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NEONATAL SEPSIS Ekawaty Lutfia Haksari Perinatology, Department of Child Health Gadjah Mada...
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Transcript of NEONATAL SEPSIS Ekawaty Lutfia Haksari Perinatology, Department of Child Health Gadjah Mada...
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NEONATAL SEPSIS
Ekawaty Lutfia HaksariPerinatology, Department of Child Health Gadjah Mada
University
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Trends in child mortality among those younger than 5 years and in first 28days of life 1965-2015(Lawn et al. 4 million neonatal deaths:When?Where?Why?Lancet 2005;365:891-900)
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Worldwide causes of neonatal mortality Save the Children. Saving Newborn Lives. Washington, 2000
32%
24%10%
5%
29%
AsphyxiaLBW+prematurityI nf ectionsCongenital anomalyOthers
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NEONATAL SEPSIS• Systemic infection
important cause morbidity & mortality
• Laboratory, clinical diagnose – difficult leading to delayed treatment
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ONSET OF NEONATAL SEPSIS•Early onset sepsis - Onset 0-72 hours of age - Acquired around birth - Usually vertical transmission - mother •Late onset sepsis - Onset >72 hours age - Acquired environtment - Hospital acquired or nosocomial infection
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Risk factors – Late onset neonatal sepsis
• Prematurity/ low birth weight• In hospital• Invasive procedures: ventolator, iv lines,
central lines, urine catheter, chest tube• Contact with infectious disease- doctors,
nurses, babies with with infections, siblings
• Not fed maternal breast milk
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CLINICAL DIAGNOSISoEarly sign very subtle, non specific very quickly to late sign death
oAnticipate possible severe infection carefull examine observe them – slight changes early diagnosis, T/
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•Algorithms - symptoms/signs health workers to identify neonatal sepsis referral/ home treatment (WHO, 2002)
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• Newborn has not been well since birth
• Well infant 1 or > signs neonatal sepsis poor feeding + sucking
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SIGNS OF INFECTION (WHO, 2002)
Early signs Late signs Local/specific sign
Not able to feed /suck, after fedding normallyLethargyAbnormal body temp
Breathing difficulties
Severe lethargyUnconciousnessSeizureApneaJaundiceScleremaBleeding
DiarrhoeaAbdominal distensionUmbilical rednessPus draining-eyesmovement of limbCrying-limb is touch/movedSwelling,warmth, redness- limb/jointBulging fontanelleOpisthotonus
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Possible infection (Kosim, 2004)
A BBreathing difficultiesSeizureUnconciousnessAbnormal body temperature (sepsis)Delivery problem (sepsis)Condition (sepsis)
Tremor Lethargy Weak Irritability Onzet day 4 (sepsis) Poor feeding (sepsis)
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Risk factors of early onset•Maternal history-uterine
infection PROM > 18 hours• Birth weight <2000g or
gestation age < 35 weeks • Signs of infection possible severe infection
Kosim, 2004
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Perinasia 1991 POSSIBLE SEPSIS
•Clinically sepsis at least 1 sign is found in 4 out of 6 group categories
•Risk factors
Surjono, 2004
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Perinasia konsensus 1991
Clinically sepsisat least 1 sign is found in 4 out of 6 group categories: (1) General condition (2) Gastrointestinal system (3) Respiratory system (4) cardiovascular system (5) central nervous system (6) hematologic system
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(1) General condition not doing well, poor feeding, temperature instability, sclerema
(2) Gastrointestinal system abdominal distention, vomiting,
diarrhea, hepatomegaly
(3) Respiratory system apnea, dyspnea, tachypnea, retraction,
flaring, grunting, cyanosis
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(4) Cardiovascular system tachycardia, bradycardia, poor perfussion
(5) Central nervous system irritability, lethargy, tremor, seizure
(6) Hematologic system jaundice, splenomegaly, pallor, petechiae, bleeding, leucopenia, ratio immature/mature neutrophil (I/T>0,2), thrombocytopenia, toxic granulation
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CLINICALLY SEPSIS (cont)
Not doing well Poor feeding Lethargy Respiratory problem Hypothermia > hyperthermia
(Yu & Monintja, 1997)
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• C-reactive protein (CRP)• Chest X-Ray• Gold standard• Culture – body fluid: blood, urine, stools,
endotracheal aspirates, cerebrospinal fluid (CSF), pleural or pus
Diagnosis (cont)
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TREATMENT•Specific: Antibiotics - Ampicillin and Gentamicin - Cephalosporin•Supportive care - Temperature - Cardiorespiratory - Hematological - Gastrointestinal - Immunological ?
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Antibiotic resistance pattern in developing countries
(from Vergnano S, et al. Arch Dis Child Fetal Neonatal Ed 2005)
Klebsiella spp E.coli
Ampicillin 65 – 100% 69 – 100%
Gentamicin 16 – 85% 30- 93%
Amikacin 0 – 74% 0 – 67%
Cefotaxime 0 – 86% 0 – 75%
Imipenem 0 – 6% 0%
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Supportive Care • Temperature support- hypothermia • GI support - vomiting, ileus• Cardiorespiratory support - hypoxia, apnea,
ARDS, hypotension, shock• Hematological support: anemia,
thrombocytopenia, DIC• Neurological support- seizures
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SUGGESTIONS TO PREVENT NEONATAL SEPSIS
• Treat mother’s infections - pregnancy• Use clean delivery practices -labor and birth• Use infection prevention steps – labor,birth and post natal care• Treat a mother with antibiotics -labor - she has the sign of infection / prolonged rupture membrane >18hours
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suggestions
• Wash the hands before and after handling each newborn • Rooming in – normal newborn • Do not bring the baby into contact
with sick people• Isolate a sick newborn from healthy ones
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suggestions
• Teach the mother & family - to keep the baby away from sick people
- to use infection prevention steps, especially hand washing
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Human milk• Enteral feeding - human milk is generally regarded as beneficial
• Breastfeed the newborn exclusively
(Kramer, 2002; Beck, 2004)
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HUMAN MILK (cont)• NICU: incidence of neonatal infection (el-Mohandes, 1997; Tysson, 1997; Xanthou,1998; Hanson, 2002)
• Early full enteral feeding significantly the risk of late onset of septichaemia - extremely premature infant
(Ronnestad, 2005)
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LOCALIZED INFECTIONS• Umbilical cord: uncovered, clean and dry• Skin infection• Eye infection• Oral trush (WHO 2002, Kosim 2004, Beck 2004)
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PREVENTION OF NOSOCOMIAL INFECTION
• The lay out & organisation - the neonatal unit may have an important effect on infection control practices• Hand washing is a cornerstone of
infection control