Neonatal Sepsis Dr.Kanithi Ravishankar MD(pediatrics) DM(Neonatology) Consultant Neonatologist Sowmya Children Hospital

Prologue Common illness (sometimes wastebasket diagnosis) Great killer (or rather spoiler) Growing stronger day by day Incidence depends on Design (space,ventilation etc) Nurse-to-baby ratio Infection control practices Invasiveness Antibiotic use and abuse

What can neonatal sepsis lead to? Death Prolonged hospitalization Neurological morbidity CNS infection Hypoxemic/ischemic injury Biotrauma

Why are neonates more susceptible to septicemia? Weak and easily/often broken barrier Neonatal PMNs are deficient in chemotaxis and killing capacity Immature T and NK cells Immunoglobin and complement deficiencies

Clinical features

Laboratory investigations CBP Leukopenia (TLC <5000/cmm) Neutropenia (ANC <1800/cmm) Immature neutrophil to total neutrophil (I/T) ratio (> 0.2) Micro ESR (> 15mm 1st hour) CRP Low platelet count Pro-calcitonin Blood Culture CSF analysis

Choosing antibiotics Knowledge of bacteriological profile in the unit Refrain from prophylactic antibiotics Preference for narrow spectrum antibiotics Stop antibiotics when culture negative

Adjuvants and supportive therapy IVIG Blood products Exchange transfusion Colony stimulating factors Glucose homeostasis Electrolyte balance Ventilation Inotropes

Hospital acquired sepsis On the rise Rampant antibiotic abuse Invasiveness Resistant bugs - mutations (betalactamases, ESBL’s and carbapenases) and gene transfer(plasmid) Emergence of fungal infections

Case Baby P, male 7 days old referred from a distant town. Term birth asphyxia. Maternal PIH. Emergency LSCS. Weight 2.8 kg. Ventilated for 6 hrs. later had 2 episodes of seizures-controlled. Had RD since birth. Administered the following antibiotics- ceftazidime, amikacin, piperacillin-tazobactum and meropenem. Also used FFP. Referred for persistent RD and Oxygen requirement. On examination , at admission, severe sclerema, abdominal distention and mod RD. CXR N. Functional ECHO showed biventricular dysfunction. FS 18%. Platelet count 12000/cmm. CRP 82mg/L. Blood culture E.Coli resistant to all antibiotics. Started diuretics and other appropriate medications. Discharged after 22 days.

Antibiotic overuse and abuse ‘Almost every baby admitted to NICU is either infected or at very high risk of getting sepsis.’ ‘As we do not know about what organism is causing sepsis, we should start a broad coverage’ ‘any change in the condition warrants a change in antibiotics’ ‘safe to continue antibiotics as we do not have access to blood cultures or the final cultures take 7 days to be reported’

Infection control strategies

Infection control practices Strategic nursery design – space, sinks, soaps, paper towel Housekeeping protocols Adequate staffing Hand hygiene compliance Minimization of catheter days Sterile preparation of all fluids to be administered Promoting enteral feeding esp. with EBM/breastfeeding Monitoring/ surviellance of nosocomial infection Education and frequent feedback from staff

Good NICU planning

Adequate Staff

Good house-keeping

Hand-washing

Antibiotic policy

Do-not wait for NICU to become vacant for cleaning

OT like aseptic precautions for procedures

Utmost care during IV line insertion

Do-not disconnect IV infusion

Aseptic procedures

Early enteral feeding

Use human milk

Non-invasive management

Contact-Isolation

Monitoring and surviellance of nosocomial infection

Education

Conclusions Neonatal sepsis is a great killer and spoiler Human battle with microbes is getting tougher and tougher Do not make them stronger Clean care is the best care