MANAGEMENT OF NEONATAL SEPSIS

MODERATOR- DR. AVYACT AGRAWAL SIR

PRESENTED BY- DR. RAJANI PATIDAR

DEFINITIONS

• NEONATAL SEPSIS• NEONATAL SEPSIS IS DEFINED AS A CLINICAL SYNDROME OF BACTEREMIA WITH

SYSTEMIC SIGNS AND SYMPTOMS OF INFECTION IN THE FIRST 4 WEEKS OF LIFE. WHEN PATHOGENIC BACTERIA GAIN ACCESS INTO THE BLOOD STREAM, THEY MAY CAUSE OVERWHELMING INFECTION WITHOUT MUCH LOCALIZATION (SEPTICEMIA) OR MAY GET PREDOMINANTLY LOCALIZED TO THE LUNG (PNEUMONIA) OR THE MENINGES (MENINGITIS), ARTHRITIS, OSTEOMYELITIS.

WHY NEONATES ARE PRONE FOR NEONATAL SEPSIS

• NEONATES HAVE ONLY 2 TYPES OF IMMUNITY 1)- INNATE IMUNITY

• 2)- MATERNAL IMMUNITY (VIA AB+IG+COMPLIMENT

• THEY HAVE NO ACQUIRED ANTIBODY( SINCE NO CONTACT WITH INFETION)

• MATERNAL AB NOT PROTECTIVE AGAINST MOST OF THE INFECTIONS( MOTHER IS NOT EXPOSED TO THESE INFECTIONS SO NO ANTIBODY AGAINST THEM)

• NEONATAL NEUTROPHILS HAVE - 1) DECREASED CHEMOTAXIS

• 2) DECREASED DEFORMABILITY

• 3) DECREASED PHAGOCYTOSIS

• 4) DECREASED STORAGE POOL (ADULT 14 FOLD MORE CIRCULATORY POOL WHEREHAS NEONATES HAVE ONLY 2 FOLD CIRCULATORY POOL

• THE TERMINAL CYTOTOXIC COMPONENTS OF THE COMPLEMENT CASCADE THAT LEAD TO KILLING OF ORGANISMS, ESPECIALLY GRAM-NEGATIVE BACTERIA, ARE DEFICIENT.

• NEONATAL SERA HAVE REDUCED OPSONIC EFFICIENCY AGAINST GBS, E COLI, AND STREPTOCOCCUS PNEUMONIAE BECAUSE OF DECREASED LEVELS OF FIBRONECTIN, A SERUM PROTEIN THAT ASSISTS WITH NEUTROPHIL ADHERENCE AND HAS OPSONIC PROPERTIES.

• IMMATURE NEONATAL BARRIERS ( IMMATURE SKIN & MUCOSAL SURFACE)

• 1) DECREASED LAYERS

• 2) IMMATURE JUNCTION BETWEEN CELLS

• 3) DECREASED SECRETORY IG A

• 4) UMBILICAL CORD

• 5) BREACHES LIKE CATHETER ,

• INFECTIONS CAN COLONISE IN UTERO OR AT DELIVERY VIA SWALLOWING INFECTED AMNIOTIC FLUIDS WHEN THERE IS ALREADY IMMATURE GI DEFENCE (SPECIALLY IN PRETERM)

• HIGHER GLYCOGEN CONTENT OF CHOROID PLEXUS PROVIDE EXCELLENT MEDIUM FOR BACTERIA TO COLONISE & REPRODUCE TO CAUSE VENTRICULITIS ;MENINGITIS; HYDROCEPHALUS

EPIDEMIOLOGY

• .

• INTRAMURAL BIRTHS KLEBSIELLA PNEUMONIAE WAS THE MOST FREQUENTLY ISOLATED PATHOGEN (32.5%), FOLLOWED BY STAPHYLOCOCCUS AUREUS (13.6%).

• EXTRAMURAL NEONATES (REFERRED FROM COMMUNITY/OTHER HOSPITALS), KLEBSIELLA PNEUMONIAE WAS AGAIN THE COMMONEST ORGANISM (27%), FOLLOWED BY STAPHYLOCOCCUS AUREUS (15%) AND PSEUDOMONAS (13%).

EARLY-ONSET INFECTION

• GROUP B STREPTOCOCCUS (GBS)

• ESCHERICHIA COLI

• COAGULASE-NEGATIVE STAPHYLOCOCCUS

• HAEMOPHILUS INFLUENZAE

• LISTERIA MONOCYTOGENES

EARLY ONSET SEPSIS

• IT PRESENTS WITHIN THE FIRST 72 HOURS OF LIFE. INFANTS WITH EOS USUALLY PRESENT WITH RESPIRATORY DISTRESS AND PNEUMONIA. THE SOURCE OF INFECTION IS GENERALLY THE MATERNAL GENITAL TRACT.

• RISK FACTORS

• 1. LOW BIRTH WEIGHT (<2500 GRAMS) OR PREMATURITY

• 2. FEBRILE ILLNESS IN THE MOTHER WITH EVIDENCE OF BACTERIAL INFECTION WITHIN 2 WEEKS PRIOR TO DELIVERY

• 3. FOUL SMELLING AND/OR MECONIUM STAINED LIQUOR

• 4. RUPTURE OF MEMBRANES >24 HOURS

• 5. SINGLE UNCLEAN OR > 3 STERILE VAGINAL EXAMINATION(S) DURING LABOR

• 6. PROLONGED LABOR (SUM OF 1ST AND 2ND STAGE OF LABOR > 24 HRS)

• 7. PERINATAL ASPHYXIA (APGAR SCORE <4 AT 1 MINUTE)

LATE-ONSET SEPSIS

• COAGULASE-NEGATIVE STAPHYLOCOCCUS

• STAPHYLOCOCCUS AUREUS

• E COLI

• KLEBSIELLA

• PSEUDOMONAS

• ENTEROBACTER

• CANDIDA

• GBS

• SERRATIA

• ACINETOBACTER

• ANAEROBES

LATE ONSET SEPSIS

• IT USUALLY PRESENTS AFTER 72 HOURS OF AGE. THE SOURCE OF INFECTION IN LOS IS EITHER NOSOCOMIAL (HOSPITAL-ACQUIRED) OR COMMUNITY-ACQUIRED AND NEONATES USUALLY PRESENT WITH SEPTICEMIA, PNEUMONIA

• RISK FACTORS

• LOW BIRTH WEIGHT, PREMATURITY

• ADMISSION IN INTENSIVE CARE UNIT

• MECHANICAL VENTILATION

• INVASIVE PROCEDURES

• ADMINISTRATION OF PARENTERAL FLUIDS

• FACTORS THAT MIGHT INCREASE THE RISK OF COMMUNITY-ACQUIRED LOS INCLUDE POOR HYGIENE, POOR CORD CARE, BOTTLE-FEEDING, AND PRELACTEAL FEEDS

• BREASTFEEDING HELPS IN PREVENTION OF INFECTIONS.

CLINICAL PRESENTATION• (A) HYPOTHERMIA OR FEVER

• (B) LETHARGY, POOR CRY, REFUSAL TO SUCK

• (C) POOR PERFUSION, PROLONGED CAPILLARY REFILL TIME, MOTTLING OF SKIN

• (D) HYPOTONIA, ABSENT NEONATAL REFLEXES

• (E) BRADY/TACHYCARDIA

• (F) RESPIRATORY DISTRESS, APNEA AND GASPING RESPIRATION

• (G) HYPO/HYPERGLYCEMIA

• (H) METABOLIC ACIDOSIS.

• (I) JAUNDICE

• (J) SCLEREMA

• (K) DIARRHOEA, VOMITING, ABDOMINAL DISTENSION

• (L) DIC

SPECIFIC FEATURES RELATED TO VARIOUS SYSTEMS:

• CENTRAL NERVOUS SYSTEM (CNS): BULGING ANTERIOR FONTANELLE, VACANT STARE, HIGH-PITCHED CRY, EXCESS IRRITABILITY, STUPOR/COMA, SEIZURES, NECK RETRACTION. PRESENCE OF THESE FEATURES SHOULD RAISE A CLINICAL SUSPICION OF MENINGITIS

• CARDIAC: HYPOTENSION, POOR PERFUSION, SHOCK

• GASTROINTESTINAL: FEED INTOLERANCE, VOMITING, DIARRHEA, ABDOMINAL DISTENSION, PARALYTIC ILEUS, NECROTIZING ENTEROCOLITIS (NEC)

• HEPATIC: HEPATOMEGALY, DIRECT HYPERBILIRUBINEMIA (ESPECIALLY WITH URINARY TRACT INFECTIONS)

• RENAL: ACUTE RENAL FAILURE

• HEMATOLOGICAL: BLEEDING, PETECHIAE, PURPURA

• SKIN CHANGES: MULTIPLE PUSTULES, ABSCESS, SCLEREMA, MOTTLING, UMBILICAL REDNESS AND DISCHARGE.

SEPSIS SCREENING

TOTAL LEUKOCYTE COUNT <5000/MM3

ABSOLUTE NEUTROPHIL COUNT <1800 CUMM

IMMATURE/TOTAL NEUTROPHIL >0.2

MICRO-ESR >15 MM IN 1ST HOUR

C REACTIVE PROTEIN (CRP) >1 MG/DL

PRESENCE OF TWO ABNORMAL PARAMETERS IN A SCREEN IS ASSOCIATED WITH A SENSITIVITY OF 93-100%, SPECIFICITY OF 83%, POSITIVE AND NEGATIVE PREDICTIVE VALUES OF 27% AND 100% RESPECTIVELY IN DETECTING SEPSIS. HENCE, IF TWO (OR MORE) PARAMETERS ARE ABNORMAL, IT SHOULD BE CONSIDERED AS A POSITIVE SCREEN AND THE NEONATE SHOULD BE STARTED ON ANTIBIOTICS. IF THE SCREEN IS NEGATIVE BUT CLINICAL SUSPICION PERSISTS, IT SHOULD BE REPEATED WITHIN 12 HOURS. IF THE SCREEN IS STILL NEGATIVE, SEPSIS CAN BE EXCLUDED WITH REASONABLE CERTAINTY.

IT RATIO

• N VALUE = 0.16 IN FIRST 24 HOURS, DECREASING TO 0.12 BY 60 HOURS

• UPPER LIMIT= >0.2

MICRO ESR

• POSITIVE VALUE = > 3+ AGE IN DAYS ( FIRST WEEK OF LIFE)

• > 10 THEREAFTER

CRP• NON SPECIFIC MARKER OF INFLAMMATION & TISSUE NECROSIS.

• NORMAL VALUE < 1 MG/DL

• DETECTABLE INCREASED CRP VALUE- WITHIN 6 TO 18 HOURS,

• PEAK- 8 TO 60 HOURS AFTER ONSET.

• HALF LIFE- 5 TO 7 HOURS.

• DECREASES PROMPTLY IN THE PRESENCE OF APPROPRIATE THERAPY.

• SERIAL CRP LEVELS ARE USEFUL IN THE DIAGNOSTIC EVALUATION OF NEONATES WITH SUSPECTED INFECTION. TWO CRP LEVELS 12 HRS APART;8 TO 48 HRS AFTER PRESENTATION INDICATE BACTERIAL INFECTION IS UNLIKELY.

• QUANTITATIVE CRP ASSAYED BY NEPHELOMETRY IS SUPERIOR TO CRP BY ELISA & SEMI QUANTITATIVE CRP BY A LATEX AGGLUTINATION KIT.

CBC RECOMMENDATIONS

• < 1 HR- DO NOT OBTAIN CBC

• 1-4 HOURS- CBC NPT RECOMMENDED, IF OBTAINED REPEAT AT 6-12 HRS.

• > 4 HR- OBTAIN CBC & BLOOD CULTURE

• BLOOD CULTURE ONE-ML SAMPLE OF BLOOD SHOULD BE ADEQUATE FOR A BLOOD CULTURE BOTTLE CONTAINING 5-10 ML OF CULTURE MEDIA. IT IS NOW POSSIBLE TO DETECT BACTERIAL GROWTH WITHIN 12-24 HOURS BY USING IMPROVED BACTERIOLOGICAL TECHNIQUES SUCH AS BACTEC AND BACT/ALERT BLOOD CULTURE SYSTEMS.

• PROCALCITONIN->0.5 MCG/L

• BECOME DETECTABLE WITHIN 2 TO 4 HOURS AFTER A TRIGGER EVENT & PEAKS BY 12 TO 24 HOURS.

• PROCT SECRETION PARELLELS CLOSELY THE SEVERITY OF THE INFLAMMATORY INSULT, WITH HIGHER LEVELS ASSOCIATED WITH MORE SEVERE DISEASE & DECLINING LEVEL WITH RESOLUTION OF DISEASE.

• IN THE ABSENCE OF ONGOING STIMULUS, PROCALCITONIN IS ELIMINATED WITH A HALF LIFE OF 24 TO 35 HOURS, MAKING IT SUITABLE FOR SERIAL MONITORING.

• LEVELS- >2.0 NG/ML= PREDICTS SEPSIS

• > 10 NG/ML= SEPTIC SHOCK

• > 20 NG/ML= GUARDED PROGNOSIS

• PREALBUMIN & TRANSFERRIN- NEGATIVE REACTANTS

• GASTRIC ASPIRATE- POLYMORPHS >5/HPF

• PCR

• BIO MARKERS-

• CYTOKINES IL-1B, IL-6, IL-8 & TNF

• SURFACE NEUTROPHILS- CD11

• RADIOLOGY: CHEST X-RAY SHOULD BE CONSIDERED IN THE PRESENCE OF RESPIRATORY DISTRESS OR APNEA. AN ABDOMINAL X-RAY IS INDICATED IN THE PRESENCE OF ABDOMINAL SIGNS SUGGESTIVE OF NECROTIZING ENTEROCOLITIS (NEC). NEUROSONOGRAM AND COMPUTED TOMOGRAPHY (CT SCAN) SHOULD BE PERFORMED IN ALL PATIENTS DIAGNOSED TO HAVE MENINGITIS.

• URINE R & M- >10 LEUKOCYTES/MM3,

• >10)4 ORG/MI

LUMBAR PUNCTURE

• IN EOS, LUMBAR PUNCTURE IS INDICATED IN THE PRESENCE OF A POSITIVE BLOOD CULTURE OR IF THE CLINICAL PICTURE IS CONSISTENT WITH SEPTICEMIA. IT IS NOT INDICATED IF ANTIBIOTICS HAVE BEEN STARTED SOLELY DUE TO THE PRESENCE OF RISK FACTORS. IN SITUATIONS OF LATE ONSET SEPSIS, LP SHOULD BE DONE IN ALL INFANTS PRIOR TO STARTING ANTIBIOTICS.

NORMAL CEREBROSPINAL FLUID EXAMINATION IN NEONATES

CSF COMPONENTS NORMAL RANGE

• CELLS/MM3 8 (0-30 CELLS)

• PMN (%) 60%

• CSF PROTEIN (MG/DL) 90 (20-170) T>150 PT>180

• CSF GLUCOSE (MG/DL) 52 (34-119)

• CSF/ BLOOD GLUCOSE (%) 51 (44-248)

• GRAM POSITIVE BACTERIA CLEAR IN 36 HOURS OF APPROPRIATE THERAPY WHEREAS GRAM NEGATIVE BACTERIA MAY TAKE UP TO 5 DAYS

• RECOMMENDATIONS:

• PRETERM INFANTS: TREAT IF CSF WBC COUNT ≥10 OR GLUCOSE <24 OR PROTEIN >170. DO NOT TREAT IF “CSF WBC COUNT <25 AND GLUCOSE ≥25 AND PROTEIN <170”.

• TERM INFANTS: TREAT IF CSF WBC COUNT >8 OR GLUCOSE <20 OR PROTEIN >120

INDICATIONS FOR STARTING ANTIBIOTICS• FOR EARLY ONSET SEPSIS

(A) PRESENCE OF >3 RISK FACTORS

(B) PRESENCE OF FOUL SMELLING LIQUOR

(C) PRESENCE OF 2 ANTENATAL RISK FACTOR(S) AND A POSITIVE SEPTIC SCREEN AND

(D) STRONG CLINICAL SUSPICION OF SEPSIS.

• FOR LOS :

(a) POSITIVE SEPTIC SCREEN AND/OR

(B) STRONG CLINICAL SUSPICION OF SEPSIS.

• COMMUNITY-ACQUIRED WHERE RESISTANT STRAINS ARE UNLIKELY- AMPICILLIN OR PENICILLIN WITH GENTAMICIN

• HOSPITAL ACQUIRED INFECTIONS (RESISTANT PATHOGENS ARE LIKELY) - AMPICILLIN OR CLOXACILLIN WITH GENTAMICIN OR AMIKACIN.

• MULTIPLE RESISTANT STRAINS OF KLEBSIELLA AND OTHER GRAM-NEGATIVE BACILLI- THIRD GENERATION CEPHALOSPORIN (CEFOTAXIME OR CEFTAZIDIME) WITH AMIKACIN.

• IN UNITS WITH HIGH INCIDENCE OF RESISTANT STRAINS -PIPERACILLIN-TAZOBACTAM OR METHICILLIN/VANCOMYCIN.

• PSEUDOMONAS SEPSIS- PIPERACILLIN-TAZOBACTAM WITH AMIKACIN.

• PENICILLIN RESISTANT STAPHYLOCOCCUS AUREUS -CLOXACILLIN, NAFCILLIN OR METHICILLIN+ AMINOGLYCOSIDE.

• METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) - CIPROFLOXACIN OR VANCOMYCIN WITH AMIKACIN..

• ENTEROCOCCUS- AMPICILLIN AND GENTAMICIN. VANCOMYCIN SHOULD BE USED FOR THE TREATMENT OF ENTEROCOCCUS RESISTANT TO THE FIRST LINE OF THERAPY

UPGRADATION OF ANTIBIOTICS

• NO EXPECTED CLINICAL IMPROVEMENT WITH ONGOIN LINE OF ABS.

• AT LEAST 48-72 HRS PERIOD OF OBSERVATION SHOULD BE ALLOWED BEFORE DECLARING FAILURE.

• BEWARE- CEPHALOSPORINS RAPIDLY INDUCE THE PRODUCTION OF EXTENDED SPECTRUM B- LACTAMASES (ESBL), CEPHALOSPORINASES & FUNGAL COLONIZATION.

RESERVE ANTIBIOTICS

• NEWER ANTIBIOTICS LIKE AZTREONAM, MEROPENEM AND IMIPENEM ARE ALSO NOW AVAILABLE IN THE MARKET. AZTREONAM HAS EXCELLENT ACTIVITY AGAINST GRAM-NEGATIVE ORGANISMS WHILE MEROPENEM IS EFFECTIVE AGAINST MOST BACTERIAL PATHOGENS EXCEPT METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) AND ENTEROCOCCUS. IMIPENEM IS GENERALLY AVOIDED IN NEONATES BECAUSE OF THE REPORTED INCREASE IN THE INCIDENCE OF SEIZURES FOLLOWING ITS USE. EMPIRICAL USE OF THESE ANTIBIOTICS SHOULD BE AVOIDED; THEY SHOULD BE RESERVED FOR SITUATIONS WHERE SENSITIVITY OF THE ISOLATED ORGANISM WARRANTS ITS USE.

DURATION OF ANTIBIOTIC THERAPY IN NEONATAL SEPSIS

• DIAGNOSIS DURATION

• MENINGITIS (WITH OR WITHOUT POSITIVE BLOOD/CSF CULTURE) 21 DAYS

• BLOOD CULTURE POSITIVE BUT NO MENINGITIS 14 DAYS

• CULTURE NEGATIVE SEPSIS (SCREEN POSITIVE AND CLINICAL

COURSE CONSISTENT WITH SEPSIS) 5-7 DAYS

• OSTEOMYELITIS & ARTHRITIS, ENDOCARDITIS 4-6 WEEKS

• VENTRICULITIS 6 WEEKS

ANAEROBIC BACTERIAL INFECTIONS

• CAUSATIVE AGENTS-

• B. FRAGILIS

• PEPTOSTREPTOCOCCUS

• C. PERFRINGENS

• PRESENTATION-

• ABDOMINAL ABSCESS, MENINGITIS, OMPHALITIS, CELLULITIS, ENDOCARDITIS, OSTEOMYELITIS & ARTHRITIS.

• TREATMENT-

• B. FRAGILIS- MERTRONIDAZOLE, CLINDAMYCIN, CEFOXITIN, OR MEROPENAM

• PEPTOSTREPTOCOCCUS & CLOSTRIDIA- PENICILLIN G

• NEC & INTESTINAL PERFORATION- AMPICILLIN, GENTAMYCIN & CLINDAMYCIN

FUNGAL INFECTIONS

• SYSTEMIC CANDIDIASIS-

• CAUSATIVE ORGANISM- C. ABICANS, C. PARAPSILOSIS

• NOSOCOMIAL

• RISK FACTORS-

• PRETERM <1500GM

• BABIES REQUIRING PROLONGED VENTILATION, VENOUS CATHETERIZATION, EXCHANGE BLOOD TRANSFUSION & TPN.

• PROLONGED ADMINISTRATION OF ANTIBIOTICS, H2 BLOCKERS, STEROIDS.

• CLINICAL FEATURES-.

• INTOLERANCE TO FEEDS, HYPERTHERMIA, HYPERGLYCEMIA & THROMCYTOPENIA.

• .DIAGNOSIS- BLOOD CULTURE, URINE RM & CULTURE

TREATMENT

• DOC-

• AMPHOTERICIN B INFUSION- 250MCG/KG/DAY TO 1 MG/KG/DAY DISSOLVED IN D5% OVER

• 6 HRS FOR 3-4 WEEKS.

• MONITOR- S. POTASSIUM, RFT.

• LIPOSOMAL PREPARATION- 5 MG/KG/DAY OVER 2 HRS (NOT FOR RENAL CANDIDIASIS)

• FOR CNS INVOLVEMENT-

• 5- FLUROCYTOSINE- 50-150 MG/KG/DAY (ORALLY)

• FLUCONAZOLE- 6 MG/KG/DAY (I/V OR ORALLY)

UTI• CLINICAL FEATURES ARE NONSPECIFIC AND VARIED-

• FAILURE TO THRIVE (50%), FEVER (39%), VOMITING (37%), DIARRHOEA (25%), CYANOSIS (23%), JAUNDICE (18%) AND IRRITABILITY & LETHARGY (17%).

• ROUTINE URINE CULTURE IN ALL NEONATES WITH NON-SPECIFIC SYMPTOMS IS NOT RECOMMENDED.

• NEONATES WITH THE ABOVE CLINICAL SIGNS, OR SEPTIC NEONATES WITH LOS OR WHO ARE VLBW HAVE KNOWN URINARY TRACT ANOMALIES OR HAVE HAD PREVIOUS OR ON-GOING BLADDER CATHETERIZATION OR VISIBLY TURBID URINE SHOULD BE INVESTIGATED FOR UTI.

• URINE ANALYSIS SHOULD BE PERFORMED WITH A HEMOCYTOMETER ON UNCENTRIFUGED URINE AND THE CELLS SHOULD BE REPORTED AS NUMBER PER CUBIC MILLIMETER.

• SUPRA PUBIC ASPIRATION IS THE IDEAL METHOD OF SAMPLE COLLECTION IN CASES OF SUSPECTED UTI. BAG SAMPLE AND FREE FLOW SAMPLE ARE HIGHLY PRONE FOR CONTAMINATION.

• URINE R & M- >10 LEUKOCYTES/MM3,

• >10)4 ORG/MI

• CEFOTAXIME/CEFTRIAXONE PLUS AMIKACIN, AND MODIFY AS PER CULTURE REPORT. NALIDIXIC ACID OR NITROFURANTOIN SHOULD NOT BE USED TO TREAT UTI .

• UTI OCCURRING IN THE SETTING OF GENERALIZED SEPTICEMIA MAY NOT BE ASSOCIATED WITH VUR OR MALFORMATIONS. HOWEVER, AN ISOLATED UTI COULD BE ASSOCIATED WITH THESE CONDITIONS. HENCE, AFTER TREATMENT OF ISOLATED UTI, ALL CASES MUST BE STARTED ON AMOXYCILLIN 10 MG/KG ONCE A DAY ORAL PROPHYLAXIS, TILL SUCH TIME THAT A RENAL ULTRASOUND, MCU AND DMSA SCAN ARE PERFORMED TO EXCLUDE VUR OR MALFORMATIONS.

ADJUNCTIVE THERAPY EXCHANGE TRANSFUSION (ET):

• DOUBLE-VOLUME EXCHANGE TRANSFUSION WITH CROSS- MATCHED FRESH WHOLE BLOOD AS ADJUNCTIVE THERAPY IN SEPTIC NEONATES WITH SCLEREMA.

SUPPORTIVE CARE OF A SEPTIC NEONATE

• : 1. PROVIDE WARMTH, ENSURE CONSISTENTLY NORMAL TEMPERATURE

• 2. START INTRAVENOUS LINE.

• 3. INFUSE NORMAL SALINE 10 ML/KG OVER 5-10 MINUTES, IF PERFUSION IS POOR AS EVIDENCED BY CAPILLARY REFILL TIME (CRT) OF MORE THAN 3 SECONDS. REPEAT THE SAME DOSE 1-2 TIMES OVER THE NEXT 30-45 MINUTES, IF PERFUSION CONTINUES TO BE POOR.

• 4. INFUSE GLUCOSE (10 PERCENT) 2 ML/KG STAT.

• 5. INJECT VITAMIN K 1 MG INTRAMUSCULARLY.

• 6. START OXYGEN BY HOOD OR MASK, IF CYANOSED OR GRUNTING.

• 7. PROVIDE GENTLE PHYSICAL STIMULATION, IF APNEIC.

• 8. PROVIDE BAG AND MASK VENTILATION WITH OXYGEN IF BREATHING IS INADEQUATE.

• 9. AVOID ENTERAL FEED IF VERY SICK, GIVE MAINTENANCE FLUIDS INTRAVENOUSLY

• 10. CONSIDER USE OF DOPAMINE IF PERFUSION IS PERSISTENTLY POOR.

• 11. CONSIDER EXCHANGE TRANSFUSION IF THERE IS SCLEREMA.

SUPERFICIAL INFECTIONS

• SUPERFICIAL INFECTIONS CAN BE TREATED WITH LOCAL APPLICATION OF ANTIMICROBIAL AGENTS. PUSTULES CAN BE PUNCTURED WITH STERILE NEEDLES AND CLEANED WITH SPIRIT OR BETADINE. PURULENT CONJUNCTIVITIS CAN BE TREATED WITH NEOSPORIN OR CHLORAMPHENICOL OPHTHALMIC DROPS. ORAL THRUSH RESPONDS TO LOCAL APPLICATION OF CLOTRIMAZOLE OR NYSTATIN (200,000 UNITS PER ML) AND HYGIENIC PRECAUTIONS. SUPERFICIAL INFECTIONS MUST BE ADEQUATELY MANAGED; IF NEGLECTED THEY CAN LEAD TO SEPSIS OR EVEN AN EPIDEMIC.

IVIG• ENDOGENOUS IMMUNOGLOBULINS SYNTHESIS- FROM 24 WEEKS OF LIFE

• PLACENTAL TRANSFER- AFTER 32 WEEKS.

• THERE ARE TWO INDIAN TRIALS ON THE USE OF

• IMMUNOGLOBULINS IN NEONATAL INFECTIONS, BUT NONE SHOWED ANY BENEFIT.

•

• RECOMMENDATIONS: THE CURRENTLY AVAILABLE EVIDENCE DOES NOT SUPPORT THE USE OF IVIG.

• THE CURRENTLY UNDERGOING INTERNATIONAL NEONATAL IMMUNOTHERAPY STUDY IS EXPECTED TO BE PROVIDE SOME IMPORTANT AND DEFINITIVE INFORMATION IN THIS ASPECT.

GM- CSF & G- CSF

• THESE ARE THE CYTOKINES THAT STIMULATE THE PRODUCTIN OF BONE-MARROW NEUTROPHILS.

• AS PREMATURE INFANTS HAVE LIMITED NUM & FUNCTION OF NEUTROPHILS, SO INVESTIGATORS EVALUATED THESE FACTORS FOR PREVENTION & ADJUVANT TREATMENT OF NEONATAL SEPSIS.

• BUT COMBINATION OF 5 STUDIES EXAMINED THE EFFECT OF ADJUVANT G-CSF OR GM-CSF ON 14 & 28T DAY SHOWED A REDUCTION IN ALL-CAUSE MORTALITY IN TREATED INFANTS.

• RECOMMENDATION-

• : THERE IS CURRENTLY NO EVIDENCE TO SUPPORT THE USE OF COLONY STIMULATING FACTORS EITHER AS A TREATMENT MODALITY OR AS A PROPHYLAXIS THERAPY..

PROBIOTICS

• LACTOBACILLUS & BIFIDOBACTERIUM SP.

• STUDIES CONCLUDED THAT PROBIOTICS REDUCED THE RISK OF DEATH OR NEC AMONG VLBW INFANTS BUT FOUND NO SIGNIFICANT EFFECT IN THE INCIDENCE OF LOS.

LACTOFERRIN

• IT HAS BROAD SPECRUM ANTIMICROBIAL ACTIVITY.

• RESULTS FOR EFFICACY & RECOMMENDATION ARE YET TO BE ESTABLISTED.

GLUTAMINE

• MOST ABUNDANT AA IN PLASMA & MILK.

• STUDIES IN IMMUNOCOMPROMISED ADULTS SUGGESTS DECREASE IN RISK OF SEPSIS & MORTALITY.

• BUT NO STATISTISTICALLY SIGNIFICANT DIFFERENCE NOT FOUND IN STUDIES TILL NOW.

RECOMBINANT HUMAN PROTEIN C

• STUDIES SHOWED NO IMPROVEMENT IN CLINICAL SCORE IN OUTCOME.

• THANKYOU