unresponsive and refuses to suckle. neck retraction. In sick neonates. The infection is often transmitted through the hands of the care-providers. poor feeding. fever. the skin may become tight giving a hide-bound feel (sclerema) and the perfusion . renal failure. Episodes of apneic spells or gasping may be the only manifestation of septicemia. cyanosis. seizures. sclerema. jaundice. A heart rate above 160 can also be an indicator of sepsis. The baby. Late-onset septicemia is caused by the organisms thriving in the external environment of the home or the hospital. a blank look. who had been active and sucking well. poor perfusion. Hypothermia is a common manifestation of sepsis. whilst fever is infrequent. high pitched cry. superficial infections (pyoderma. tachypnea.

No spontaneous movement 3. blank look. Resp rate > 60/minute 7. New York. A critical neonate may develop shock. Cough is unusual. Prolonged capillary refill time 5. The evidence of pneumonia includes tachypnea. Temperature >38 C 4. 1. Cyanosis may appear. Grunting 8. neck retraction or bulging anterior fontanel are highly suggestive of meningitis. seizures. grunting. 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. chest retractions. early cyanosis and apneic spells in addition to inactivity and poor feeding. Meningitis is often silent. Feeding ability reduced 2. However. Findings on auscultation of the chest are nonspecific and non. H/o of convulsions Risk factors: A study performed at Strong Memorial Hospital in Rochester. the clinical picture being dominated by manifestations of associated septicemia. fever.becomes poor (capillary refill time of over 3 seconds). bleeding and renal failure. Lower chest wall in drawing 6. 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 . Cyanosis 9. the appearance of excessive or high-pitched crying.contributory. A large WHO study published in 2003 identified nine clinical features which predict severe bacterial illness in young infants . : Clinical manifestations of neonatal sepsis: Lethargy Refusal to suckle Poor cry Not arousable.

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. 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. joint.000-15. 4. One risk for GBS infection is Preterm rupture of membranes. . increased haptoglobins. DLC: band cells > 20%. Listeria. including Escherichia coli (E.     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. soft tissue. or with a single dose of intramuscular antibiotics. 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. DLC showing increased numbers of polymorphs. Cause: A number of different bacteria.coli). The baby gets the infection from the mother before or during delivery. may cause neonatal sepsis. 2.000/mm3 absolute band count ≤ 1. Early-onset neonatal sepsis most often appears within 24 hours of birth. bone. and are felt to be safe for discharge home without antibiotic treatment. 3. micro ESR (Erythrocyte Sedimentation Rate) titer > 55mm. and certain strains of streptococcus. or ear infection WBC count 5.500/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. but will still require close outpatient follow-up.

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

administered parenterally throughout.or more positive tests as given below: 1.) Of course.(This is the main rationale for using ampicillin versus other beta-lactams. while GM-CSF corrects neutropenia if present. Neutropenia (ANC <1800/cmm) 3. At a small hospital. Although uncommon. Exams and Tests: Laboratory tests can help diagnose neonatal sepsis and identify the bacteria that is causing the infection. CRP +ve If possible. Leukopenia (TLC <5000/cmm) 2. 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. in neonates. sepsis is difficult to diagnose clinically. neonates are also vulnerable to other common pathogens that can cause meningitis and bacteremia such as Streptococcus pneumoniae and Neisseria meningitidis. They may be relatively asymptomatic until hemodynamic and respiratory collapse is imminent.) The organisms which are targeted are species that predominate in the female genitourinary tract and to which neonates are especially vulnerable to. so. they are frequently treated with antibiotics empirically until cultures are sufficiently proven to be negative. if anaerobic species are suspected (such as in cases where necrotizing enterocolitis or intestinal perforation is a concern.2) 4. however a recent study found that. Granulocyte-macrophage colony stimulating factor (GM-CSF) is often used in neonatal sepsis. and Listeria monocytogenes . one may only depend on the CSF cells. Immature neutrophil to total neutrophil (I/T) ratio (> 0. Escherichia coli. Treatment: Note that. . Micro ESR (> 15mm 1st hour) 5. 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. specifically Group B Streptococcus. 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. clindamycin is often added. if there is even a remote suspicion of sepsis. a chest x-ray will be taken. In addition to fluid resuscitation and supportive care. If the baby has a cough or problems breathing. 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.

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

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

IM IV.I. antibiotic sensitivity pattern of organisms responsible for nursery infection should be known and the antibiotic therapy should be started accordingly.5 mg/kg/dose 7.5 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.IM 8 hrly 8 hrly 8 hrly IV IV. 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. In nosocomial sepsis. Klebsiella) should be covered using aminoglycoside (gentamicin or amikacin) and a third . Usually staphylococci and Gram negative bacilli (Pseudomonas. first line of antibiotics may comprise of cloxacillin 100 mg per kg per day and an aminoglycoside (gentamicin or amikacin).

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 12 hrly 8 hrly IV mg/kg/ dose 3 weeks 3 weeks 3 weeks 3 weeks .5 mg/ 12 hrly 8 hrly IV kg/dose Inj 50 12 hrly 8 hrly IV Cefotaxi mg/kg/ me and dose 2.II.

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

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

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

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