NEONATOLOGY DIVISION

Department of Child Health Medical School

University of Sumatera Utara

Direct Causes of Neonatal Deaths

World Health Organization. State of the Worlds Newborns 2001

Infections 32%
Asphyxia 29%
Complications of prematurity 24%
Congenital anomalies 10%
Other 5%

NEONATAL SEPSIS
DEFENITION
Neonatal sepsis is a clinical
syndrome
Of sistemic illness accompanied by
bacteremia occuring in the first month
of life

PATHOPHYSIOLOGY
1.

Early-onset disease
Present in the first 5-7 days of life
Acquired the organism during the
intrapartum period from the maternal
genital tract.
Usually vertical transmission from
mother
Treponemes, viruses, Listeria, Candida

PATHOPHYSIOLOGY
2. Late-onset disease
Onset first week of life
History of obsteric complications
Horizontal transmission
Predilection for central nervous
system

Pathogens in Late Onset Sepsis

in VLBW Neonates
NICHD Neonatal Research Network Experience (Pediatrics 2002)

Organism
Gram positive organisms
Staphylococcus- coagulase negative
Staphylococcus aureus
Group B Streptococcus

%
70.2
47.9
7.8
2.3

Gram negative organisms

E.coli
Klebsiella
Pseudomonas
Enterobacter

17.6
4.9
4.0
2.7
2.5

Fungi
Candida albicans
Candida parapsilosis

12.2
5.8
4.1

PATHOPHYSIOLOGY
3. Nosocomial sepsis
Occurs in high-risk newborn infant
Invasive monitoring used in NICU
Breaks in the natural barrier function of
the skin and intestine
4. Causative organism
Most common group B strptococci (GBS)

RISK FACTOR
1.
2.
3.
4.

5.

Prematurity and low birth weight

Rupture of membranes: > 18 h
Maternal peripartum fever (>380C) or
infection.
Amniotic fluid problems: meconiumstained or foul smelling, cloudy amniotic
fluid
Resuscitation at birth

RISK FACTOR
6. Multiple gestation
7. Invasive procedures
8. Infant with galactosemia
9. Iron therapy: enhances the growth of
many organism

CLINICAL PRESENTATION
Temperature irregularity: hypo or
hyperthermia
2. Change in behavior: lethargy, irritability,
or change in tone.
3. Skin: poor peripheral perfusion,
cyanosis, mottling, pallor, petechiae,
rashes, sclerema, or jaundice.
1.

Pseudomonas sepsis with DIC

Invasive Candidiasis

CLINICAL PRESENTATION
4. Feeding problem: feeding intolerance,
vomiting, diarrhea, abdominal distention.
5. Cardiopulmonary: tachypnea,
respiratory distress, apnea, tachycardia,
hypotention.
6. Metabolic: hypo or hyperglycemia or
metabolic acidosis.

DIAGNOSIS
1.

Laboratory studies
Cultures: blood and body fluids
Grams stain of various fluids
Adjunctive laboratory tests: WBC count with
differential, platelet count, acute phase
reactant (CRP, IL-1, IL-6, IL-8, and TNF),
surface neutrophil CD11.
Miscellaneous tests: bilirubin, glucose,
sodium

Lumbar Puncture

Possibility

of meningitis 1-10%
Not all infants with meningitis
will have specific symptoms
15%

of babies with meningitis will

have negative blood culture

Abnormal white blood cell count

Total

WBC count < 5000 /L, > 25.000/L

Total neutrophil count: <1000/L
Immature to total neutrophil ratio > 0.2
Immature to mature neutrophil ratio > 0.2
bandform
neutrophil

C- Reactive Protein
Acute

phase reactant: synthesized in 6 to hours

Normal: < 1.6 mg/ dl on day 1, then < 1.0 mg/ dl
Falsely elevated with asphyxia, meconium
aspiration, PROM
May not be positive early (only 60% sensitivity)
Repeated tests more useful (up to 84%
sensitivity)
Negative Predictive value: 90%

DIAGNOSIS
2. Radiologic studies
Chest x-ray
Urinary tract imaging
3. Other studies: examination of the
placenta

Chest X Ray

Group

B streptococcal sepsis:
diffuse ground glass opacity
indistinguishable from HMD
Persistent focal parenchymal lung
findings

Group B Strep
Pneumonia

Treatment of Neonatal Sepsis

Specific
Antibiotics: Ampicillin +
Aminoglycoside (gentamicin)
In nosocomial sepsis, staphylococcal
coverage with Vancomycin +
aminoglycoside or 3th generation of
cephalosporin.

Treatment of Neonatal Sepsis

Supportive care
Temperature
Cardiorespiratory
Hematological
- DIC: FFP, Vit K, exchange transfusion
- Neutropenia: recombinant human
granulocyte colony-stimulating factor (rhG
CSF) or recombinant human granulocyte
macrofag colony-stimulating factor

CNS: seizure controle

Metabolic: monitor and treat hypo or
hyperglycemia and metabolic acidosis.

Reduction of Nosocomial Infection

Handwashing
Early

feeding
Maternal breast milk
Intravenous immunoglobulin
Decrease use of broad spectrum
antibiotics
Decrease use of H2 receptor blockers

Prevention of Sepsis