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• Neonatal sepsis


  Sepsis in newborn babies
• 40% of child deaths in the developing world occur in the first month of life
• Risk factors for neonatal sepsis

  • Mother: Prolonged rupture of membranes (>24 hours), maternal fever (>38 C), chorioamnionitis
  • Baby: Preterm
  • Environment: Home delivery
• Clinical features of neonatal sepsis

  • Fever/temperature instability/hypothermia
  • Poor feeding/vomiting
  • Apnoea/bradycardia
  • Respiratory distress
  • Shock
  • Jaundice
  • Hypo-/hyperglycaemia
  • Abdominal distension
  • Irritability/seizures
• Localising signs of neonatal sepsis

  • Joints: painful, swollen, reduced movement, local tenderness
  • Skin: pustules
  • Umbilicus: redness, pus
  • Meninges: bulging fontanelle, opisthotonus
• Conjunctivitis


  'Sticky eyes' common<|>Clean gently<|>Treat with topical antibiotic eye ointment (tetracycline) for 5 days. Review after 48 hours<|>Purulent discharge and eyelid swelling: Likely Gonococcus or Chlamydia trachomatis, Wash eyes and give Ceftriaxone IM stat, Treat mother and partner, Counsel for HIV testing and screen for syphilis
• Neonatal meningitis


  • May not display classical signs of meningeal inflammation, Need to rule out, especially in 'Late-onset neonatal sepsis' (LONS)
• CSF examination


  1. Lumbar puncture under aseptic technique (L3/4 or L4/5)

  2. Contraindications: Elevated ICP due to mass lesion, Signs of impending cerebral herniation in child with probable meningitis, Critical illness, Skin infection at site of LP, Thrombocytopenia
• CSF normal ranges


  White cell count/mm3: <15<|>Protein (mg/dL): <120<|>Glucose: 60% blood glucose
• Normal CSF is clear, Essential to perform Gram stain (possibly acid fast stain/India ink also), Presence of red blood cells suggests traumatic tap or subarachnoid haemorrhage
• Neonatal meningitis complications


  • Cerebral abscess (beware of persistent fever)
  • Ventriculitis
  • Hydrocephalus (measure head circumference daily)
  • Mortality of 20-50%
  • Morbidity: One third of survivors have serious sequelae (hearing loss, neurodevelopmental impairment)

  
• Nosocomial infection


  Risk in any neonatal unit or postnatal ward, STRICT HANDWASHING/USE OF ALCOHOL GEL, Indwelling catheters at risk of colonisation, especially with Coagulase-negative Staphylococcus. Remove when no longer required.
• Causative organisms - Early-onset (0-48h)


  • Resource-rich: Most commonly Escherichia coli, Group B streptococcus (Streptococcus agalactiae). Listeria monocytogenes less common.
  • Resource-poor: Most commonly Escherichia coli, Klebsiella pneumoniae.
• Causative organisms - Late-onset (48h-28days)


  • Resource-rich: Gram negative organisms, Staphylococcal aureus, Streptococcal pneumoniae, Coagulase-negative Staphylococcus (indwelling lines)
  • Resource-poor: Gram negative organisms, Staphylococcal aureus, Streptococcal pneumoniae
• Group B streptococcus

  Commonly found in female genitourinary tract, Early-onset disease: Day 1-3 of life, Pneumonia, septicaemia, meningitis (less common), Late-onset disease: One week – 3 months of life, Usually causes meningitis but may cause focal infection e.g. osteomyelitis
• Listeria monocytogenes

  Transmitted to mother in food e.g. unpasteurised milk, undercooked chicken, Infection in pregnancy may cause spontaneous abortion, preterm delivery or fetal infection (transplacental/ascending), Classically causes meconium-stained liquor, Early-onset disease: First few hours of life, Septicaemia, pneumonia, rash, meningitis, Late-onset disease: 1-8 weeks of age, Often meningitis, Better prognosis
• Investigation of neonatal sepsis

  1. Blood tests: CBC, Blood glucose, If available, inflammatory markers e.g. CRP (acute phase reactant)

  2. Cultures: Blood, CSF, Urine (in LONS), Pus

  3. Imaging: Chest radiograph (if respiratory symptoms)
• Management of neonatal sepsis

  Admit to hospital, Supportive treatment: Oxygen if required, Intravenous fluids/nasogastric feeds, Maintain normothermia, Treat seizures promptly, Antibiotics: Ampicillin and gentamicin, Add cloxacillin if skin pustules or abscesses, Consider changing antibiotics after 2-3 days if not improving
• Prevention of neonatal infection

  1. Early: Good hygiene during delivery, Attention to cord care (keep clean and dry), Eye care

  2. Late: Exclusive breastfeeding, Strict handwashing/use of alcohol gel, Avoid incubator use if possible (KMC), Strict sterility for procedures, Remove intravenous cannulae when no longer required