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Ophthalmia Neonatorum (Newborn Conjunctivitis, Neonatal Conjunctivitis)

Conjunctivitis
Ophthalmia neonatorum is conjunctivitis that occurs in the newborn. Conjunctivitis is an inflammation of the surface or covering of the eye because of infectious or non-infectious causes. Any eye infection that occurs in the first month of a babys life can be classified as ophthalmia neonatorum. While an infection has the potential to damage the delicate eye of an infant, there are a number of ways these infections can be prevented.

Definition
Neonatal conjunctivitis is defined as conjunctivitis presenting before 1 month of age Generally it can be divided into noninfectious and infectious categories.
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The most common noninfectious cause is a chemical conjunctivitis induced by silver nitrate solution used for prophylaxis against infectious conjunctivitis. Bacterial, chlamydial, and viral infections are major causes of infectious neonatal conjunctivitis; chlamydia is the most common. Other infectious agents that the infant may acquire as it passes through the birth canal during include, Streptococcus spp., Staphylococcus spp., Escherichia coli, Haemophilus spp., Neisseria gonorrhea, and herpes simplex .The time of onset of the conjunctivitis as well conjunctival scraping can aid in the diagnosis of the specific etiology of the neonatal conjunctivitis If an infection does occur, effective treatment is available for infants who develop an eye infection. If you suspect your baby may be at risk for an infection, or may have an eye infection, you should contact your doctor immediately.

Causes
The cause of the conjunctivitis may be simply an irritation in the eye, or a blocked tear duct. However, bacteria can also cause an infection in the eye. The most common types of bacteria that cause infection in the infants eye come from the mothers birth canal, and are passed to the infant during delivery. These infections can include:

Sexually transmitted diseases (STDs)The most common bacteria passed to infants during delivery are due to STDs from the mothers birth canal. If untreated, many of these infections can cause serious damage to the infants eye. STDs that can cause eye damage include: o Chlamydia aureus o Gonorrhea o The virus that causes oral and genital herpes Skin bacteria such as Staphylococcus Bacteria from the mothers gastrointestinal tract, such as Pseudomonas

Risk Factors
The biggest risk factor for developing ophthalmia neonatorum is a maternal infection or STD at the time of delivery. Unfortunately, with some infections, the mother may not have any symptoms during delivery and still be able to transmit the infection. If you are pregnant, it is important to discuss any STDs that you have, or had in the past. You and your doctor can develop a plan to protect your baby from infections during delivery.

Symptoms :
Redness and swelling of the conjunctiva in the newborn. If your baby has this or any of the other symptoms described below, see your pediatrician. baby's

Some of the other symptoms of ophthalmia neonatorum include: Drainage and discharge from the eye; it may be watery or thick and pus-like. Swollen eyelids .

Diagnosis:
If your babys pediatrician suspects ophthalmia neonatorum your physician will first perform an eye examination. The doctor will look at your babys eyes to check for anything that may be irritating the eye, and to see if any damage has occurred. The doctor may look at the babys tear ducts to see if they are blocked. The doctor may also want to take a sample of any discharge to determine what type of bacteria or virus is causing the infection.

Treatment:
Since the potential for serious eye damage to the infant is so great, it is standard treatment in US hospitals to give infants antibiotic eye drops or ointment immediately following delivery. This helps prevent the development of an eye infection even if the mother shows no symptoms of infection. In cases where conjunctivitis does develop, the treatment of ophthalmia neonatorum depends on the cause: Blocked Tear Duct In cases of ophthalmia neonatorum that are due to a blocked tear duct, the doctor may recommend warm compresses and gentle massage to the area to help unclog the duct. Irritation Ophthalmia neonatorum due to irritation usually resolves on its own in a few days. In some cases, the irritation may be due to the antibiotic given after delivery. Silver nitrate, which was often used in the past to prevent eye infection, can cause irritation in the babys eye. Many hospitals now use other types of antibiotics to avoid this irritation. Bacteria Infants that have an eye infection due to bacteria are given antibiotics. These antibiotics may be given as topical drops or ointments, orally, or as an injection. In addition, the eye may be irrigated to remove the discharge. Fortunately, since hospitals today have such effective prevention measures, bacterial cases of ophthalmia neonatorum are rare. And when they do occur, they are usually identified quickly. Antibiotic treatment is very effective and generally, the infection resolves rapidly. If you suspect that your infant may have an infection in the eye, it is important to call your babys doctor as soon as possible to receive prompt treatment.

Prevention:
The best prevention of ophthalmia neonatorum is treatment of any sexually transmitted diseases in the mother prior to labor and delivery. In most cases, effective treatment of the mother before the time of delivery can prevent the transmission of infection to the newborn. For mothers with active genital herpes lesions at the time of delivery, a cesarean section can prevent the infant from getting the infection. An open, honest relationship with your doctor is

important during your pregnancy. Disclosure of your full medical history can help protect your baby from infection

Table 1. Fig. 1. Neonatal conjunctivitis.

TABLE 1. Time of Onset (Days after Birth) 02 27

Etiology (Clinical Presentation) Chemical (mild lid edema with watery discharge) Gonococcal (severe lid swelling with purulent discharge) Chlamydial (variable lid swelling with serous or purulent discharge) Bacteria (Staphylococcus, Streptococcus, Haemophilus purulent discharge) Herpes simples virus (serous discharge with dendritic keratitis or geographic ulcers)

Conjunctival Scraping

Minimal reactive cells to few PMN Many reactive cells with gram negative intracellular diplococci Many reactive cells with Giemsa stain for basophilic cytoplasmic inclusion bodies or direct immunofluorescent assay Gram stain for bacteria

310

47

314

Variable reactive cells with multinucleated giant cells

Laboratory studies:
Laboratory studies for neonatal conjunctivitis are essential for proper management and diagnosis. Initial culture on chocolate agar or a Thayer-Martin test for N. gonorrhoeae should be obtained as well as blood agar for other bacteria. Chlamydial infection can be ruled out with a conjunctival scraping Giemsa stain for intracytoplasmic inclusion bodies or direct immunofluorescent antibody assay. In herpetic conjunctivitis, gram stain may reveal multinucleate giant cells or Papanicolaou smear may show eosinophilic intranuclear inclusions in epithelial cells. Culture for herpes simplex virus also can be indicated if a corneal epithelial defect is present or the diagnosis cannot be made on ocular examination

alone with presence of vesicular lesions.

Medical treatement:
Topical 1% silver nitrate, 0.5% erythromycin, and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea and chlamydial ophthalmia in newborn infants. Recent studies indicate that 2.5% povidone-iodine solution also may be effective in preventing neonatal ophthalmia and appears to cause less chemical conjunctivitis as compared with either silver nitrate or erythromycin.7 Specific treatment for chemical conjunctivitis is not necessary, with spontaneous resolution in 2 to 3 days. Specific treatment for infectious neonatal conjunctivitis is based on the clinical picture and the findings on Gram, Giemsa, and Papanicolaou stains. Most bacterial conjunctivitis respond quickly to topical antibiotic treatment; erythromycin, or bacitracin ointment for gram-positive organisms; gentamicin or tobramycin drops for gramnegative organisms; and fortified topical antibiotics for Pseudomonas. Gonococcal conjunctivitis can progress rapidly. It presents with severe purulent conjunctivitis with lid edema and chemosis This organism can penetrate intact corneal epithelium and cause rapid ulceration and perforation. Acute neonatal conjunctivitis should be treated as gonococcal conjunctivitis until culture results become available, after which the treatment can be altered based on laboratory results. cephalosporin Treatment before laboratory results should include topical erythromycin ointment and penicillin G intravenous (IV) or intramuscular (IM) thirdgeneration. Because of the prevalence of penicillin-resistant N. gonorrhoeae, the treatment of choice for this organism is a systemic, third-generation cephalosporin such as ceftriaxone 30 to 50 mg/kg per day in divided doses IV or IM, not to exceed 125 mg. Irrigation of the affected eyes with saline until discharge is eliminated may be useful. In addition, a single dose of cefotaxime 100 mg/kg IM is an alternative treatment. The mother and her sexual contacts also should be treated. A pediatrician should be consulted for possible extraocular involvement. Fig. 2. Gonococcal conjunctivitis.

Chlamydial conjunctivitis has a later onset than gonococcal conjunctivitis typically from 3 to 10 days after birth. It is much more indolent and less severe. Diagnosis is made by observing intracytoplasmic inclusion bodies by Giemsa stain or direct immune fluorescent assay, which has high sensitivity and specificity. Treatment includes both topical erythromycin ointment and oral erythromycin 30 to 50 mg/kg per day divided in four doses. Typical treatment lasts for 2 weeks to prevent recurrence and secondary pneumonitis. Both parents also should be treated for chlamydia even if they are asymptomatic. Herpetic conjunctivitis can be the sole manifestation of a neonate infected with herpes simplex. Most cases of herpetic conjunctivitis are type II; however, up to 30%

can be type I. Most present with later onset conjunctivitis with corneal keratitis usually presenting as microdendrites or small geographic ulcers. Treatment consists of topical trifluorothymidine 1% drops every 2 hour or 3% vidarabine ointment. In cases with systemic involvement (e.g., pneumonitis, septicemia, or meningitis), systemic acyclovir should be used.

Neonatal sepsis

Introduction
Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days old. Early-onset sepsis is seen in the first week of life. Late-onset sepsis occurs between days 8 and 89. In common clinical usage, neonatal sepsis specifically refers to the presence of a bacterial blood stream infection (BSI) (such as meningitis, pneumonia, pyelonephritis, or gastroenteritis) in the setting of fever. Older textbooks may refer to neonatal sepsis as "Sepsis neonatorum". Criteria with regards to hemodynamic compromise or respiratory failure are not useful clinically because these symptoms often do not arise in neonates until death is imminent and unpreventable. Neonatal sepsis is divided into two categories: Early Onset Sepsis (EOS) and Late Onset Sepsis (LOS). EOS refers to sepsis presenting in the first 7 days of life (although some refer to EOS as within the first 72 hours of life), with LOS referring to presentation of sepsis after 7 days (or 72 hours, depending on the system used). It is difficult to clinically exclude sepsis in newborns less than 90 days old that have fever (defined as a temperature > 38C (100.4F). Except in the case of obvious acute viral bronchiolitis, the current practice in newborns less than 30 days old is to perform a complete workup including complete blood count with differential, blood culture, urinalysis, urine culture, and cerebrospinal fluid(CSF) studies and CSF culture, admit the newborn to the hospital, and treat empirically for serious bacterial infection for at least 48 hours until cultures are demonstrated to show no growth. Attempts have been made to see whether it is possible to risk stratify newborns in order to decide if a newborn can be safely monitored at home without treatment despite having a fever. One such attempt is the Rochester criteria.

Definition:
Neonatal sepsis is defined as a clinical syndrome of bacteremia with systemic signs and symptoms of infection in the first 4 weeks of life. When pathogenic bacteria gain access into the blood stream, they may cause overwhelming infection without much localization (septicemia) or may get predominantly localized to the lung (pneumonia) or the meninges (meningitis).

Importance :
Neonatal sepsis is the single most important cause of neonatal deaths in the community, accounting for over half of them. If diagnosed early and treated aggressively with antibiotics and good supportive care, it is possible to save most cases of neonatal sepsis.

Etiology
Most cases of neonatal sepsis in the community are caused by Escherichia coli and Staphylococcus aureus. In hospitals, Klebsiella pneumoniae is also a common organism

Early vs. late sepsis


Neonatal sepsis can be classified into two sub-types depending upon whether the onset of symptoms is before 72 hours of life (early onset) or later (late onset). Earlyonset infections are caused by organisms prevalent in the maternal genital tract or in the delivery area. The associated factors for early-onset sepsis include low birth weight,

prolonged rupture of membranes, foul smelling liquor, multiple per vaginum examinations,

difficult or prolonged labour and aspiration of meconium. Early onset sepsis manifests frequently as pneumonia and less commonly as septicemia or meningitis. Late-onset septicemia is caused by the organisms thriving in the external environment of the home or the hospital. The infection is often transmitted through the hands of the care-providers. The onset of symptoms is usually delayed beyond 72 hours after birth and the presentation is that of septicemia, pneumonia or meningitis. The associated factors of late-onset sepsis include: low birth weight, lack of breastfeeding, superficial infections (pyoderma, umbilical sepsis), aspiration of feeds, disruption of skin integrity with needle pricks and use of intravenous fluids. These factors enhance the chances of entry of organisms into the blood stream of the neonates whose immune defences are poor as compared to older children and adults.

Clinical signs of neonatal sepsis


The signs of sepsis are non-specific and include: lethargy, a poor cry, poor feeding, fever, jaundice, poor perfusion, sclerema, poor weight gain, renal failure, cyanosis, tachypnea, chest retractions, grunt, apnea/gasping, fever, seizures, a blank look, high pitched cry, excessive crying/irritability, neck retraction, bulging fontanelle and seizures. A heart rate above 160 can also be an indicator of sepsis, this tachycardia can present up to 24 hours before the onset of other signs.

Symptoms
Infants with neonatal sepsis may have the following symptoms:

Body temperature changes Breathing problems Diarrhea Low blood sugar Reduced movements Reduced sucking Seizures Slow heart rate Swollen belly area Vomiting Yellow skin and whites of the eyes (jaundice)

Clinical features

The manifestations of neonatal septicemia are often vague and therefore demand a high index of suspicion for early diagnosis (Table I). The most common and characteristic manifestation is an alteration in the established feeding behavior in late onset sepsis and respiratory distress in early onset sepsis. The baby, who had been active and sucking well, gradually or suddenly, becomes lethargic, inactive or unresponsive and refuses to suckle. Hypothermia is a common manifestation of sepsis, whilst fever is infrequent. Diarrhea, vomiting and abdominal distension may occur. Episodes of apneic spells or gasping may be the only manifestation of septicemia. In sick neonates, the skin may become tight giving a hide-bound feel (sclerema) and the perfusion

becomes poor (capillary refill time of over 3 seconds). Cyanosis may appear. A critical neonate may develop shock, bleeding and renal failure.
: Clinical manifestations of neonatal sepsis: Lethargy Refusal to suckle Poor cry Not arousable, comatosed Abdominal distension Diarrhea Vomiting Hypothermia Poor perfusion Sclerema Poor weight gain Shock Bleeding Renal failure Cyanosis* Tachypnea* Chest retractions* Grunt* Apnea/gasping* + Fever + Seizures + Blank look + High pitched cry Excessive + crying/irritability + Neck retraction + Bulging fontanel

The additional features of pneumonia or meningitis may be present depending upon the localization of infection in different systems and organs of the body. The evidence of pneumonia includes tachypnea, chest retractions, grunting, early cyanosis and apneic spells in addition to inactivity and poor feeding. Cough is unusual. Findings on auscultation of the chest are nonspecific and non- contributory. Meningitis is often silent, the clinical picture being dominated by manifestations of associated septicemia. However, the appearance of excessive or high-pitched crying, fever, seizures, blank look, neck retraction or bulging anterior fontanel are highly suggestive of meningitis. A large WHO study published in 2003 identified nine clinical features which predict severe bacterial illness in young infants ;

1. Feeding ability reduced 2. No spontaneous movement 3. Temperature >38 C 4. Prolonged capillary refill time 5. Lower chest wall in drawing 6. Resp rate > 60/minute 7. Grunting 8. Cyanosis 9. H/o of convulsions

Risk factors:
A study performed at Strong Memorial Hospital in Rochester, New York, showed that infants 60 days old meeting the following criteria were at low-risk for having a serious bacterial illness:

generally well-appearing previously healthy

full term (at 37 weeks gestation) no antibiotics perinatally no unexplained hyperbilirubinemia that required treatment no antibiotics since discharge no hospitalizations no chronic illness discharged at the same time or before the mother no evidence of skin, soft tissue, bone, joint, or ear infection WBC count 5,000-15,000/mm3 absolute band count 1,500/mm3 urine WBC count 10 per high power field (hpf) stool WBC count 5 per high power field (hpf) only in infants with diarrhea
o o o o o o o

Those meeting these criteria likely do not require a lumbar puncture, and are felt to be safe for discharge home without antibiotic treatment, or with a single dose of intramuscular antibiotics, but will still require close outpatient follow-up. One risk for GBS infection is Preterm rupture of membranes. Screening women for GBS (via vaginal and rectal swabbing) and treating culture positive women with intra partum chemoprophylaxis is reducing the number of neonatal sepsis caused by GBS.

Cause:
A number of different bacteria, including Escherichia coli (E.coli), Listeria, and certain strains of streptococcus, may cause neonatal sepsis. Early-onset neonatal sepsis most often appears within 24 hours of birth. The baby gets the infection from the mother before or during delivery. The following increases an infant's risk of early-onset sepsis:

Group B streptococcus infection during pregnancy Preterm delivery Water breaking (rupture of membranes) that lasts longer than 24 hours before birth Infection of the placenta tissues and amniotic fluid (chorioamnionitis)

Babies with late-onset neonatal sepsis get infected after delivery. The following increase an infant's risk of sepsis after delivery:

Having a catheter in a blood vessel for a long time Staying in the hospital for an extended period of time

Diagnosis:
Neonatal sepsis screening: 1. 2. 3. 4. DLC showing increased numbers of polymorphs. DLC: band cells > 20%. increased haptoglobins. micro ESR (Erythrocyte Sedimentation Rate) titer > 55mm.

5. gastric aspirate showing > 5 polymorphs per high power field. 6. newborn CSF (CerebroSpinal Fluid) screen: showing increased cells and proteins. 7. suggestive history of chorioamnionitis, PROM (Premature Rupture Of Membranes), etc... Culturing for microorganisms from a sample of CSF, blood or urine, is the gold standard test for definitive diagnosis of neonatal sepsis. This can give false negatives due to the low sensitivity of culture methods and because of concomitant antibiotic therapy. Lumbar punctures should be done when possible as 10-15% presenting with sepsis also have meningitis, which warrants an antibiotic with a high CSF penetration. Direct method: Isolation of microorganisms from blood, CSF, urine, pleural fluid or pus is diagnostic. Indirect method: There are a variety of tests which are helpful for screening of neonates with sepsis. The most useful and widely used is the white blood cell count and differential count. An absolute neutrophil count of < 1800 per cmm is an indicator of infection. Neutropenia is more predictive of neonatal sepsis than neutrophilia but it may be present in maternal hypertension, birth asphyxia and periventricular hemorrhage. Immature neutrophils (Band cells + myelocytes + metamyelocytes) to total neutrophils ratio (l/T) > 0.20 means that immature neutrophils are over 20 percent of the total neutrophils because bone marrow pushes even the premature cells into circulation, to fight infection. Platelet count of less than 100,000 per cmm, toxic granules on peripheral smear and gastric aspirate smears showing more than 5 leucocytes per high power field are also useful indirect evidences of infection. The micro-ESR may be elevated with sepsis and fall of > 15 mm during first hour indicates infection. Acute phase reactants are also frequently used in predicting neonatal sepsis. The most widely used is C-reactive protein (CRP) which has a high degree of sensitivity for neonatal sepsis. The CRP can be affected by asphyxia, shock, meconium aspiration and prolonged rupture of membranes. There are a variety of other tests which can be used to predict sepsis but it may be difficult to perform them at all places and hence the clinical acumen remains crucial. A practical positive "sepsis screen" takes into account two

or more positive tests as given below: 1. Leukopenia (TLC <5000/cmm) 2. Neutropenia (ANC <1800/cmm) 3. Immature neutrophil to total neutrophil (I/T) ratio (> 0.2) 4. Micro ESR (> 15mm 1st hour) 5. CRP +ve If possible, lumbar puncture should be done in all cases of late onset (>72 hours) and symptomatic early onset sepsis because 10-15 percent of them may have associated meningitis. At a small hospital, one may only depend on the CSF cells. The implications of detecting meningitis in the setting of septicemia include: the need for using antibiotics with a high CSF penetration and provision of antibiotic treatment for at least 3 weeks, administered parenterally throughout.

Treatment:
Note that, in neonates, sepsis is difficult to diagnose clinically. They may be relatively asymptomatic until hemodynamic and respiratory collapse is imminent, so, if there is even a remote suspicion of sepsis, they are frequently treated with antibiotics empirically until cultures are sufficiently proven to be negative. In addition to fluid resuscitation and supportive care, a common antibiotic regimen in infants with suspected sepsis is a beta-lactam antibiotic (usually ampicillin) in combination with an aminoglycoside (usually gentamicin) or a third-generation cephalosporin (usually cefotaximeceftriaxone is generally avoided in neonates due to the theoretical risk of kernicterus.) The organisms which are targeted are species that predominate in the female genitourinary tract and to which neonates are especially vulnerable to, specifically Group B Streptococcus, Escherichia coli, and Listeria monocytogenes .(This is the main rationale for using ampicillin versus other beta-lactams.) Of course, neonates are also vulnerable to other common pathogens that can cause meningitis and bacteremia such as Streptococcus pneumoniae and Neisseria meningitidis. Although uncommon, if anaerobic species are suspected (such as in cases where necrotizing enterocolitis or intestinal perforation is a concern, clindamycin is often added. Granulocyte-macrophage colony stimulating factor (GM-CSF) is often used in neonatal sepsis, however a recent study found that, while GM-CSF corrects neutropenia if present, it has no effect on reducing sepsis or improving survival.

Exams and Tests:


Laboratory tests can help diagnose neonatal sepsis and identify the bacteria that is causing the infection. Blood tests may include:

Blood culture C-reactive protein Complete blood count (CBC)

A lumbar puncture (spinal tap) will be done to examine the cerebrospinal fluid for bacteria. If the baby has a cough or problems breathing, a chest x-ray will be taken.

Urine culture tests are done in babies older than several days.

Treatment:
Babies in the hospital and those younger than 4 weeks old are started on antibiotics before lab results are back. (Lab results may take 24-72 hours.) This practice has saved many lives. Older babies may not be given antibiotics if all lab results are within normal limits. Instead, the child may be followed closely on an outpatient basis. Babies who do require treatment will be admitted to the hospital for monitoring.

Outlook (Prognosis):
With prompt treatment, many babies with these bacterial infections will recover completely with no remaining problems. Nevertheless, neonatal sepsis is a leading cause of infant death. The more quickly an infant receives treatment, the better the outcome.

Possible Complications:

Disability Death

When to Contact a Medical Professional


Seek immediate medical help if your infant shows symptoms of neonatal sepsis.

Prevention
Preventative antibiotics may be given to pregnant women who have chorioamnionitis, Group B strep, or who have previously given birth to an infant with sepsis due to the bacteria. Preventing and treating infections in mothers, providing a clean birth environment, and delivering the baby within 24 hours of rupture of membranes, where possible, can all help lower the chance of neonatal sepsis.

Alternative Names
Sepsis neonatorum; Neonatal septicemia; Sepsis - infant

Supportive care :

The purpose of supportive care is to normalize the temperature, stabilize the cardiopulmonary status, correct hypoglycemia and prevent bleeding tendency (Table-II). The septic neonate should be nursed in a thermo neutral environment. If hypothermic, the temperature should be raised using a heat source. An intravenous line should be established. If perfusion is poor as indicated by a capillary refill time of more than 3 seconds, normal saline bolus should be infused immediately. A dextrose bolus will help correct hypoglycemia which is often present in septic infants. Vitamin K should be given to prevent bleeding. Oxygen should be provided if the infant is having retractions, grunt or cyanosis. Apneic neonates should be given physical stimulation and bag-mask ventilation, if required. Enteral feeds are avoided if infant is very sick or has abdominal distension. Appropriate maintenance intravenous fluids are administered. In neonates with sclerema, exchange transfusion with fresh whole blood may be contemplated. There is no role of intravenous immunoglobulin therapy in neonatal sepsis. TABLE -II: Supportive care of a septic neonate 1. Provide warmth, ensure consistently normal temperature 2. Start intravenous line. 3. Infuse normal saline 10 ml/kg over 5-10 minutes, if perfusion is poor as evidenced by capillary refill time (CRT) of more than 3 seconds. Repeat the same dose 1-2 times over the next 30-45 minutes, if perfusion continues to be poor. 4. Infuse glucose (10 percent) 2 ml/kg stat. 5. Inject Vitamin K 1 mg intramuscularly. 6. Start oxygen by hood or mask, if cyanosed or grunting. 7. Provide gentle physical stimulation, if apneic. 8. Provide bag and mask ventilation with oxygen if breathing is inadequate. 9. Avoid enteral feed if very sick, give maintenance fluids intravenously 10. Consider use of dopamine if perfusion is persistently poor. 11. Consider exchange transfusion if there is sclerema. Antibiotic therapy Antibiotic therapy should cover the common causative bacteria, namely, Escherichia coli, Staphylococcus aureus and Klebsiella pneumoniae. A combination of ampicillin and gentamicin is recommended for treatment of sepsis and pneumonia. In cases of suspected meningitis, cefotaxime should be used along with an aminoglycoside. Table III shows detailed guidelines about antibiotic therapy.

I. Septicemia or Pneumonia Antibiotic <7 days age Inj Ampicillin or Inj cloxacillin AND Inj Gentamicin or Inj Amikacin

TABLE III: Antibiotic therapy of neonatal sepsis Each dose Frequency Route Duration > 7 days age 8 hrly IV,IM 8 hrly 8 hrly 8 hrly IV IV, IM IV, IM

50 mg/kg/dose 50 mg/kg/ dose 2.5 mg/kg/dose 7.5 mg/kg/dose

12 hrly 12 hrly 12 hrly 12 hrly

7-10 days 7-10 days 7-10 days 7-10 days

In late-onset sepsis to cover nosocomial staphylococcal infection, first line of antibiotics may comprise of cloxacillin 100 mg per kg per day and an aminoglycoside (gentamicin or amikacin). In nosocomial sepsis, antibiotic sensitivity pattern of organisms responsible for nursery infection should be known and the antibiotic therapy should be started accordingly. Usually staphylococci and Gram negative bacilli (Pseudomonas, Klebsiella) should be covered using aminoglycoside (gentamicin or amikacin) and a third

II. Meningitis Antibiotic <7 days age (1)

Each dose

Frequency

Route

Duration

Inj Gentamicin OR (2) Inj Gentamicin

> 7 days age Inj 100 12 hrly 8 hrly IV Ampicilli mg/kg/ n dose and 2.5 mg/ 12 hrly 8 hrly IV kg/dose Inj 50 12 hrly 8 hrly IV Cefotaxi mg/kg/ me and dose 2.5 12 hrly 8 hrly IV mg/kg/ dose

3 weeks

3 weeks 3 weeks 3 weeks

generation cephalosporin (cefotaxime). For resistant staphylococcal infection, vancomycin (30 mg per kg per day) should be used. On confirmation of sensitivity pattern, appropriate antibiotics are used singly or in combination. In a baby in whom the antibiotics were started on low suspicion, these may be stopped after 3 days, if baby is clinically well and the culture is negative. However, if a baby appears ill even though the cultures are negative, antibiotic therapy should be continued for 7 to 10 days as bacterial infection can occur with negative cultures. The duration of antibiotic therapy in sepsis depends upon the pathogen, site of infection and the clinical response of the baby. 7-10 days therapy is required for soft tissue infections or pneumonia. Deep-seated infections (osteomyelitis) and meningitis may require therapy for 3-6 weeks.
Superficial infections

Superficial infections can be treated with local application of antimicrobial agents. Pustules can be punctured with sterile needles and cleaned with spirit or betadine. Purulent conjunctivitis can be treated with neosporin or chloramphenicol ophthalmic drops. Oral thrush responds to local application of clotrimazole or nystatin (200,000 units per ml) and hygienic precautions. Superficial infections must be adequately managed; if neglected they can lead to sepsis or even an epidemic. A good antenatal care goes a long way in decreasing the incidence, morbidity and mortality from neonatal sepsis. All mothers should be immunized against tetanus. All types of infections should be diagnosed early and treated vigorously in pregnant mothers. Babies should be fed early and exclusively with expressed breast milk (or breastfed) without any prelacteal feeds. Cord should be kept clean and dry. Unnecessary interventions should be avoided. This is the simplest and the most effective method for control of infection in the hospital. All persons taking care of the baby should strictly follow hand washing policies before touching any baby. The sleeves should be rolled above the elbows. Rings, watches and jewellery should be removed. Wash hands up to elbows with a thorough scrub for 2 minutes with soap and water taking care to cover all areas including the under surface of well trimmed nails. Rinse thoroughly with running water. Dry hands with sterile hand towel/paper towel. Wash hands up to the wrist for 20 seconds in between patients. Hands should be rewashed after touching contaminated material like ones face, hair, papers etc. It is preferable to use bar soaps rather than liquid soaps as the latter tend to harbor organisms after storage. In emergency situations bactericidal and

Prevention of infections

Hand washing

virucidal solutions like Sterillium can be used to clean hands before touching babies. Surgical, elbow- operated taps should be used in the hospitals for hand washing.
Prevention of infection in hospital

The nursery environment should be clean and dry with 24 hour water supply and electricity. There should be adequate ventilation and lighting. The nursery temperature should be maintained between 30+2C. Overcrowding should be avoided. All procedures should be performed after wearing mask and gloves. Unnecessary invasive interventions such as needle pricks and setting up of intravenous lines should be kept to the barest minimum. There should be no compromise in the use of disposables. Stock solutions for rinsing should be avoided. Every baby must have separate thermometer and stethoscope and all barrier nursing measures must be followed.Strict house-keeping routines for washing, disinfection, cleaning of cots and incubators should be ensured and these policy guidelines should be available in the form of a manual in the nursery. The use of prophylactic antibiotics for prevention of nosocomial infections is strongly condemned. They are not only useless but also dangerous because of the potential risk of emergence of resistant strains of bacteria. General measures for the control of an outbreak include detailed epidemiological investigations, increased emphasis on hand washing, review of protocols, procedures and techniques, disinfection and sterilization of nursery and assessment of the need for additional measures. The nursery may be fumigated using formalin 40% and potassium permanganate (70 gms of KMNO4 with 170 ml of formalin for 1000 cubic feet area). Alternatively, bacillocid spray for 1-2 hours may be used. Linen and cotton should be washed thoroughly, dried and autoclaved. Use of disposable items for invasive and non- invasive interventions (catheters, probes, cannulae, chest tubes etc.) though costly, reduces the risk of infection. Depending upon the pathogen and type of outbreak, culture surveys of susceptible patients, cohorting of infants in nursery and a review of antibiotic policy may be necessary. Most of the times a scrupulous reinforcement of general control measures may be sufficient to stop the outbreak.

Control of outbreak

Conclusion In conclusion, manifestations of neonatal sepsis are non-specific. A high index of suspicion with or without lab evidences of infection is the key for early diagnosis. Prompt institution of antibiotic therapy and supportive care will save most of the cases of neonatal sepsis.

References
Verani JR, McGee L, Schrag S. Prevention of Perinatal Group B Streptococcal Disease, Revised Guidelines from CDC, 2010. Morbidity and Mortality Weekly Report. 59(RR-10): 1-36, 2010. Stoll et al . Early onset neonatal sepsis: the burden of group B streptococcal and E. coli disease continues. Pediatrics 2011: 127:817-826.