NEONATAL  INFECTION

   Infections are most important cause of mortality and morbidity in the neonatal period in Bangladesh. These can be reduced significantly by timely intervention.

Neonatal infections occur due to the invasion of neonates by harmful organisms.

There may be deeper invasion of blood or superficial infections. Superficial infections can develop deeper invasion.

Classification:

1.   Major infection: With deeper invasion & systemic manifestations

   a)      Septicemia

   b)      Pneumonia

   c)      Meningitis

   d)      UTI

   e)      Osteomyelitis  & septic arthritis

   f) Perinatal congenital (TORCH) infection

   g)      Tetanus neonatorum………..

   h)      Cong. syphilis

Important organism:

Klebsiella pneumoniae,  Pseudomonas,

Staph. Aurous, Anaerobes, 

E- Coli.

In some areas-- group –B Streptococcus , L-monocytogens…………….

2.   Minor infection – Superficial infections with localization & no systemic manifestation……..

   a)      Conjunctivitis – Staphylococcus, Chlamydia, trachomatis, N.gonorhoeae

   b)      Oral thrush →Candida  albecans

   c)      Omphalitis – Staph aureus

   d)      Pyderma – Staph /streptococcus

According to onset:

1.Early onset neonatal infections from birth to 7 days of age (Usually < 72 hrs)

Usually follows some maternal obstetrics  complications

2.Late  onset

By 7-30 days of age. Usually community acquired.

3.Late, late onset – after 30 days

Factors influencing neonatal infections:

1.Diverse modes of transmission of infection

-       transplacental infections, vertical transmission

2.Immunological deficiencies.

a)                       Due to diminished concentrations & functions of immunologic factors i.e  immunoglobin, complement, leucocytes cytokines, antibody, & RE system.

3.Associated conditions & coexisting disease

4.Gestational  age & birth wt.

   Premature  & LBW-- infections are 3-10 fold susceptable…………..

5.Sex – Males have 2 fold higher than females

6.Physical defense

7.Advanced neonatal care.

Features suggesting neonatal septicemia:

1.   Poor sucking

2.   Lethargy

3.   Poor cry

4.   Not rousable, comatose

5.   Distention of abdomen

6.   Cyanosis

7.   Tachypnea………………

8.   Chest retractions

9.   Grunting

10. Apnea/ Gasping

11. Hypo/ hyperthermia

12. Delayed capillary refill time

13. Bleeding maniesfestations

14. Irretability / seizures

Features suggestion of Pneumonia:

1.   Tachypnea

2.   Cyanosis

3.   Grunting

4.   Chest retractions

5.   Apnea/ Grunting

6.   Feeding difficulty

Features suggestive of meningitisp

1.   Fever

2.   Irritability

3.   Seizures…………

4.   Blank look

5.   High pitched cry

6.   Bulging fontanelle

7.   Poor feeding / vomiting

Risk factors for neonatal sepsis:

A.   Major risk factors:

   1.      Premature rupture of membrane (PROM) > 24 hrs

   2.      Maternal intrapertum fever >100.4⁰ f

   3.      Chorioamnienitis

   4.      Sustained fetal heart rate >160

B.  Minor risk factors:

   1.      PROM > 12 hrs

   2.      Maternal intrapertum fever > 99.5⁰ f

   3.      Mater WBC count >15000/mm³

     4.      Low APG AR score (<5 at 1min, <7 at 5 min)

   5.      LBW (<1500gm)

   6.      Preterm labor

   7.      Multiple gestations

   8.      Foul lochia

   9.      Maternal GBS colonization. Infant with 1 major or 2 minor risk factors should have  a CBC count and blood culture.

Laboratory investigations:

1.   Lab, diagnostic criteria for sepsis

   a.      Total WBC count < 5000/ mm³ > 30,000/ mm³

     b.      Band: Neutrophils >0.2 (>20%)

   c.      CRP +ve

   d.      Micro – ESR > 15 mm in 1^st hr.

   e.      Elevated heptaglobin

Interpretation:

   1.      If 5 tests are abnormal, the probality of infection is >90%

   If all 5 tests are normal, the probality of infection is only 1%

2.Blood culture

3.CSF study

4.Urine RME & C/S

5.CXR

6.Serum electrolytes, calcium, RBS

7.Arterial blood gas.

Management of major infection:

1.   Provide wormth, ensure constantly normal temperature

2.   Start 1/v line

3.   1mg vit k – 1 mg I/m stat

4.   Provide gentle stimulation if apnea

5.   O2- if required

6.   Provide bag & mask ventilation  with 02 therapy.

7.   Avoid enteral feeding if very sick. Otherwise BF should be continued

8.   Antibiotic- always parentrally

Ampicillin 50mg/kg /dose – 12 hourly and     / 1^st line 

a) Gentamicin 2.5 mg /kg/dose – 12 hourly

Infection presenting after 72 hrs of delivery to be treated with cloxacillin 50 mg/kg/dose – 12 hourly instead of Ampicillin.

Duration – 10-14 days

b)   Inj. Ceftriaxone – 100 mg/kg/day in 2^dd if meningitis is suspected

● Fluid restriction for inappropriate ADH secretion

● Anticonvulsant therapy for seizures

● Surgical drainage for seated obsess

9.   Antenatal prophylaxis:      

                     1.      Prom > 18 hrs

                     2.      Preterm labor

                     3.      Intrapartrem temp > 100.4⁰ F

                     4.      Culture +ve unkndwn status for GBS

10.                Supportive case:

a)                  Immunotherapy – IVIG (pentaglobin – 50 mg)

b.                  Granulocyte infusion

c.                  Double vol. exchange transfusion

d.                  DIC- FFP. Whole blood, platelet transfusion

Management of minor infection:

1.                  Conjunctivitis – Chloramphenical eye drop. Frequent penicillin drops. Ceftriaxone is required in gonococcal conjunctivitis

2.                  Oral thrush- Nystation drops

3.                  Omphalitis – Start parental infection

4.                  Pyoderma- Geution violet 1%

            Local antibiotic cream

            Parenteral antibiotic (if

            systemic manifestations )

Neonatal Convulsions:http://neonatalconvulsion.blogspot.com/