Download Sepsis

Neonatal Sepsis
Author: Sherrill Roskam RNC MN NNP CNS
Updated presentation: Susan Greenleaf RNC, BSN
Objectives
Identify major causative organisms
and routes of transmission of sepsis.
Discuss clinical manifestations and
modalities used in diagnosis of sepsis.
Describe antibiotic therapy used in
the treatment of neonatal sepsis.
Sepsis
Definition: A systemic response to an
invasive organism. Frequently
signified by a positive blood culture.
A systemic illness due to the
presence of bacteria and or bacterial
toxins in the blood
Neonatal Immune System
Sepsis occurs in 1-8:1000 term
infants and 1:250 premature infants
Neonates are immunocompromised
even at term gestation
The neonatal immune system is
functional at birth, but not mature
Sepsis
Two types of sepsis
Early-onset sepsis, with in the first
72 hours of life
Late-onset sepsis, those infections
acquired later by horizontal
transmission. Highest risk for the
first month of life
Predisposing Factors: Pregnancy
Prematurity
PROM < 36 weeks
Prolonged ROM
Prolonged labor
Excessive manipulation
Predisposing Factors: Maternal
History of infection
Bacterial
Viral
History of GBS bacteriuria
History of previously affected infant
Temperature in labor
Predisposing Factors: Neonatal
Invasive procedures
Resuscitation
Intubation
IV starts / PICC lines
Umbilical Catheterization
Skin colonization
Predisposing Factors: Nursery
Humidifiers
Respiratory therapy equipment
Staff members
Unsterile equipment
Scales
Stethoscopes
Thermometers
Transmission
Transplacental
Ascending
Birth
Nosocomial
Antibodies
IgG
IgM
IgA
Human Immunoglobulins
Antibodies are the immunoglobulins
produced in response to specific
antigens
IgG is the only antibody that crosses
the placenta and provides
immuological protection over the first
few months
Transfer peaks at 32 weeks gestation
Immunoglobulins cont.
IgM and IgA are directly responsible for
antibodies against bacteria
Neonatal IgM production starts at 30
weeks gestation and increases over the
first year of life
IgA passes through breast milk to provide
early defense against infection. Found in
the intestinal tract.
Causative Organisms:
Bacterial
Group B strep
E Coli
Haemophilus Influenzae
Coagulase Negative Staph
Staph Aureus
Neisseria Meningitis
Listeria
Causative Organisms: Viral
Maternal in origin
Toxoplasmosis
Rubella
Cytomegalovirus
Herpes
Hepatitis B
HIV
Recognition: Clinical Signs
Temperature instability
Lethargy
Pallor, mottling, poor cap refill
Respiratory distress
Poor feeding
Apnea
Neurologic
Jaundice
Hypoglycemia
Recognition
Recognition is of utmost importance,
because newborns with sepsis can get
very sick very fast
Be aware of risk factors – review
maternal history
Diagnostic tests for sepsis
CBC
Cultures
Blood ~ Most common Gold Standard
Urine
Surface - only indicates colonization
CSF Lumbar puncture
CRP
C-Reactive Protein
What is CRP?
Laboratory test that identifies an
inflammatory response in the body.
Binds to Calcium and phosphocholine
sites; forming CRP-ligand complexes.
CRP
CRP’s unique binding characteristics
have led to the identification of
elevated CRP levels in over 70
different infectious and
noninfectious disorders.
It is associated with acute and
chronic inflammatory disorders.
CRP Continued. . .
Paired mother and infant sampling
shows that CRP does not cross the
placenta.
4 types of inflammatory response to
tissue injury
Infectious, noninfectious, chemical,
physical or immunologic toxins.
Use of CRP
2 schools of thought
Early diagnostic tool for confirming
sepsis
Screening tool to r/o the presence of
sepsis
CRP Levels: What is normal?
In the neonatal period: Level of 10mg/L is
considered normal
Healthy full-term and preterm infants may
range from 2 to 5mg/L during the first
few days of life.
More than 1 Level?
Conflicting information about
obtaining more than one level
Serial CRP levels drawn 12 to 24
hours after onset of S/S of sepsis
may be superior to a single level.
More About the CBC: WBC
White cell count
Differential
Neutrophils - bacteria fighting cells
Polys, Segs - most mature
Bands - immature
Metas – really immature
Absolute Neutrophil Count
I:T Ratio
White Blood Cells
The main defense against invading
microorganisms
Neutrophils (pack man cells) and
macrophages(monocytes)
Circulating cells that migrate to sites of
inflamation, ingesting and killing foreign
material or bacteria (phagocytosis)
Small stores in neonates, not as effective in
killing bacteria, quickly depleted
Differential of the WBC
Mature Neutrophils – Segmented
Immature Neutrophils – Bands
Monocytes
Basophils
Eosinophils
Lymphocytes
Neutrophils
As mature neutrophols (polys, segs,
neuts, or PMNs) are mobilized and
consumed in the presence of a
pathogen, their numbers decrease
and immature cells are released from
the bone marrow.
Immature neutrophils (bands, metas
or stabs)
Absolute Neutrophil Count
(ANC)
Helps determine how many
neutrophils are available to fight
bacterial infections
Premature infants have lower ANC
than term infants
Must plot on the Manroe chart
How to calculate an ANC
Identify the immature and the
mature neutrophils on the CBC.
Add the segs, bands and metas ( total
number of neutrophils) together and
turn it into a percentage
Multiply this number by the total
WBC
This resulting number is the ANC
Manroe Chart
WBC: 20,000
Differential is expressed as a percent
of total white cells
Poly’s (Segs, Neuts):
48%
Bands
12%
Lymphs:
20%
Monos:
17%
Eso:
3%
ANC: Absolute number of neutrophils
WBC X % Neutrophils
ANC WBC X % Neutrophils
20,000 X .6 (60%) = 12,000
Manroe Chart
Immature to Total Ratio (I:T)
An Increased IT ratio is called a left shift.
It show an increase in the number of
immature sells
An IT ratio of >.25 may indicate sepsis
I/T ratio: Ratio of immature to total
neutrophils
___Bands + Meta___
Polys + Bands + Meta
WBC: 20,000
Differential is expressed as a percent
of total white cells
Poly’s (Segs, Neuts):
48%
Bands
12%
Lymphs:
20%
Monos:
17%
Eso:
3%
I/T ratio:
Bands + Metas
Polys + Bands + Metas
12/60=0.2 (not indicative of sepsis)
If WBC 3000 Polys 30 and Bands 15:
15/45=0.33 (indicative of sepsis)
3,000 X .45 (45%) = 1,350
Platelet Count
Normal Values
VLBW – 275,000 +/- 60,000
Preterm – 290,000 +/- 60,000
Term – 310,000 +/- 60,000
Infants with infection may have a low
platelet count
Management
Support Systems
Neutral Thermal Environment
Monitor
Cardiac/Respiratory
Pulse Oximetry
Vital signs
Feedings
IV
Management (con’t)
Antibiotics
Ampicillin 50-100 mg/kg/dose IV q8-12 hours
Varies with gestation and age
Gentamicin 4 mg/kg/dose IV q24-48 hours
Varies with gestation
Give over 30 minutes
Monitor Gent levels
Antiviral
Acyclovir 20 mg/kg/dose IV q8
Give over 1 hour
Do not refrigerate
Prognosis
Prognosis depends on organism
involved and when treatment
started
A bit more practice
CBC results
WBC
10.4
Metamyelocytes
0
Band Neutrophils
14
Segmented neutrophils 5
Platelets
141,000
What is the ANC and the IT ratio?
CBC Practice
CBC results
WBC
1.3
Metamyelocytes
2
Band Neutrohils
17
Segmented Neutrophils 42
Platelets
262,000
Calculate the ANC and IT ratio
CBC Practice
CBC results
WBC
6.3
Metamyelocytes
6
Band Neutrophils 44
Segmented Neutrophils 23
Platelets
95,000
What is the ANC and the IT ratio?
Same patient, 6 hours later
CBC results
WBC
0.8
Metamyelocytes
2
Band Neutrophils 4
Segmented Neutrophils 2
Platelets
24,000
What is the ANC and IT ratio?
References
Behrman, R. E., Kliegman, R.M.,Editors (1998) Nelson
Essentials of Pediatrics, 3rd Ed. Philadelphia: W.B.
Saunders Co.
Cloherty, J.P., Eichenwald, E.C., Stark, A.R. (2004) Manual
of Neonatal Care, 5th Ed. Philadelphia: Lippincott, Williams
& Wilkins.
Hengst, J.M., The Role of C-Reactive Protein in the
Evaluation and Management of Infants with Suspected
Sepsis. Advances in Neonatal Care. 2003;3(1):3-13.
References
Karlsen, K.A. (2001) The S.TA.B.L.E. Program:
Transporting Newborns the S.T.A.B.L.E.Way, Learner
Manual, 8th Ed.
Merenstein, G.B., Gardner, S.L. (2002) Handbook of
Neonatal Intensive Care, 5th Ed. St. Louis:Mosby Inc.