CHAPTER I

PRELIMINARY

A. Background
Infection is one of the most important causes of morbidity and
mortality newborn baby. Sepsis is associated with mortality rates of 13% - 50%
and the likelihood of strong morbidity in surviving infants. (Fanaroff &
Martin, 1992). Infection in the neonate in our country is still a serious
problem. In Jakarta, especially in RSCM, infection is 10-15% of perinatal
morbidity.
Infection of the neonate is more common in LBW. Infection more
often found in infants born in hospital compared to babies born in outside the
hospital. In this case excluding babies born outside the hospital with septic way.
Neonatal sepsis, neonatal sepsis, and neonatal septicemia are terms which
has been used to describe the systemic response to infections in
infants Newborn. There is little agreement on the use of the term exactly, ie
whether should be limited to bacterial infections, positive blood cultures, or
severity of pain. Now, there is considerable discussion of the exact definition of
sepsis in the literature critical care.
B. Purpose
1. To fulfill the nursing task of the child.
2. To find out the definition of neonatal sepsis.
3. To know the course of the disease from neonatal sepsis so it can raises
nursing issues.
4. To study the asception of neonatal sepsis.
 CHAPTER II
LITERATURE REVIEW

A. Definition
Sepsis is the body's response to infections that spread through the blood
and other tissues. Sepsis occurs in less than 1% of newborns but is the cause of
30% mortality in newborns. Bacterial infections are 5 times more common in
newborns who weigh less than 2.75 kg and twice as often as boys.
In more than 50% of cases, sepsis begins to develop within 6 hours of birth,
but mostly occurs within 72 hours of birth. Newly occurring sepsis within 4 days
or more may be due to nasokomial infection (hospital-acquired infection).
Sepsis is a syndrome characterized by clinical signs and symptoms-
symptoms of severe infection, which can progress to septicemia and septic
shock. (Marilynn E. Doenges, 1999).
1. Sepsis is a common bacterium in the bloodstream. (Donna L. Wong, 2003).
2. Neonatal sepsis neonatal or sepsicemia is defined as a bacterial infection
infant blood flow during the first four weeks of life. (Bobak, 2004).
3. Sepsis is a generalized bacterial infection that usually occurs in the first
month life. (Mary E. Muscari, 2005).
The neonate is particularly vulnerable because of an imperfect immune
response. Number mortality has decreased but the incidence is not. Risk factors
include, among others, prematurity, invasive procedures, steroid use for chronic
lung problems, and nosocomial exposure against pathogens. Antibodies in
efantective colostrum against gramegegative bacteria, therefore, breastfeeding
provides protection benefits against infection.
B. Etiology
The cause of neonate sepsis / sepsis neonatorum is a variety of germs such
as bacteria, viruses, parasites, or fungi. Sepsis in infants is almost always caused
by bacteria.
1. Escherichia koli bacteria
2. Streptococus group B
3. Stophylococus aureus
4. Enterococus
5. Listeria monocytogenes
6. Klepsiella
7. Entererobacter sp
8. Pseudemonas aeruginosa
9. Proteus sp
10. Anaerobic organisms
Streptococcus group B can enter the baby's body during the birth
process. According to the American Centers for Disease Control and Prevention
(CDC), there is at least one bacterium in the vagina or rectum in one of every five
pregnant women, which can contaminate the baby during childbirth. Premature
infants undergoing intensive care are susceptible to sepsis because of their
immature immune system and they usually undergo invasive procedures such as
long-term infusion, insertion of a number of catheters, and breathing through the
hose associated with the ventilator. Organisms that normally live on the surface of
the skin can enter the body then into the bloodstream through the tools as
mentioned above.
Infants aged 3 months to 3 years are at risk of developing disguised
bacteremia, which if not treated immediately, can sometimes lead to
sepsis. Disguised bacteremia means that bacteria have entered the bloodstream,
but there is no obvious source of infection. The most common sign of occult
bacteremia is fever. Almost one-third of all infants of this age range have a fever
for no apparent reason - and studies show that 4% of them end up with bacterial
infections in the blood. Streptococcus pneumoniae (pneumococcus) accounts for
about 85% of all cases of disguised bacteremia in infants aged 3 months to 3 years
Factors affecting the likelihood of infection generally come from three groups:
1. Maternal Factors
a. Socio-economic status of mother, race, and background. Influences the
tendency for infection to occur for a reason that is not fully
known. Mothers with low socio-economic status may have poor nutrition
and densely unhygienic housing. Black babies are more infected than
white babies.
 b. Parity status (multiparous or gravida women over 3) and maternal age
(less than 20 years or more than 30 years
c. Lack of prenatal care.
d. Premature rupture of membranes (KPD)
e. Procedures during labor.
2. Neonatatal Factors
a. Prematurius (infant weight less than 1500 grams), is a major risk factor
for neonatal sepsis. Generally less than months of infant immunity is
lower than in term infants. Immunuglobulin transport through the
placenta mainly occurs in the last half of the third trimester. After birth,
serum immunoglobulin concentrations continue to decline, leading to
severe hypigamaglobulinemia. Skin immaturity also weakens the skin's
defenses.
b. Immune deficiency. Neonates may develop specific IgG deficiency,
especially against streptococcus or Haemophilus influenza. IgG and IgA
do not cross the placenta and are virtually undetectable in cord
blood. Given this, the activity of the complement path is delayed, and C3
and B are not produced in response to lipopolysaccharide. The
combination of immune deficiency and decreased total and specific
antibodies, along with decreased fibronectin, led to a substantial decrease
in opsonization activity.
c. Male and twin pregnancy. The incidence of sepsis in male infants is four
times greater than in female infants.
3. Environmental Factors
a. there is an infant's immune deficiency tends to be easily sick so it often
requires invasive procedures, and requires longer hospitalization
time. The use of the venous / arterial catheter and the parenteral nutrition
catheter is the entry point for microorganisms on the wounded
skin. Babies may also be infected as a result of contaminated equipment.
b. Exposure to certain drugs, such as steroids, may pose a risk to neonates
that exceed the risk of broad-spectrum antibiotics, leading to broad-
spectrum colonization, resulting in multiple resistance.
 c. Sometimes in the treatment room of the epidemic the spread of
microorganisms originating from officers (nosocomial infections), most
often due to hand contact.
d. In breast-fed infants, Lactbacillus and E.colli species are found in the
stool, whereas infants who drink formula are only dominated by E.colli.

Microorganisms or germs that cause infection can reach the neonate

through several ways, namely:
1. In antenatal or before birth.
In the antenatal period of germs from the mother after passing through the
placenta and the umbilicus entering the baby through the fetal blood
circulation. Infectious germs are germs that can penetrate the placenta such as
rubella virus, herpes, sitomegalo, koksaki, hepatitis, influenza,
parotitis. Bacteria that can pass through this pathway, include malaria,
syphilis, and toxoplasma.
2. In the intranatal period or during labor.
Infections during labor occur because of the presence of the vagina and cervix
up to reach the chorion and amnion. As a result, amniotis and chorionitis
occur, then germs through the umbilicus enter the baby's body. Alternatively,
during labor, the infected amniotic fluid is infested by the infant and enters
and enters the digestive tract and respiratory tract, causing infection at the
site. In addition to the above mentioned methods of infection in the fetus may
occur through the baby's skin or other port de entre as the infant passes
through the birth canal contaminated by germs. Some germs that pass through
this birth canal are Herpes genetalis, Candida albican, and N.gonorrea.
3. Postpartum or postpartum infections.
Postnatal infections are commonly caused by nosocomial infections from the
environment outside the uterus (eg through devices: mucous sucker,
endotracheal tube, infusion, nasogastric tube, bottle of drink or
pacifier). Nurses or other professions who take care of the baby can cause
nosocomil infection. Infection may also occur through umbilical lesions
(AsriningS., 2003)
C. Signs and symptoms
Symptoms of sepsis infection in neonates are characterized by:
1. Baby looks lethargic
2. not strong sucking
3. heart rate is slow and body temperature is up and down
4. respiratory disorders
5. seizures
6. jaundice (jaundice)
7. gag
8. diarrhea
9. bloated
D. Risk Factors
1. Early Sepsis
a. Maternal colonization in GBS, fecal infection
b. Malnutrition to the mother
c. Prematurity, LBW
2. Nosocomial Sepsis
a. BBLR-> is associated with immune defenses
b. Total Parenteral Nutrition, feeding through the hose
c. Administration of antibiotics (superinfection and infection of resistant
organisms)

E. Pathophysiology
Neonates are particularly susceptible to infection as a result of low non-
immunity specific (inflammatory) and specific (humoral), such as low
phagocytosis, delays chemotaxic response, minimal or absence of
immunoglobulin A and immunoglobulin M (IgA and IgM), and low levels of
complement.
Sepsis in the neonatal period may be obtained before birth through the
placenta from maternal blood flow or during labor due to ingestion or aspiration
of fluids infected amnion.
 Initial sepsis (less than 3 days) is obtained in the perinatal period, infection
can occurs from direct contact with organisms from the gastrointestinal tract
or maternal genitourinaria. The organism that most often infects is
streptococcus group B (GBS) and escherichia coli, present in the vagina. GBS
appears as a highly virulent microorganism in the neonate, with a high mortality
rate (50%) in infants affected by Haemophilus influenzae and negative
coagulation co-staphylococcus also often seen in early onset of sepsis in BBLSR
infants.
Advanced sepsis (1 to 3 weeks after birth) is primarily nosocomial,
and the invading organisms are usually staphylococci, klebsiella, enterokoki,
and pseudomonas. Staphylococcal coagulation, baiasa is found to be the
cause septicemia in infants BBLR and BBLSR. Bacterial invasion can occur
through such as the umbilical cord, skin, mucous membranes of the eyes, nose,
pharynx, and ears, and internal systems such as respiration, nervous system,
urinary, and gastrointestinal.
Postnatal infections are obtained from cross-contamination with other
infants, personnel, or things in the environment. Bacteria are often found in
water sources, moisturizers, sink pipe, suction machine, most respiration
equipment, and venous catheters and installed arteries used for infusion, blood
sampling, monitoring vital signs. (Donna L. Wong, 2009).
The pathophysiology of sepsis begins with bacterial invasion and systemic
contamination. The release of endotoxin by bacteria causes a change in
myocardial function changes in oxygen uptake and inhibition of mitochondrial
function, and progressive metabolic disorder. In severe and severe sepsis,
complemen cascade causes death and cell damage. The result is a decline tissue
perfusion, metabolic acidosis, and shock, resulting in disseminatedintravascular
coagulation (DIC) and death (Bobak, 2004).
Patients with immune disorders have an increased risk for get serious
nosocomial sepsis. Cardiopulmonary manifestations of sepsis Gram-negative can
be replicated with endotoxin injection or tumor necrosis factor (FNT). FNT
occupational barriers by anti-FNT monoclonal antibodies are greatly
weakened the manifestation of septic shock. When the bacterial cell wall
 components are released in the flow blood, activated cytokines, and may further
lead to more physiological disorders continued either alone or in combination,
bacterial products and cytokines proradang triggers a physiological response to
stop microbial invaders. FNT and other inflammatory mediators increase
vascular permeability, and occurrence vascular tone imbalance, and an
imbalance between perfusion and an increase in metabolic requirements of
tissues.
Shock is defined by systolic pressure below the 5th percentile by age or
defined with cold extremities. Later capillary refill (> 2 seconds) is seen as a
reliable indicator of decreased perfusion peripheral. The peripheral vascular
pressure in septic shock (heat) but becomes very rising in a further shock
(cold). In septic shock use of tissue oxygen exceeds the supply of oxygen. This
imbalance is caused by peripheral vasodilation at first, vasoconstriction in the
later, myocardial depression, hypotension, ventilator insufficiency,
anemia. (Nelson, 1999).
Septicemia suggests the emergence of systemic infection of the blood
caused by rapidly doubling of microorganisms or toxic substances, which
may resulting in enormous psychological changes.Pathogens can be bacteria,
fungi, viruses, and riketsia. The most common cause of septicemia is a gram-
negative organism. If the protection of the body is not effective in
controlling invasion of microorganisms, there may be septic shock, which is
characterized with hemodynamic changes, cellular functional imbalances, and
failures multiple systems. (Marilynn E. Doenges, 1999).
F. Clinical manifestations
1. General: heat, hypothermia, looking unhealthy, lazy drinking, lethargy,
sclerema.
2. Gastrointestinal tract: abdominal distension, anorexia (poor appetite),
vomiting, diarrhea, hepatomegaly.
3. Channels of breath: apneu, dispneu, takipneu, retraction, irregular breath,
moaning, cyanosis.
4. Cardiovascular system: pallor, cyanosis, marmorata cutane, moist skin,
hypotension, tachycardia, bradycardia.
 5. Central nervous system: irritability, tremor, seizures, hyporeflection,
decreased activity- lethargy, coma, increased or decreased tone, abnormal
eye movements, fontanel prominent.
6. Hematology: pallor, ptekie, purpura, bleeding, jaundice.
7. Circulatory system: pallor, cyanosis, cold skin, hypotension, edema, heart rate
irregular. (Kapita Selekta, 2000).
G. SUPPORTING EXAMINATION
1. Microscopic examination and pembiaakan to urine blood samples, if
suspected of a meningitis, then performed lumbar function.
2. When clinical syndrome leads to sepsis, sepsis should be evaluated
thoroughly. These include blood culture, lumbar function, urine analysis and
culture.
a. Leukocytosis (> 34,000 × 10 9 / L)
b. Leukopenia (<4.000x 10 9 / L)
c. Young Netrofil 10%
d. The ratio of immature netrofil (stab) to total (stb + segment) or I / T
ratio> 0.2
e. Thrombocytopenia (<100,000 x 109 / L)
f. CRP> 10mg / dl or 2 SD from normal
Factors on the problem of hematology:
a. Increased capillary vulnerability
b. Increased bleeding tendency (low plasma protrombin level)
c. Deceleration of the development of red blood cells
d. Increased hemolysis
e. Blood loss due to test laboratories are often done
H. MANAGEMENT
1. Given combination of antibiotics Ampicillin group dose 200 mg / kg BW / 24
hr iv (divided into 2 doses for neonates age <7 days, for neonates> 7 days
divided by 3 doses), and Netylmycin (Amino glycoside) dose 7 1/2 mg / kg
BW / day divided by 2 doses use of Netylmycin and other Aminoglycosides
when administered iv should be diluted and delivery time up to 1 hour
slowly).
 2. Septic work up before antibiotics are administered (complete blood, urine,
complete, complete stool, blood culture, cerebrospinal fluid, urine and feces
(above indication), lumbar puncture with cerebrospinal fluid analysis (cell
count, chemistry, Gram stain) chest, CRP quantitative examination).
3. Other examinations depend on indications such as bilirubin examination,
blood sugar, blood gas analysis, abdominal photo, ultrasound head and others.
4. If clinical symptoms and re-examination do not show infection, blood and
CRP tests are normal, and blood culture is negative then antibiotics are
discharged on day 7.
5. If clinical symptoms worsen and / or laboratory results support infection,
CRP remains abnormal, then Cefepim 100 mg / kg / day is given 2 doses or
Meropenem with doses of 30-40 mg / kg BW / day iv and Amikasin at a dose
of 15 mg / kg BB / per day iv im (on special indication). Administration of
antibiotics is continued according to the sensitivity test. Duration of
antibiotics 10-14 days. In the case of meningitis antibiotics at least 21 days.
6. Supportive treatment includes:
Thermoregulation, oxygen therapy / mechanical ventilation, shock therapy,
metabolic correction of acidosis, hypoglycemic / hyperglycemic therapy,
blood transfusion, plasma, platelets, seizure therapy, exchange transfusion.
I. COMPLICATIONS
1. Congenital abnormalities of the heart, lungs, and other organs
2. Severe sepsis: sepsis with hypotension and single organ dysfunction
3. Septic shock: severe sepsis with hypotension \
4. Multiorgan dysfunction syndrome (MODS)
5. Bleeding
6. Fever that occurs in the mother
7. Infections of the uterus or placenta
8. Rupture of membranes early (before 37 weeks of pregnancy)
9. The membranes rupture too quickly during childbirth (18 hours or more
before delivery)
10. The process of birth is long and difficult
J. PREVENTION
1. In the Antenatal period :
Antenatal care includes regular maternal examination, immunization,
treatment of maternal infectious diseases, adequate nutrition, immediate
treatment of conditions that can reduce maternal and fetal health. Refer to the
health center when needed.
2. In the Laboring Period:
Maternal care during labor is done aseptically.
3. In the post-delivery period:
Treat the baby if normal, breastfeed as soon as possible, keep the
environment and equipment clean, sterile umbilical wound care.
 CHAPTER III
COVER

A. Conclusion
Neonatal sepsis neonatal or sepsicemia is defined as bacterial
infection infant blood flow during the first four weeks of life. The cause starts
at antenatal infection, intranatal infections, postnatal infections.
An examination to diagnose sepsis is a complete blood count (HDL),
thrombocyte, blood culture, lumbar puncture and cerebrospinal fluid
sensitivity (CSS), urine culture, chest x-rays are performed when there are
respiratory symptoms.
B. Suggestion
1. An ounce of prevention is worth a pound of cure.
2. Avoid nosocomial infections
 BIBLIOGRAPHY

Arif, mansjoer (2000). Kapita selekta medicine. Jakarta: EGC.

Behrman (2000). Nelson child health science. Jakarta: EGC.
Bobak (2005). Maternity keperawatn textbook. Jakarta: EGC.
Doenges (2000). Nursing care plan; guidelines for planning and documenting
patient care. Jakarta: EGC.
 TABLE OF CONTENTS
TITLE PAGE .......................................................................................................i
PREFACE .................................................................................................. ii
TABLE OF CONTENTS .................................................................................. iii
CHAPTER IP INTRODUCTION .............................................................
1. Understanding .................................................................................................
2. Etiology ...................................................................................................
3.Patofisiologi ..............................................................................................
4. Clinical Manifestations .......................................................................................
5.Advanced Investigation .................................................................................
6.Penatalaksanaan ..........................................................................................
7.Complication ................................................................................................
8. Prevention ................................................................................................