Neonatal Sepsis

 It is the most common cause of neonatal mortality even though they are preventable and treatable.
 Infection can occur in, intra-uterine life, or during delivery, or neonatal period.
 When pathogenic bacteria gains access into the blood stream, they may cause an overwhelming
infection like septicemia, localized infections, pneumonia or meningitis.
 Sepsis is a serious illness and can quickly cause death (a clinical syndrome of bacteremia with
systemic signs and symptoms of infection).

Incidence:

According to The World Bank (2015), the neonatal mortality rate of Nepal is 22 per thousand live births.
It was 38.6 per 1000 live birth in 2001 AD.

About 30-50 % of the total neonatal death in developing countries occurs due to neonatal sepsis. Among
which about 64% are male and 36% female.

[Kathmandu University Medical Journal (2003) Vol.1, No. 2, 117-120

Clinical Profile of Neonatal Sepsis]

Etiology:

The most common bacteria leading to neonatal sepsis are E. coli, Staphylococcus aureus, Group
B Streptococcus and klebsiella species. Other various types of bacteria, virus and fungi may also cause
neonatal sepsis.

Manifestations of neonatal sepsis:

1. Abdomen
 Peritonitis
 Gastro-enteritis
 Omphalitis
 Hepatitis
2. Brain
 Meningitis
3. Cardio-vascular
 Pericarditis
 Endocarditis
 Myocarditis
4. Ocular
 Ophthalmic neonatrum
 Conjunctivitis
5. Skeletal
 Arthritis
 Osteomyelitis
6. Respiratory tract

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  Pneumonia
 Empyema
7. Skin
 Pemphigus neonatrum
 Fasciitis
 Impetigo
8. Others
 UTI
 Neonatal tetanus

Risk factors:

i. Maternal history of uterine infection or fever anytime from the onset of labour to 3 days after
birth or rupture of membranes for more than 18 hours before birth
ii. Prolonged labour
iii. Unclean delivery
iv. Complicated or different labor
v. New onset illness:
 Human contact
 Cross infection
 Contaminated article
 Invasive procedure
 Infected environment

Newborn risk factors:

i. Low birth weight

ii. Fetal distress
iii. Prolong hospitalization
iv. Preterm
v. Instrumentation of newborn Eg: intubation catheter
vi. Birth asphyxia resuscitation
vii. Congenital anomalies
viii. Inadequate asepsis during invasive procedure
ix. Male are more prone
x. Lack of breastfeeding

Type:
Early Sepsis
 Usually seen within 72 hours
 Early onset sepsis manifests frequently as pneumonia and less commonly as septicemia or
meningitis
 The predisposing factors are low birth weight, prolonged rupture of membrane, foul smelling liquor,
multiple per vaginal examination, maternal fever, difficult or prolonged labor, meconium aspiration

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Late Sepsis
 Seen after 72 hours
 Caused by organism thriving in the external environment
 Infection is often transmitted through caregiver
 The predisposing factors are low birth weight, lack of breastfeeding, poor cord care, superficial
infection, disruption of skin integrity with needle prick or cannula, etc.

Clinical Manifestation:

The newborns may have non-specific features such as:

1. In eyes:
 Redness and swelling
 Discharge may be watery, purulent or mucopurulent
 Eyelids may be sticky or markedly swollen
2. Irritable and always crying
3. Alteration in feeding pattern- unable to suck or sucks poorly
4. Rigid muscles- locked jaw, rigid abdomen, neck and trunk
5. Vomiting all feeding
6. Diarrhoea with or without mucus and blood
7. Breathing too slow or apnea
8. Lethargy, difficult to arouse
9. Hypothermia or hyperthermia
10. Respiratory rate >60 breath/ min, lower chest indrawing, nasal flaring, grunting
11. Abdominal distention
12. Bulging or sunken fontanelle
13. Drowsiness
14. Convulsion
15. Jaundice
16. Bleeding from any site
17. Umbilical redness and swelling extending to surrounding skin
18. Discharge from the umbilical site
19. Superficial blisters may be present on any part of the skin.

Diagnostic investigations:

1. History taking
2. Physical examination
3. Culture- blood, urine, discharge from ear, nose
4. Total Leucocyte Count <5000/mm
5. Differential Count
6. Lumbar Puncture and CSF assessment
7. C-reactive protein positive
8. Chest X-ray
9. Maternal or neonatal serology

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Treatment and Management:

1. Initial management (in community, PHC facility):

Stabilize the newborn baby before referral
 Counsel the mother on baby’s condition and arrange for referral and transport of newborn.
 Give an emergency treatment with consent.
 Keep the baby warm (Kangaroo Mother Care can be done).
 If the baby is alert, encourage breastfeeding if possible or cup/ spoon feeding of expressed breast
milk.
 If serious infection, give first dose of antibiotic before referral following referral guidelines.

Arrange transport and notify referral center

 Send mother and baby together so breastfeeding will be continued.
 Encourage only 1 or 2 support people to go (like husband).
 If possible, notify the referral center about baby’s condition and estimated time of arrival.
 Care during transport.
 Health workers to accompany, if possible.
 Keep the baby warm.
 If baby alert, continue to give breast milk.

2. Management in hospital:
 Institute prompt treatment
 Antibiotic therapy:
S.N. Clinical situation Septicemia and Meningitis
Pneumonia
1. First line Ampicillin or Penicillin Cefotaxime
Community acquired, resistant strains and Gentamycin
unlikely
2. Second line Ampicillin or Cloxacillin Add Cefotaxime
Hospital acquired or when there is low to and Amikacin
moderate probability of resistant strains
3. Third line Cefotaxime and
Hospital acquired sepsis or when there is Amikacin
high probability of resistant strains
 If the baby’s condition is improving after 3 days of treatment with antibiotic, and if the culture is
negative then discontinue antibiotics after 5 days of treatment with antibiotic; if the culture is
positive then continue antibiotic upto 10 days of treatment.
 If the baby’s condition is not improving after 3 days of treatment with antibiotic, and if the
culture is positive then change the antibiotic according to the result of culture and sensitivity, and
give antibiotics for 7 days after signs of improvement are first noted
 If culture is not possible or organism cannot be identified, discontinue ampicillin. Give cefotaxime
IV according to the baby age, in addition to gentamycin, for 7 days after signs of improvement
are first noted.

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  After 12 hours of treatment with antibiotic or when the baby’s condition begins to improve,
allow the baby to breastfeed. If the baby cannot breastfeed, give expressed breast milk using an
alternative feeding method.

3. Supportive Care:
Ensure adequate warmth:
 Provide warmth, ensure consistent normal temperature.
 Kangaroo Mother Care is a useful modality especially in case of low birth weight babies.

Adequate breathing pattern:

 Start oxygen therapy if cyanosed.
 Bag and mask ventilation with oxygen is to be started if breathing is inadequate.

Adequate nutrition:
 Exclusive breastfeeding is to be initiated and continued, or spoon feeding/ cup feeding of
expressed breast milk is to be done.
 Ensure optimal nutrition.
 Parenteral nutrition or NG feeding is to be given if the newborn is very sick (inactive).
 If hypoglycemia, then infuse 10% glucose 2ml/kg. Do not use glucose bolus.

Adequate hydration:
 Start IV infusion as per requirement to maintain fluid and electrolyte balance and tissue
perfusion.
 Monitor intake and output of the newborn.

Monitor blood test results and take appropriate action:

 Administer vitamin K 1mg IM, as it is a coagulant drug and prevents bleeding excessively.
 Take a blood sample, and send it to lab for culture and sensitivity, and other lab tests.
 Blood transfusion is to be done if blood haemoglobin is <10 gm/dl.
 Measure haemoglobin twice weekly during hospitalization and again at discharge.

Diagnosis:
 Identify the disease condition and treat as per that disease’s treatment protocol.

Monitor condition of the newborn baby:

 Assess the baby’s condition every 6 hourly.
 Observe the baby for 24 hours after discontinuation of antibiotics;
 If the baby is feeding well and there are no other problems requiring hospitalization,
discharge the baby.
 If signs of sepsis recur, repeat the culture and sensitivity, and treat with additional
antibiotics as necessary.

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 Family Support:
 Counsel and educate mother and family- gently explain findings, diagnosis and plan of care using
good communication and counseling skills

Preventive Measures:

1. Prevention and management of prenatal infection of mother

2. Treatment of mother’s infection during pregnancy
3. Use clean delivery practices during labor and birth. Five clean practices of delivery
4. Use infection prevention steps during labor, birth and postnatal care
5. Treat a mother with antibiotics during labour if she has signs of infection or prolonged rupture of
membrane >18 hours
6. Treat a mother with antibiotics after birth if the mother had fever during labour
7. Prophylaxis antibiotic for high risk babies
8. Handwashing before handling the baby
9. Hygiene of the baby
10. Clean environment
11. Visitor restriction in postnatal unit
12. Exclusive breastfeeding
13. Avoid unnecessary invasive procedure
14. Aseptic technique in invasive procedure
15. Teach the mother and family to keep the baby away from sick people
16. Separate accommodation (isolation) of infected babies
17. Keep the umbilical cord uncovered, clean and dry. Do not put anything on cord.
18. Teach the mother and family to use infection prevention steps (handwashing, use of clean clothing,
the utensils are to be steamed or boiled that are to be used by the baby like spoon, cups, etc)

REFERENCES

Essential Newborn Care (Training Package for PCL Nursing Program) Participant’s Manual- (Revised
2014).CTEVT and Save The Children
Ghai,O.P.(2009).Ghai Essential Paediatrics,(7thed.).CBS publishers and distributors
Nelson(2008).Text Book of Paediatrics Volume1 part1-XVI,(18thed.).Elsevier Publication
Prasai,D.S., and Bhattarai,S.G.(2012).Midwifery Nursing Part-III,(1sted.).Medhavi Publication
Shrestha,T.(2012).Essential Child Health Nursing,(1sted.).Medhavi Publication
Tuitui,R.(2009).Manual of Midwifery Nursing III,(6thed.). VidyarthiPustakBhandar