Neonatal sepsis
Definition:
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).
Importance
Neonatal sepsis is the single most important cause of
neonatal deaths in the community, accounting for over half of them. If
diagnosed early and treated aggressively with antibiotics and good supportive
care, it is possible to save most cases of neonatal sepsis.
Etiology
Most cases of neonatal sepsis in the community are
caused by Escherichia coli and Staphylococcus aureus. In hospitals, Klebsiella
pneumonia is also a common organism.
Early vs. late
sepsis
Neonatal sepsis can be classified into two sub-types
depending upon whether the onset of symptoms is before 72 hours of life (early
onset) or later (late onset).
Early-onset infections are caused by organisms
prevalent in the maternal genital tract or in the delivery area. The associated
factors for early-onset sepsis include low birth weight, prolonged rupture of
membranes, foul smelling liquor, multiple per vaginum examinations, maternal
fever,
children and adults.
Clinical features:
Difficult or prolonged labour and aspiration of
meconium. Early onset sepsis manifests frequently as pneumonia and less
commonly as septicemia or meningitis.
Late-onset
septicemia is caused by the organisms thriving in the external environment of
the home or the hospital. The infection is often transmitted through the hands
of the care-providers. The onset of symptoms is usually delayed beyond 72 hours
after birth and the presentation is that of septicemia, pneumonia or
meningitis. The associated factors of late-onset sepsis include: low birth
weight, lack of breastfeeding, superficial infections (pyoderma, umbilical
sepsis), aspiration of feeds, disruption of skin integrity with needle pricks
and use of intravenous fluids. These factors enhance the chances of entry of
organisms into the blood stream of the neonates whose immune defences are poor
as compared to older
The manifestations of neonatal
septicemia are often vague and therefore demand a high index of suspicion for
early diagnosis (Table I). The most common and characteristic manifestation is
an alteration in the established feeding behavior in late onset sepsis and
respiratory distress in early onset sepsis. The baby, who had been active and
sucking well, gradually or suddenly, becomes lethargic, inactive or
unresponsive and refuses to suckle. Hypothermia is a common manifestation of
sepsis, whilst fever is infrequent. Diarrhea, vomiting and abdominal distension
may occur. Episodes of apneic spells or gasping may be the only manifestation
of septicemia. In sick neonates, the skin may become tight giving a hide-bound
feel (sclerema) and the perfusion becomes poor (capillary refill time of over 3
seconds). Cyanosis may appear. A critical neonate may develop shock, bleeding
and renal failure.
TABLE 1: Clinical manifestations of
neonatal sepsis Lethargy
|
Cyanosis*
|
Refusal to suckle
|
Tachypnea*
|
Poor cry
|
Chest retractions*
|
Not arousable, comatose
|
Grunt*
|
Abdominal distension
|
Apnea/gasping*
|
Diarrhea
|
Fever+
|
Vomiting
|
Seizures+
|
Hypothermia
|
Blank look+
|
Poor perfusion
|
High pitched cry+
|
Sclerema
|
Excessive crying/irritability+
|
Poor weight gain
|
Neck retraction+
|
Shock
|
Bulging fontanel+
|
Bleeding
|
|
Renal failure
|
|
Causes
Neonatal sepsis cases are more common in premature babies. The disease can be classified as: congenital, early-onset and late-onset. Congenital neonatal sepsis is when the child is infected during pregnancy i.e. before birth. The baby can be infected by virus through placenta or birth canal. HIV (Human Immunodeficiency Virus), syphilis are some of the viruses that can infect the child before delivery. Early-onset neonatal sepsis is when the infant is infected, while taking birth or soon after the delivery. Group B streptococcus (GBS) and Escherichia coli (E. coli) are considered as chief viruses that infect the baby, while birth. Early-onset neonatal sepsis is a result of asymptomatic colonization in the intestinal or genital tract of the mother. Colonization is the existence of bacteria/viruses in a body part. An infant is said to be affected by late-onset neonatal sepsis, when it is infected a few days after delivery. This infection can be due to the organisms present in the environment of the hospital. After getting discharged from hospital, babies can get infected due to the bacteria present in the environment at home. GBS and E. coli are also responsible for late-onset neonatal sepsis.
Risk Factors
There are number of risk factors related to the infant getting affected by neonatal sepsis. Males are noticed to be infected more than females, the ratio being 2:1. Risk factors of early-onset neonatal sepsis:
Neonatal sepsis cases are more common in premature babies. The disease can be classified as: congenital, early-onset and late-onset. Congenital neonatal sepsis is when the child is infected during pregnancy i.e. before birth. The baby can be infected by virus through placenta or birth canal. HIV (Human Immunodeficiency Virus), syphilis are some of the viruses that can infect the child before delivery. Early-onset neonatal sepsis is when the infant is infected, while taking birth or soon after the delivery. Group B streptococcus (GBS) and Escherichia coli (E. coli) are considered as chief viruses that infect the baby, while birth. Early-onset neonatal sepsis is a result of asymptomatic colonization in the intestinal or genital tract of the mother. Colonization is the existence of bacteria/viruses in a body part. An infant is said to be affected by late-onset neonatal sepsis, when it is infected a few days after delivery. This infection can be due to the organisms present in the environment of the hospital. After getting discharged from hospital, babies can get infected due to the bacteria present in the environment at home. GBS and E. coli are also responsible for late-onset neonatal sepsis.
Risk Factors
There are number of risk factors related to the infant getting affected by neonatal sepsis. Males are noticed to be infected more than females, the ratio being 2:1. Risk factors of early-onset neonatal sepsis:
·
Frequent vaginal checkups during pregnancy.
·
Premature birth
·
Infected placenta
·
GSB infection to the mother during pregnancy.
Risk factors of late-onset neonatal sepsis:
·
Infected hospital environment
·
Staying in hospital for a long period of time.
Symptoms
Symptoms of early-onset neonatal sepsis are observed mostly within 24 hours of delivery, while that of late-onset neonatal sepsis can be observed between 8th-89th day of delivery. The following list gives the symptoms observed in infants suffering from neonatal sepsis:
Symptoms of early-onset neonatal sepsis are observed mostly within 24 hours of delivery, while that of late-onset neonatal sepsis can be observed between 8th-89th day of delivery. The following list gives the symptoms observed in infants suffering from neonatal sepsis:
·
Unstable body temperature
·
Unable to suck breast milk properly.
·
Apnea
·
Fever in rare cases.
·
Vomiting and diarrhea
·
Respiratory distress
·
Reduced heart rate
·
Jaundice
·
Belly area may be swollen
Diagnosis
Physical examination of the baby and the laboratory tests help to diagnose the infection. The physical examination include, assessing the body temperature, heart rate, breathing, etc. The laboratory tests aim at finding out the bacteria/virus that has caused infection. Blood tests that are performed on the infant consist of WBC count, platelet count, blood culture, etc. Chest X-rays and urine tests are performed, when infection due to bacteria is suspected.
Treatment
Neonatal sepsis should be treated at the earliest because the immune system of an infant is not completely developed and the infection may be fatal. Antibiotics are recommended when diagnosis is not yet confirmed. This can help prevent further complications. Further treatment depends on the result of the laboratory tests. Infections caused due to GSB and E. coli are given medications, like ampicillin and gentamicin. These medications help in curing early-onset neonatal sepsis. Intravenous immune globulin replacement, granulocyte transfusions are the treatments given, if the infection is too severe. If the baby is given the proper treatment, it can recover soon from the infection. Pregnant women having GSB infection can be given antibiotics that can prevent the baby from getting infected by the same.
A child suffering from neonatal sepsis should be given treatment at the earliest. Chances of the baby getting infected can be reduced, if the delivery is done in a germ-free environment, proper care of mother is taken during pregnancy and exposing the child to any infection after delivery is avoided. Premature babies are highly susceptible to neonatal sepsis, so baby care should be taken to a great extent. In United States, neonatal sepsis cases are found in 1-8 live births among 1000. 50% mortality rate has been noticed, if the infection goes untreated.
Physical examination of the baby and the laboratory tests help to diagnose the infection. The physical examination include, assessing the body temperature, heart rate, breathing, etc. The laboratory tests aim at finding out the bacteria/virus that has caused infection. Blood tests that are performed on the infant consist of WBC count, platelet count, blood culture, etc. Chest X-rays and urine tests are performed, when infection due to bacteria is suspected.
Treatment
Neonatal sepsis should be treated at the earliest because the immune system of an infant is not completely developed and the infection may be fatal. Antibiotics are recommended when diagnosis is not yet confirmed. This can help prevent further complications. Further treatment depends on the result of the laboratory tests. Infections caused due to GSB and E. coli are given medications, like ampicillin and gentamicin. These medications help in curing early-onset neonatal sepsis. Intravenous immune globulin replacement, granulocyte transfusions are the treatments given, if the infection is too severe. If the baby is given the proper treatment, it can recover soon from the infection. Pregnant women having GSB infection can be given antibiotics that can prevent the baby from getting infected by the same.
A child suffering from neonatal sepsis should be given treatment at the earliest. Chances of the baby getting infected can be reduced, if the delivery is done in a germ-free environment, proper care of mother is taken during pregnancy and exposing the child to any infection after delivery is avoided. Premature babies are highly susceptible to neonatal sepsis, so baby care should be taken to a great extent. In United States, neonatal sepsis cases are found in 1-8 live births among 1000. 50% mortality rate has been noticed, if the infection goes untreated.
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