Transcript Slide 1

Resident Lecture Series:
Sepsis
Nneka I. Nzegwu, DO
Neonatal-Perinatal Clinical Fellow
Yale-New Haven Children’s Hospital
Objectives
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Define early and late onset sepsis
Describe the pathogens that occur in early
and late onset sepsis
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Describe the risk factors for neonatal sepsis
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Create a differential for neonatal sepsis
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Describe the workup for neonatal sepsis
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Know empiric treatment for neonatal sepsis
Introduction
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Neonatal sepsis is a common cause of
morbidity and mortality
Neonatal sepsis is a clinical syndrome
of systemic illness accompanied by
bacteremia in the first month of life
Definitions
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Early Onset Sepsis (EOS):
– Culture proven infection within the first
72 hours of life
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Late Onset Sepsis (LOS):
– Culture proven infection after 72 hours of
life
– Sepsis, UTI, pneumonia, meningitis,
osteomyelitis, NEC
Incidence
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1-5 per 1000 live births
Higher incidence of neonatal sepsis in
VLBWs
Mortality rate is high (13-25%)
Etiology: EOS
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Early Onset Sepsis (EOS):
– Group B Streptococcus (GBS)
– E. Coli
– Listeria monocytogenes
– Streptococcus species ie. Viridans
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Due to maternal or perinatal factors
Etiology: LOS
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Late Onset Sepsis (LOS):
– Coagulase-negative staphylococcus
– Staphylococcus aureus
– Gram negative bacilli ie. Klebsiella
– Candida spp.
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Nosocomial or focal infection
Etiology: Viral Sepsis
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Congenital
– Enteroviruses (ie. Coxsackievirus A & B)
– Herpes Simplex Virus
– TORCH infections ie. CMV, Toxoplasmosis
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Acquired
– HIV
– Varicella
– Respiratory syncytial virus
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Can be either early or late onset sepsis
Risk Factors
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Prematurity
Low birthweight
ROM > 18 hours
Maternal peripartum fever or infection
Resuscitation at birth
Multiple gestation
Male sex
Clinical Signs and Symptoms
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Lethargy
Hypo/hyperthermia
Feeding intolerance
Jaundice
Abdominal distention
Vomiting
Apnea
Differential Diagnosis
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Respiratory
Cardiac
CNS
GI
Inborn errors of metabolism
Hematologic
Sepsis Work-Up
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Blood cultures (x 2 due to low
sensitivity)
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Urine cultures
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Lumbar puncture
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Tracheal aspirates
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CBC with differential
Management : GBS Prophylaxis
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All women screened at 35-37 weeks
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Intrapartum antibiotics given to:
– GBS bacteruria during pregnancy
– GBS positive rectovaginal culture
– Prior infant w/ EOS GBS
– GBS unknown with risk factors
Temp > 100.4
 GA < 37 weeks
 ROM >18 hours
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Empiric Antibiotic Therapy
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EOS
– Penicillin and Aminoglycoside
– Ampicillin and Gentamicin
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LOS
– Vancomycin and Aminoglycoside
– Vancomycin and Gentamicin
Prognosis
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Low birth weight and gram negative
infection are associated with adverse
outcomes
Septic meningitis in preterm infants
may lead to neurological disabilities
– May acquire hydrocephalus or
periventricular leukomalacia
Question # 1
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What is the major risk factor for
neonatal sepsis?
– A. Maternal GBS colonization
– B. Male sex
– C. Prematurity
– D. ROM >18 hours
– E. Low birthweight
Question # 1

What is the major risk factor for
neonatal sepsis?
– A. Maternal GBS colonization
– B. Male sex
– C. Prematurity
– D. ROM >18 hours
– E. Low birthweight
Question # 2
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If meningitis is suspected what
antibiotic may be added for better CNS
penetration?
– A. Vancomycin
– B. Tobramycin
– C. Cefotaxime
– D. Ceftriaxone
– E. Meropenem
Question # 2
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If meningitis is suspected what
antibiotic may be added for better CNS
penetration?
– A. Vancomycin
– B. Tobramycin
– C. Cefotaxime
– D. Ceftriaxone
– E. Meropenem
Question # 3
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What is the gold standard for
diagnosing neonatal sepsis?
– A. Blood culture
– B. Lumbar culture
– C. CBC
– D. Chest X-ray
– E. CRP
Question # 3
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What is the gold standard for
diagnosing neonatal sepsis?
– A. Blood culture
– B. Lumbar culture
– C. CBC
– D. Chest X-ray
– E. CRP
PREP Case # 1
A 2,700 gram male infant born at 36 weeks’ gestation is being treated
for suspected neonatal sepsis following the development of
respiratory distress shortly after birth. His mother had a fever to
102° F (38.9° C) during labor and delivery, but reports she had no
illnesses during pregnancy.
Of the following, the MOST appropriate antibiotic regimen for this infant
is
A.
Ampicillin and an aminoglycoside
B.
Clindamycin and a third-generation cephalosporin
C.
Meropenem and an aminoglycoside
D.
Piperacillin and an aminoglycoside
E.
Vancomycin and a third-generation cephalosporin
PREP Case # 1
Of the following, the MOST appropriate antibiotic regimen for
this infant is
A.
B.
C.
D.
E.
Ampicillin and an aminoglycoside
Clindamycin and a third-generation cephalosporin
Meropenem and an aminoglycoside
Piperacillin and an aminoglycoside
Vancomycin and a third-generation cephalosporin
PREP Case # 2
You are called to labor and delivery to attend the vaginal
delivery of a 37 weeks' gestation male to a 24-year-old
primiparous mother. She reports that her membranes
ruptured 36 hours ago. She is afebrile.
Of the following, the maternal condition that is MOST likely to
require antibiotic therapy for this neonate is
A. Chorioamnionitis
B. Diabetes mellitus
C. Group B streptococcal colonization
D. Preeclampsia
E. Urinary tract infection in the first trimester
PREP Case # 2
You are called to labor and delivery to attend the vaginal
delivery of a 37 weeks' gestation male to a 24-year-old
primiparous mother. She reports that her membranes
ruptured 36 hours ago. She is afebrile.
Of the following, the maternal condition that is MOST likely to
require antibiotic therapy for this neonate is
A. Chorioamnionitis
B. Diabetes mellitus
C. Group B streptococcal colonization
D. Preeclampsia
E. Urinary tract infection in the first trimester
Summary
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Neonatal sepsis is a common cause of
morbidity and mortality
Blood culture is the gold standard for
diagnosis
Universal GBS prophylaxis of pregnant
women has significantly decreased the
rate of GBS EOS
References
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Fanaroff, A. A. & Martin, R. J. (Eds.). (2010). “Part
2: Postnatal Bacterial Infections”. NeonatalPerinatal Medicine: Diseases of the Fetus and
Infant. 9th ed.: October 2010; St. Louis: Mosby,
2010; 793-806.
Gomella, TL, Cunningham, MD, Eyal FG, and Zenk
KE. Zenk. "Sepsis." Neonatology: management,
procedures, on-call problems, diseases, and drugs.
6th ed. New York: Lange Medical Books/McGrawHill Medical Pub. Division, 2009; 665-672.
References
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Bentlin MR, Rugolo LMSS. Late-onset Sepsis:
Epidemiology, Evaluation, and Outcome.
Neoreviews 2010; 11(8): e426-e435.
Pupulo KM. Epidemiology of Neonatal Early-onset
Sepsis. Neoreviews 2008; Volume 9(12): e571e578.
Centers for Disease Control and Prevention.
Prevention of Perinatal Group B Streptococcal
Disease. MMWR 2010; 59(RR-10): 1-32.