Infections of the Newborn:

Evaluation and Management

 Menu

Background statistics
Terminology
Why babies are more vulnerable
Risk factors
Clinical signs
Screening
Workups
Treatment
Aftermath
Prevention
Future Trends
Specific Clinical Entities
 Background Statistics

Neonatal literature says:

– Actual infection rate 1-8/1000 newborns
– LBW infection rate 1-2/100 newborns
– 5 infants die from neonatal infection every
minute
– 4-5 (10%) deaths are due directly to infection
but mortality as high as 25%
– Romania – poorly control and not exactly
report of the infections
 Terminology(1)
Bacteriemia-presence of viable bacteria in the
circulating blood confirmed by culture

Sepsis-clinical suspicion of infection and evidence

of systemic response to infection (tachycardia,
tachypnea, hyperthermia, or hypothermia)

Sepsis syndrome-sepsis plus evidence of altered

organ perfusion with at least one of the following:
acute changes in mental status, oliguria, elevated
blood lactate and hipoxemia
 Terminology (2)
Septic shock-Sepsis syndrome with
hypotension that is responsive to IV fluids or
pharmacologic intervention

Refractory septic shock-sepsis syndrome with

hypotension that last for more than 1hour and
does not respond to IV fluids or pharmacologic
intervention and requires vasopressor support

Multiorgan failure-any combination of DIC,

ARDS, acute renal failure, hepatobiliary
dysfunction, and CNS dysfunctions
 Historical Changes in
Predominant Infectious Agent
Historical Changes in Predominant Infectious
Agent
1930: Group A Strep
1940: E. coli
1950: Staph aureus
1970: Group B Strep
For reasons which remain unclear neonatal
infectons in the developing nations are
dominated by Gram-negative and Gram-
positive organisms, GBS only accounts 1-8%
infants
 Setting Priorities

Newborns are not small children

Competing perceptions of parents,
pediatricians, house-staff, neonatology
Personal responsibility, hands-on
assessments are key
Remember that 10 babies are worked
up for each proven case
 Neonatal Vulnerability

Immature immune system (slow to react,

decreased IgG and complement production,
poor phagocytosis, poor migration)
Unavoidable exposure to pathogenic
organisms in birth canal
Peripartum stress
Invasive procedures
Exposure to highly resistant nosocomial
organisms in NICU
 Risk Factors

PROM (7X)
Prematurity (7X)
Maternal fever, chorioamnioitis (4X)
Perinatal asphyxia (4X)
Male (2-6X)
Recent colonization with GBS, Herpes, etc.
Multiple gestation
Foul smelling is not necessarily a risk factor
- usually anaerobes
 Clinical Signs (1)

Not breathing well

Not feeding well
Not looking well
 Clinical Signs (2)

Respiratory
– dusky spells
– tachypnea - sensitive but nonspecific - but
respiratory distress in term newborn is sepsis
until proven otherwise.
– apnea in normal newborn - septic w/u and
supportive measures should be knee-jerk
reaction, then rule out other causes
– increased A&B episodes (growing premie)
 Clinical Signs (3)

Feeding
– not hungry
– distension
– residuals
– vomiting
– heme-positive stools
– watery or mucousy stools
 Clinical Signs (4)

Appearance
– lethargic
– mottled
– poor perfusion
– temperature instability (not necessarily fever,
but fever is more specific)
– early-onset jaundice
 Clinical Signs (5)

Chance Finding during Routine Tests

– Chemstrip
– Urine dipstick - hemoglobin or sugar
 Clinical Signs (6)

Ominous Late Signs

– Apnea
– Seizures
– Hypotension/Shock
 Clinical Signs (7)

Sepsis-like Presentations:
– Ductal-dependent congenital heart disease
– Inborn errors of metabolism (IEM)
 Screening

CBC with manual diff

– WBC: up, down, or normal
– Left shift helpful but may be delayed
– ANC, I/T ratio
– Unexplained thrombocytopenia
PT/PTT suddenly abnormal
Blood sugar may be high or low - change in pattern
ESR and CRP? Varies from center to center.
CIE or Latex fixation for GBS? Numerous false
positives.
Gastric aspirate or ET aspirate? Not very specific.
 Workup (1)

Workup During First 24 Hours of Life

– Blood culture
– Amniotic fluid or placenta culture if available
– ET aspirate (if intubated)
– Very low yield for LP or urine cultures in first
24 hours unless specific clinical indication
– LP later if blood culture positive or specific
symptoms - but note that 10-15% of babies
with positive LP have negative blood cultures
 Workup (2)

Classic Septic Workup (> 24 hours, < 30

days)
– Blood culture
– LP
– Urine - catherized or suprapubic aspirate
– ET aspirate if intubated
– Surface cultures skin/eye/secretions
– Stool culture if stools abnormal
– CXR
– Abd. X-ray if symptomatic
 Workup (3)

Goals of workup
– Recover organism
– Determine specific antibiotics
– Determine antibiotic doses
– Determine length of therapy
 Treatment (1)

Antibiotics
General supportive measures
IVIG?
GCSF or GMCSF?
 Treatment (2)

General supportive measures

– Assisted ventilation and/or oxygen as needed
– IV and possibly arterial access
– NPO, NG suction if needed
– Volume support, pressors
– Transfuse if indicated
– FFP/cryo if clotting disorders
– Thermal regulation/support
 Treatment (3)

Selection of antibiotics based on:

– Age of onset
– Location (home vs hospital)
– Maternal history
– Known colonization
– Epidemic situations
– etc.
 Treatment (4)
Late Onset (Home)
– GBS
– GramNegatives
– Herpes
Early onset:
– GBS
– E. Coli
– Listeria
– Others less common:
Herpes
Staph aureus
Strep A and D
H. influenza
Klebsiella
Pseudomonas
Enterobacter
 Treatment(5)
Late Onset (Hospital)
– Staph epidermidis
– Gram negatives (often resistant)
Pseudomonas, Klebsiella
Xanthomonas, Enterobacter
Serratia, Acinetobacter, etc.
– Candida (esp. if deep line)
 Treatment (6)

Antibiotic selection
– Early - usually Ampicillin and Gentamicin
– Late onset for premie in hospital - Vancomycin and
Gent or drugs specific to known colonization or
epidemic situations. Third line drugs –Cefotaxime,
Ceftazidime, Imepenam, Piperacillin, etc.
– Abdominal catastrophes - Amp, Gent, Flagyl, etc.
– Late onset home - Amp and Gent if<30 days of age,
Amp and Cefotaxime if greater than 30 days .
– Fungus - Ampho, etc.
 Aftermath(1)

How long to treat?

– Was organism recovered?
– Where was organism found?
– Clinical course?
– Repeat cultures?
Sequelae?
– Few in uncomplicated neonatal sepsis
– Frequent with NEC, gram-negative meningitis
 Aftermath (2)

Negative cultures and course not

consistent with infection: 48-72 hours
of treatment
UTI - 7-10 days treatment, screen for
renal anomalies
Sepsis/NEC - 10-14 days of treatment
Meningitis: 14 days (GBS), 21 days
(gram-negative), recommend ID consult
Osteo - prolonged treatment, get ID
consult
 Prevention

GBS - maternal prophylaxis > 4 hrs PTD

Primary or active herpes - C/S
Chlamydia - maternal prophylaxis
 Future Trends

GCSF or GMCSF
Monoclonal antibodies
Prophylaxis - various modes
 Specific Clinical Entities

Gram negative
GBS
Herpes
Chlamydia
Mycoplasma/Ureaplasma
NEC
Listeriosis
Botulism
 Gram negative
Gastrointestinal tract is a source of
systemic neonatal infections caused by
coliform and other Gram-negative
bacteria
Septic shock is most commonly
associated with Gram-negative
bacterial sepsis
Group B Streptococcus (GBS)

Early onset - acquired from birth canal -

typically pneumonia or mild septic
picture but can be fulminant
pneumonia with septic shock
Late onset - acquired from household
contacts - more indolent presentation
of fever + meningitis, sepsis
Changing clinical picture over 3
decades
Necrotizing Enterocolitis (NEC)

Distension, residuals (particularly bilious residuals),

heme + stools
X-ray picture - pneumotosis intestinalis, portal air,
free air, fixed loops, etc.
Supportive measures: antibiotics, volume +
pressors, TPN, NPO, NG suction, etc.
Surgery indicated if free air, peritonitis, falling WBC
or platelet count
First 24-48 hours is crisis period
Long-term damage is frequent - strictures,
obstruction, malabsorbtion, dysmotility
Separate noon lecture for housestaff on this topic
 Herpes Simplex

Birth to 1 month of age

Transmission: birth canal, postpartum contact,
transplacental (rare)
Risk factors: primary infection > 2ndary infection,
PROM 18 hrs, instrumentation (e.g. scalp monitor),
prematurity
Presentation: Local disease (skin eye mouth),
disseminated disease (only 30% have skin lesions ),
neurologic disease
Diagnosis: Culture
Treatment: Acyclovir
Prognosis: neurological disease 50% mortality,
disseminated 80% mortality
 Chlamydia Trachomatis

Transmission: birth canal. 20-30% lower SES

are carriers, 50% of infants get infected
Risk factors: Colonized mom, PROM,
prematurity
Presentation
– 25-50% conjunctivitis - most common cause
– 5-20% pneumonia - gradual onset at 3-12 weeks,
stacatto cough, tachypnea, rales, usually afebrile
Diagnosis: IFA, ELISA, Giemsa stain, CXR
interstitial
Treatment: Erythromycin
 Ureaplasma/Mycoplasma

Transmission: birth canal, 40-80% carriers

for ureaplasma, 21-50% mycoplasma
Presentation: non-acute pneumonia, ?
meningitis, ? associated with stillbirths and
chronic lung disease
Treatment: Erythromycin for symptomatic
ureaplasma infections, no really good
treatment for mycoplasma (tetracycline is
contraindicated)
 Listeriosis
Infections in newborns has a bimodal
distribution,with early-oset septicemic infection
associated with low birth weight,obstetric
complications and maternal colonisations
Late onset disease tends to occur in infants with
normal birth weight, with meningitis as a
prominent finding, and is frequently associated
with maternal colonisation or obstetric
complications
 Infant Botulism

Typical history is 3-6 week old infant with

history of constipation and poor feeding
progressing to apnea
Endemic in California, Utah, Pennsylvania
Raw honey has been implicated in some
cases
Supportive therapy esp. ventilatory
assistance, IV nutrition
No aminoglycosides!