Kelli pirruccello, DNP, APRN, SEPSIS IN THE NEONATE NNP-BC

OBJECTIVES

• Describe different types of infection in the neonate. • List symptoms that may be seen in . • Identify the clinical signs and laboratory data that encompass a sepsis evaluation. • Discuss management modalities for sepsis in the neonate. • Discuss the latest CDC algorithm for secondary prevention of EOGBS disease among newborns.

DEFINITION

Generalized bacterial infection that has been documented by a positive blood culture during the first month of life, in an infant who is also clinically ill. • Sepsis = The presence of pathogens &/or their toxins in the bloodstream • Infection = Pathogens in or on the body • Pneumonia • UTI • Meningitis • Omphalitis

1 EARLY VS. LATE-ONSET SEPSIS

Early Onset Sepsis Late Onset Sepsis (infection occurring in the first 5-7 days of (infection occurring after 5-7 days of age) life)

Exposure to bacteria can occur: Usually due to:

• Before delivery due to infected • Nosocomial infection, organisms amniotic fluid or occasionally following acquired from the environment maternal sepsis • Coagulase negative Staphylococci • During delivery when contact with are the most common causative organisms in the vagina can occur organisms

• After delivery following exposure to • VLBW infants with indwelling organisms in the infants environment catheters, central lines, chest drains etc are at particular risk

THE PATHOGENS

•Gram positive bacteria •Staphylococcus aureus (MRSA or MSSA) •Streptococci •Listeria monocytogenes •Group B Strep (GBS) •Gram negative bacteria •E coli •Enterobacter species •Haemophilis influenza

VIRAL INFECTIONS

Herpes Simplex Virus- type 1 or type 2 may both be present within the maternal genital tract. Severe more likely with primary infection late in gestation. Symptoms present between 3-14 days, including skin vesicles, poor feeding, lethargy, fever, shock and seizures Cytomegalovirus- commonly causes IUGR, hearing loss, brain calcifications, and thrombocytopenia, vision changes Enterovirus- commonly presents with recent maternal history of vomiting and diarrhea. Degree of infant illness varies from mild to severe Toxoplasmosis- spread through infected cat feces, usually causes or progressive eye damage Rubella- Most common among unvaccinated mothers. Can cause severe congenital abnormalities when infection occurs early in Hepatitis- Infant’s of hepatitis B positive mothers should received both vaccine and immune globulin by 12 hours of life HIV- significantly reduced risk of transmission with prenatal and postnatal antiviral therapy

2 IMMUNITY

Impaired cellular responses in both preterm and term infants • no. & inefficiency of WBCs •Premies < 2kg have less bacteriocidal capacity than full-term infants • antibody production • killing power in “stressed” infants • levels of complement, fibronectin & cytokines • IgA, IgM; and IgG (in premature infants)

MORTALITY RATE

•Early Onset = 3-40% •Late Onset = 2-20% •Of affected newborns, about 30% will spread to meningitis with increased complications and long-term effects

*risk of death, therefore we over treat!!

PREDISPOSING RISK FACTORS

•Premature Labor •PROM (prolonged or premature) • •Maternal Fever •Maternal Infection (eg. UTI) •Prolonged or Difficult Labor •Low Birth Weight Infant •Maternal Antibody Status/Vaginal Flora

3 CHORIOAMNIONITIS INTRA-AMNIOTIC INFECTION (IAI)

Definition •Maternal fever >100.4 and 2 or more of: •Fetal tachycardia •Uterine tenderness •Foul discharge •Leukocytosis •Neonatal sepsis occurs in ~3-20% of infants •Major cause of GBS prophylaxis failure

GROUP BETA STREP (GBS)

•10-30% of women are colonized with GBS in their genital tract •Screening done at 35-37 weeks for vaginal and rectal GBS •Intrapartum prophylactic antibiotics should be given to all mothers identified as GBS carriers, mothers with unknown GBS status, mothers with previous infants with GBS sepsis •Antibiotic choices include penicillin G, cefazolin, clindamycin and vancomycin •Symptoms of GBS- temperature instability, respiratory distress, lethargy, poor perfusion, tachycardia, hypotension, hypoglycemia, metabolic acidosis

CLINICAL MANIFESTATIONS

•No single set of criteria that is reliable •“Non-Specific” the baby is just “not doing well” •Often subtle changes in color, tone, activity & feeding •Temp Instability •Abdominal distension, apnea & jaundice are often said to be early signs

4 CLINICAL MANIFESTATIONS CNS

•Lethargy •Full fontanel •Irritability •Abnormal Eye Movements •Jitteriness • •Tremors •Hypertonia •Seizures •Coma

CLINICAL MANIFESTATIONS RESPIRATORY

•Apnea •Retractions •Tachypnea •Nasal Flaring •Cyanosis •With signs of shock, consider GBS •Grunting •Irregular Respirations

CLINICAL MANIFESTATIONS GI

•Poor feeding •Hepatosplenomegaly •Vomiting •Edema of Abdominal Wall •Diarrhea •Abdominal Distension

5 CLINICAL MANIFESTATIONS SKIN

Bacterial Viral •Rashes •Jaundice •Pustules •Purpura •Omphalitis •Sclerema •Purpura •Vesicular rash •Sclerema

CLINICAL MANIFESTATIONS CV

•Pallor •Tachycardia •Gray •Arrythmias •Cyanosis •Hypotension •Mottling •Edema •Cold, clammy skin

CLINICAL MANIFESTATIONS HEME/ENDOCRINE

•Petechiae •DIC •Hypoglycemia -  glucose use •Hyperglycemia •especially with fungal infections in the ELBW infant •Stress response,  insulin release,  use

6 CLINICAL MANIFESTATIONS

Septic Shock Meningitis •Higher mortality rate •Mortality rate 20-50% •30% of survivors will have some neuro deficit •MR, Blind, Deaf, DD, Seizures

DIFFERENTIAL DIAGNOSIS

•Glucose •Electrolytes •Calcium •Hematocrit •HUS/CT scan •Nursing assessment of change in condition, activity, temp, or color

LABORATORY EVALUATION

Cultures •Blood Culture & Gram Stain •+ in 82 % of infected infants •Most will be positive by 48 hours •Urine Culture •Rarely positive in 1st 3 days of life •ET Aspirate •If pneumonia suspected or infant intubated •Other

7 CRP AND ANC

ANC (absolute neutrophil count)  Useful when evaluating infant for infection  Total number of circulating neutrophils in blood stream  A low ANC is concerning because it can indicate depletion of overall neutrophil pool

CRP (C-reactive protein) • Acute phase reactant that increases in the presence of inflammation • CRP secretion starts 4-6 hours after the inflammatory stimulus with peak at 36-48 hours • Highest concentrations of CRP are reported in infants with bacterial infections • Serial CRPs are most useful because they follow the trend of CRP levels

CBC INTERPRETATION

Possible Sepsis •WBC Count • (<5,000 or > 30,000) •I:T Ratio • (> 0.2) •Total Neutrophil Count • (<2000) •Platelet Count • (< 80,000)

ANC AND IT RATIO CALCULATIONS “SHIFT TO THE LEFT”

A left shift refers to increased number of circulating immature neutrophils  Mature neutrophils- segs  Immature neutrophils- bands, metamyelocytes, myelocytes

(segs + bands +other immatures) x WBC count Definition of neutropenia dependent (35 + 15 + 3)= 53 0.53 x 15,000= 7950 on gestational age and postnatal age

Immature (I) = I/T ratio 15 bands + 3 metas = 0.34 Total (T) 15 bands + 3 metas +35 segs >0.2 correlates with risk of infection >0.8 correlates with higher risk of death from sepsis

8 KAISER SEPSIS RISK CALCULATOR

https://neonatalsepsiscalculator.kaiserpermanente.org/

TREATMENT

•Antibiotics •Ampicillin •Gentamicin (Aminoglycoside) or •Claforan (Cephlosporin)

REFERENCES

•Anderson-Berry AL. (2015). Neonatal sepsis. http://emedicine.medscape.com/article/978352- overview. •Bailey J.E. & Leonard EG. (2012). Infections in the neonate. In A.A.Fanaroff & J.M.Fanaroff (Eds), Klaus & Fanaroff’s Care of the High-Risk Neonate (6th ed.). Philadephia: Saunders Publishing (Elsevier). •Clark RH, Bloom BT, Spitzer AR, & Gerstmann DR. (2006). Empiric use of ampicillin and cefotaxime, compared with ampicillin and gentamicin, for neonates at risk for sepsis is associated with an increased risk of neonatal death. Pediatrics, 117(1), 67-74. •Ferrieri P & Wallen LD. (2012). Neonatal bacterial sepsis. In: Gleason CA, Devaskar SU. Avery’s Diseases of the Newborn, (9th ed.) Philadelphia, PA: Elsevier.

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