NEONATAL SEPSIS

Ekawaty Lutfia Haksari

Perinatology, Department of Child Health Gadjah Mada
University
Trends in child mortality among those younger than 5 years and in first 28days of life
1965-2015
(Lawn et al. 4 million neonatal deaths:When?Where?Why?Lancet 2005;365:891-900)
 29%
Asphyxia
LBW+prematurity
Infections
5%
Congenital anomaly

24% Others
10%

32%

Worldwide causes of neonatal mortality

Save the Children. Saving Newborn Lives. Washington, 2000
 NEONATAL SEPSIS
• Systemic infection
important cause
morbidity & mortality

• Laboratory, clinical diagnose

– difficult
 leading to delayed treatment
 ONSET OF NEONATAL SEPSIS
• Early onset sepsis
- Onset 0-72 hours of age
- Acquired around birth
- Usually vertical transmission - mother
• Late onset sepsis
- Onset >72 hours age
- Acquired environtment
- Hospital acquired or nosocomial infection
 Risk factors –
Late onset neonatal sepsis
• Prematurity/ low birth weight
• In hospital
• Invasive procedures: ventolator, iv lines,
central lines, urine catheter, chest tube
• Contact with infectious disease- doctors,
nurses, babies with with infections, siblings
• Not fed maternal breast milk
 CLINICAL DIAGNOSIS
o Early sign very subtle, non specific
 very quickly to late sign  death

o Anticipate possible severe infection

carefull examine
observe them – slight changes
 early diagnosis, T/
• Algorithms - symptoms/signs
 health workers
to identify neonatal sepsis
 referral/ home treatment

(WHO, 2002)
• Newborn has not been well since
birth

• Well infant
 1 or > signs neonatal sepsis
poor feeding + sucking
 SIGNS OF INFECTION (WHO, 2002)
Early signs Late signs Local/specific sign
Not able to feed Breathing Diarrhoea
/suck, after difficulties Abdominal distension
fedding normally Umbilical redness
Lethargy Pus draining-eyes
Abnormal body Severe lethargy movement of limb
temp Unconciousness Crying-limb is
Seizure touch/moved
Apnea Swelling,warmth,
Jaundice redness- limb/joint
Sclerema Bulging fontanelle
Bleeding Opisthotonus
Possible infection (Kosim, 2004)

A B
Breathing difficulties Tremor
Seizure Lethargy
Unconciousness Weak
Abnormal body Irritability
temperature (sepsis) Onzet day 4 (sepsis)
Delivery problem Poor feeding (sepsis)
(sepsis)
Condition  (sepsis)
 Risk factors of early onset
• Maternal history-uterine infection
PROM > 18 hours
• Birth weight <2000g or
gestation age < 35 weeks
• Signs of infection
 possible severe infection

Kosim, 2004
 Perinasia 1991
POSSIBLE SEPSIS

• Clinically sepsis
at least 1 sign is found
in 4 out of 6 group categories

• Risk factors

Surjono, 2004
 Perinasia konsensus 1991

Clinically sepsis
at least 1 sign is found
in 4 out of 6 group categories:
(1) General condition
(2) Gastrointestinal system
(3) Respiratory system
(4) cardiovascular system
(5) central nervous system
(6) hematologic system
(1) General condition
not doing well, poor feeding,
temperature instability, sclerema

(2) Gastrointestinal system

abdominal distention, vomiting, diarrhea,
hepatomegaly

(3) Respiratory system

apnea, dyspnea, tachypnea, retraction,
flaring, grunting, cyanosis
 (4) Cardiovascular system
tachycardia, bradycardia, poor perfussion

(5) Central nervous system

irritability, lethargy, tremor, seizure

(6) Hematologic system

jaundice, splenomegaly, pallor,
petechiae, bleeding, leucopenia,
ratio immature/mature neutrophil (I/T>0,2),
thrombocytopenia, toxic granulation
 CLINICALLY SEPSIS (cont)

Not doing well

Poor feeding
Lethargy
Respiratory problem

Hypothermia > hyperthermia

(Yu & Monintja, 1997)

 Diagnosis (cont)

• C-reactive protein (CRP)

• Chest X-Ray
• Gold standard
• Culture – body fluid: blood, urine, stools,
endotracheal aspirates, cerebrospinal fluid
(CSF), pleural or pus
 TREATMENT
• Specific:
Antibiotics
- Ampicillin and Gentamicin
- Cephalosporin
• Supportive care
- Temperature
- Cardiorespiratory
- Hematological
- Gastrointestinal
- Immunological ?
 Antibiotic resistance pattern in
developing countries
(from Vergnano S, et al. Arch Dis Child Fetal Neonatal Ed 2005)

Klebsiella spp E.coli

Ampicillin 65 – 100% 69 – 100%

Gentamicin 16 – 85% 30- 93%

Amikacin 0 – 74% 0 – 67%

Cefotaxime 0 – 86% 0 – 75%

Imipenem 0 – 6% 0%
 Supportive Care
• Temperature support- hypothermia
• GI support - vomiting, ileus
• Cardiorespiratory support - hypoxia, apnea, ARDS,
hypotension, shock
• Hematological support: anemia, thrombocytopenia,
DIC
• Neurological support- seizures
 SUGGESTIONS
TO PREVENT NEONATAL SEPSIS

• Treat mother’s infections - pregnancy

• Use clean delivery practices -labor and birth
• Use infection prevention steps
– labor,birth and post natal care
• Treat a mother with antibiotics -labor
- she has the sign of infection /
prolonged rupture membrane >18hours
 suggestions

• Wash the hands before and after

handling each newborn
• Rooming in – normal newborn
• Do not bring the baby into contact with
sick people
• Isolate a sick newborn
from healthy ones
 suggestions

• Teach the mother & family

- to keep the baby away
from sick people

- to use infection prevention steps,

especially hand washing
 Human milk
• Enteral feeding - human milk
is generally regarded as beneficial

• Breastfeed the newborn

exclusively

(Kramer, 2002; Beck, 2004)

 HUMAN MILK (cont)

• NICU:
 incidence of neonatal infection
(el-Mohandes, 1997; Tysson, 1997; Xanthou,1998; Hanson, 2002)

• Early full enteral feeding significantly 

the risk of late onset of septichaemia
- extremely premature infant
(Ronnestad, 2005)
 LOCALIZED INFECTIONS
• Umbilical cord:
uncovered, clean and dry
• Skin infection
• Eye infection
• Oral trush

(WHO 2002, Kosim 2004, Beck 2004)

 PREVENTION
OF NOSOCOMIAL INFECTION

• The lay out & organisation -

the neonatal unit may have
an important effect
on infection control practices
• Hand washing is a cornerstone of
infection control