management of neonatal sepsis niki kosmetatos, md anthony piazza, md ira adams-chapman, md j. devn...

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  • Slide 1
  • Management of Neonatal Sepsis Niki Kosmetatos, MD Anthony Piazza, MD Ira Adams-Chapman, MD J. Devn Cornish, MD Emory University Department of Pediatrics Note: Dr. Cornish does not have any financial relationships to disclose nor will he discuss any non-approved drug or device uses.
  • Slide 2
  • Babies and Bacteria Gram positive bacteria (anthrax) Gram negative bacteria (pseudomonas)
  • Slide 3
  • Dont mix!
  • Slide 4
  • Incidence Mortality Mortality 13-69% world wide 13-15% of all neonatal deaths (US) (8 th cause) Meningitis Meningitis 0.4-2.8/1000 live births (US 0.2-0.4/1000) Mortality 13-59%; US 4% of all neonatal deaths Sepsis Sepsis 1-21/1000 world wide; US,1-2/1000 live births Culture proven 2/1000 (3-8% of infants evaluated for sepsis); 10-20/1000 VLBW Prematures
  • Slide 5
  • Predisposing Factors Predisposing Factors General Host Factors Prematurity (OR 25 if < 1,000 gms) Prematurity (OR 25 if < 1,000 gms) Race GBS sepsis blacks>whites (x4) Race GBS sepsis blacks>whites (x4) Sex sepsis & meningitis more common in males, esp. gram negative infections Sex sepsis & meningitis more common in males, esp. gram negative infections Birth asphyxia, meconium staining, stress Birth asphyxia, meconium staining, stress Breaks in skin & mucous membrane integrity (e.g. omphalocoele, meningomyelocoele) Breaks in skin & mucous membrane integrity (e.g. omphalocoele, meningomyelocoele) Environmental exposure Environmental exposure Procedures (e.g. lines, ET-tubes) Procedures (e.g. lines, ET-tubes)
  • Slide 6
  • Predisposing Factors Maternal/Obstetrical Factors Maternal/Obstetrical Factors General socioeconomic status, poor prenatal care, vaginal flora, maternal substance abuse, known exposures, prematurity, twins Maternal infections chorioamnionitis (1-10% of pregnancies), fever (>38 C/100.4 F), sustained fetal tachycardia, venereal diseases, UTI/bacteriuria, foul smelling lochia, GBS+ (OR 204), other infections Obstetrical manipulation amniocentesis, amnioinfusion, prolonged labor, fetal monitoring, digital exams, previa/abruption? Premature & Prolonged ROM, preterm labor
  • Slide 7
  • Predisposing Factors Overall sepsis rate2/1000 Maternal Fever4/1000 PROM10-13/1000 Fever & PROM87/1000
  • Slide 8
  • Preterm Labor/PROM Prematurity (~10%) 15-25% due to maternal infection Prematurity (~10%) 15-25% due to maternal infection >18-24h term; >12-18h preterm >18-24h term; >12-18h preterm Bacterial infection Bacterial infection synthesis of PG Macrophage TNF/IL stimulate PG synthesis, cytokine release** Release of collagenase & elastase ROM + Amniotic fluid cultures 15% (with intact membranes) + Amniotic fluid cultures 15% (with intact membranes)
  • Slide 9
  • S EPSIS ORGANISMS (all babies) Group B strep (most common G+)41% Group B strep (most common G+)41% Other strep 23% Other strep 23% Coliforms (E. coli most common G-)17% Coliforms (E. coli most common G-)17% Staph aureus 4% Staph aureus 4% Listeria 2% Listeria 2% Nosocomial infections Nosocomial infections Candida Candida Note: 73% G+ and 27% G- Note: 73% G+ and 27% G-
  • Slide 10
  • S EPSIS ORGANISMS (VLBW) Group B strep (most common G+)12% Group B strep (most common G+)12% Other strep 9% Other strep 9% Coliforms (E. coli most common G-)41% Coliforms (E. coli most common G-)41% CONS 15% CONS 15% Listeria 2% Listeria 2% Nosocomial infections Nosocomial infections Candida 2% Candida 2% Note: 45% G+ and 53% G- Note: 45% G+ and 53% G- Source: Stoll et al Ped Inf Dis 2005, 24:635
  • Slide 11
  • Routes of Infection Transplacental/Hematogenous Transplacental/Hematogenous Ascending/Birth Canal Ascending/Birth Canal Aspiration Aspiration Device Associated Infection Device Associated Infection Nosocomial Nosocomial Epidemic Epidemic
  • Slide 12
  • Transplacental/Hematogenous Organisms (Not just TORCHS) Organisms (Not just TORCHS) Toxoplasmosis Parvovirus Rubella Gonorrhea Cytomegalovirus Mumps Herpes* TB Syphilis Varicella Acute VirusesHIV CoxsackiePolio AdenovirusGBS EchoMalaria EnterovirusLyme
  • Slide 13
  • Ascending/Birth Canal Organisms - GI/GU flora, Cervical/Blood Organisms - GI/GU flora, Cervical/Blood E. Coli Herpes GBSCandida ChlamydiaHIV UreaplasmaMycoplasma ListeriaHepatitis EnterococcusAnaerobes GonorrheaSyphilis HPV
  • Slide 14
  • Nosocomial Organisms Organisms Skin Flora, Equipment/Environment Staphylococcus Coagulase neg & pos MRSAKlebsiellaPseudomonasProteusEnterobacterSerratiaRotavirus Clostridium C dificile Fungi
  • Slide 15
  • InfectionTiming Onset Onset Early Onset 1 st 24 hrs 85 % 24-48 hrs5% 24-48 hrs5% Late Onset 7-90 days
  • Slide 16
  • Symptoms Non-specific/Common Non-specific/Common Respiratory distress (90%) - RR, apnea (55%), hypoxia/vent need (36%), flaring/grunting Temperature instability, feeding problems Lethargy-irritability (23%) Gastrointestinal poor feeding, vomiting, abdominal distention, ileus, diarrhea Color Jaundice, pallor, mottling Hypo- or hyperglycemia Cardiovascular Hypotension (5%), hypoperfusion, tachycardia Metabolic acidosis NICHD data
  • Slide 17
  • Symptoms Less common Less common Seizures DIC Petechiae Hepatosplenomegaly Sclerema Meningitis symptoms Meningitis symptoms Irritability, lethargy, poorly responsive Changes in muscle tone, etc.
  • Slide 18
  • Evaluation Non-specific Non-specific CBC/diff, platelets ANC, I/T ratio Radiographs CRP Fluid analysis LP, U/A Glucose, lytes, gases Specific Cultures, stains Specific Cultures, stains Other immunoassays, PCR, DNA microarray Other immunoassays, PCR, DNA microarray
  • Slide 19
  • Results Trigger Points CBC CBC WBC 2.0 I/T ratio > 0.2* Platelets < 100,000 CRP > 1.0 mg/dl CRP > 1.0 mg/dl CSF > 20 WBCs with few or no RBCs CSF > 20 WBCs with few or no RBCs Radiographs: infiltrates on CXR, ileus on KUB, periosteal elevation, etc. Radiographs: infiltrates on CXR, ileus on KUB, periosteal elevation, etc.
  • Slide 20
  • Treatment Prevention vaccines, GBS prophylaxis, HAND-WASHING Prevention vaccines, GBS prophylaxis, HAND-WASHING Supportive respiratory, metabolic, thermal, nutrition, monitoring drug levels/toxicity Supportive respiratory, metabolic, thermal, nutrition, monitoring drug levels/toxicity Specific antimicrobials, immune globulins Specific antimicrobials, immune globulins Non-specific IVIG, NO inhibitors & inflammatory mediators Non-specific IVIG, NO inhibitors & inflammatory mediators
  • Slide 21
  • Neonatal Sepsis: the special case of Group B Strep Sepsis
  • Slide 22
  • Mother to Infant Transmission GBS colonized mother (20-30% in US) Non-colonized newborn Colonized newborn Asymptomatic Early-onset sepsis, pneumonia, meningitis 50% 98%2%
  • Slide 23
  • RISK FACTORS Previous GBS-infected baby Previous GBS-infected baby Gestational age 18 hours Location of delivery (e.g., home) Location of delivery (e.g., home) Infant/Fetal symptommatology Infant/Fetal symptommatology Clinical suspicion Clinical suspicion Note: incidence has fallen 80% since CDC prevention guidelines were published in 1996 GBS S EPSIS
  • Slide 24
  • Mothers in labor or with ROM should be treated if: Chorioamnionitis Chorioamnionitis History of previous GBS+ baby History of previous GBS+ baby Mother GBS+ or GBS-UTI this preg. Mother GBS+ or GBS-UTI this preg. Mothers GBS status unknown and: Mothers GBS status unknown and: < 37 wks gestation ROM 18 hrs Maternal temp 38 o (100.4 o F)
  • Slide 25
  • Rate of Early- and Late-onset GBS Disease in the 1990s, U.S. Consensus guidelines 1st ACOG & AAP statements Group B Strep Association formed CDC draft guidelines published Schrag, New Engl J Med 2000 342: 15- 20
  • Slide 26
  • INFANTS TO BE SCREENED Maternal chorioamnionitis Maternal chorioamnionitis Maternal illness (i.e. UTI, pneumonia) Maternal illness (i.e. UTI, pneumonia) Maternal peripartum fever > 38 o (100.4 o F) Maternal peripartum fever > 38 o (100.4 o F) Prolonged ROM 18 hrs ( 12 hrs preterm) Prolonged ROM 18 hrs ( 12 hrs preterm) Mother GBS+ with inadequate treatment ( < 4 hrs ) Mother GBS+ with inadequate treatment ( < 4 hrs ) No screening necessary if C-section delivery with intact membranes GBS S EPSIS
  • Slide 27
  • INFANTS TO BE SCREENED Prolonged labor (> 20 hrs) Prolonged labor (> 20 hrs) Home or contaminated delivery Home or contaminated delivery Chocolate-colored/foul smelling amniotic fluid Chocolate-colored/foul smelling amniotic fluid Persistent fetal tachycardia Persistent fetal tachycardia SYMPTOMATIC INFANT SYMPTOMATIC INFANT treat immediately (in DR if possible) GBS S EPSIS
  • Slide 28
  • SEPSIS SCREEN CBC with differential CBC with differential Platelet count Platelet count Blood culture x 1-2 (ideally 1 ml) Blood culture x 1-2 (ideally 1 ml) Chest X-ray &/or LP if symptommatic Chest X-ray &/or LP if symptommatic Close observation and frequent clinical evaluation Close observation and frequent clinical evaluation Role of CRP Role of CRP GBS S EPSIS
  • Slide 29
  • * CBC, blood cx, & CXR if resp sx. If ill consider LP. ++ Duration of therapy may be 48 hrs if no sx. $ CBC with differential and bloo