NEONATAL SEPSIS

In common clinical usage, neonatal sepsis specifically refers to the presence of a bacterial blood (BSI) (such as meningitis, pneumonia, pyelonephritis, or gastroenteritis) in the setting of fever. 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. It is difficult to clinically exclude sepsis in newborns less than 90 days old that have fever (defined as a temperature > 38C (100.4F). Except in the case of obvious acute viral bronchiolitis, the current practice in newborns less than 30 days old is to perform a complete workup including complete blood count with differential, blood culture, urinalysis, urine culture, and cerebrospinal fluid(CSF) studies and CSF culture, admit the newborn to the hospital, and treat empirically for serious bacterial infection for at least 48 hours until cultures are demonstrated to show no growth. 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. One such attempt is the Rochester criteria.

RISK FACTORS
A study performed at Strong Memorial Hospital in Rochester, New York, showed that infants 60 days old meeting the following criteria were at lowrisk for having a serious bacterial illness generally well-appearing
previously healthy 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, bone, joint, or ear infection WBC count 5,000-15,000/mm3 absolute band count 1,500/mm3 urine WBC count 10 per high power field (hpf) stool WBC count 5 per high power field (hpf) only in infants with diarrhea

DIAGNOSIS
Neonatal sepsis screening: 1. DLC showing increased numbers of polymorphs. 2. DLC: band cells > 20%. 3. increased haptoglobins. 4. micro ESR (Erythrocyte Sedimentation Rate) titer > 55mm. 5. gastric aspirate showing > 5 polymorphs per high power field. 6. newborn CSF (Cerebrospinal Fluid) screen: showing increased cells and proteins. 7. suggestive history of chorioamnionitis, PROM (Premature Rupture Of Membranes), etc.

Causes, incidence, and risk factors

A number of different bacteria, including Escherichia coli (E.coli), Listeria, and certain strains of streptococcus, may cause neonatal sepsis. Early-onset neonatal sepsis most often appears within 24 hours of birth. The baby gets the infection from the mother before or during delivery. The following increases an infant's risk of early-onset sepsis: Group B streptococcus (group b strep) infection during pregnancy Preterm delivery Rupture of membranes (placenta tissue) that lasts longer than 24 hours Infection of the placenta tissues and amniotic fluid (chorioamnionitis)

Babies with late-onset neonatal sepsis get infected after delivery. 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

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)

Signs and tests

Laboratory tests can help diagnose neonatal sepsis and identify the bacteria that is causing the infection. 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. If the baby has a cough or problems breathing, a chest x-ray will be taken. Urine culture tests are done in babies older than several days.

TREATMENT
Note that, in neonates, sepsis is difficult to diagnose clinically. They may be relatively asymptomatic until hemodynamic and respiratory collapse is imminent, so, if there is even a remote suspicion of sepsis, they are

frequently treated with antibiotics empirically until cultures are sufficiently proven to be negative. In addition to fluid resuscitation and supportive care, a common antibiotic regimen in infants with suspected sepsis is a betalactam antibiotic (usually ampicillin) in combination with an aminoglycoside (usually gentamicin) or a thirdgeneration cephalosporin (usually cefotaximeceftriaxone is generally avoided in neonates due to the theoretical risk of kernicterus.) The organisms which are targeted are species that predominate in the female genitourinary tract and to which neonates are especially vulnerable to, specifically Group B Streptococcus, Escherichia coli, and Listeria monocytogenes (This is the main rationale for using ampicillin versus other beta-lactams.) Of course, neonates are also vulnerable to other common pathogens that can cause meningitis and bacteremia such asStreptococcus pneumoniae and Neisseria meningitidis. Although uncommon, if anaerobic species are suspected (such as in cases wherenecrotizing enterocolitis or intestinal perforation is a concern, clindamycin is often added. Granulocyte-macrophage colony stimulating factor (GM-CSF) is often used in neonatal sepsis, however a recent study found that, while GM-CSF corrects neutropenia if present, it has no effect on reducing sepsis or improving survival.

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN RELATED LEARNING EXPERIENCE

Submitted by: Leana Rae B. Siel BSN 4-C

Submitted to: Mr. Andrew Francisco, RN Clinical Instructor

July 8, 2011