Escolar Documentos
Profissional Documentos
Cultura Documentos
Questions?
Why are infants,
especially premies,
more susceptible to
infections?
What are the clinical
manifestations of
neonatal infections?
Bacterial?
HSV?
How to prevent
infections?
Antibiotics indications,
contraindications,
cautions, resistance,
etc.
How to interpret labs?
Any precautions with
lines?
Objectives
To briefly review neonatal immunology and why
neonates are so susceptible to infections
To review the epidemiology, clinical presentation,
diagnosis and treatment of the most common
bacterial and HSV neonatal infections.
To review modes of infection prevention.
To differentiate between preterm and term infants
in all these areas
Antibody
Antibodies
Infectious agent
Immunity
Figure 1.1 Antibodies (anti- foreign bodies) are produced by host while cells on contact with the invading micro-organism
which is acting as an antigen (e.g. generates antibodies). The individual may then be immune to further attacks.
(Modified From: Roitt, I: Essential Immunology, 4th edition, Blackwell Scientific Publications, 1980)
Antibodies
Infectious agent
Immunity
Complement
Neutrophils
Neonatal Neutrophils
Immature
Chemotaxis
Deformability
Phagocytosis
Storage pool
NormalVLBWneonates
NormalVLBWneonates
Umbilical cord
Breaches - catheters, tape
QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Epidemiology
Neonatal Infections
Sepsis
Meningitis
Pneumonia
Otitis Media
Diarrheal Disease
UTI
Osteomyelitis
Suppurative Arthritis
Conjunctivitis
Orbital Cellulitis
Cellulitis - - Omphalitis
Group B Streptococci
Escherichia coli
Streptococcus viridans
Staphylococcus aureus
Enterococcus spp
Coagulase-negative staphylococci
Klebsiella pneumoniae
Pseudomonas spp
Serratia marcescans
Others
40
17
7
6
6
5
4
3
2
10
Frequency (%)
Group B Streptococci
Listeria monocytogenes
Miscellaneous gram-positives
53
7
6
19
8
1
8
Anaerobes
Feigen&Cherry,FifthEdition,2004
Incidence of Neonatal
Group B Streptoccal Sepsis
5-35% Pregnant women colonized
1/100-200 colonized women will have an
infant with early onset disease
1-7/1000
Group B Strep
1st ACOG & AAP
Association
statements
formed
CDC draft
2
1.5
guidelines published
Consensus
guidelines
1
0.5
0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Early-onset
Schrag, New Engl J Med 2000 342: 15-20
Late-onset
2.5
Black
2
1.5
White
1
0.5
0
1993
1995
1996
1997
1998
Ampicillin Susceptibility of E. coli from EarlyOnset Sepsis Cases, Full-Term Infants, ABCs,
Selected Counties CA and GA, 1998-2000
Sensitive
Resistant
9
8
7
6
5
4
3
2
1
0
1998
N=22, p=0.52, linear trend
1999
2000
Ampicillin Susceptibility of E. coli from EarlyOnset Sepsis Cases Preterm Infants, ABCs,
Selected Counties CA and GA, 1998-2000
Sensitive
Resistant
20
15
10
5
0
1998
N=37, p=0.02, linear trend
1999
2000
Susceptibility of GBS:
ABC/EIP Isolates, 1995-2000
GBS screening
0.46 (0.36-0.60)
1.41 (0.97-2.06)
Pre-term delivery
1.50 (1.07-2.10)
Black race
1.87 (1.45-2.43)
2.22 (1.59-3.11)
5.54 (1.71-17.94)
Intrapartum fever
5.36 (3.60-7.99)
Strongly suggestive
hypoglycemia / hyperglycemia
hypotension
metabolic acidosis
apnea
shock
DIC
hepatosplenomegaly
bulging fontanelle
seizures
petechiae
hematochezia
respiratory distress
Nonspecific
lethargy, irritability
temperature instability -- hypothermia or fever
poor feeding
cyanosis
tachycardia
abdominal distention
jaundice
tachypnea
Chest Radiograph
Glucose
Bilirubin
Coagulation studies
Laboratory Diagnosis of
Neonatal Meningitis
CSF
--
> 32 WBC/mm3
> 60% PMN
Potentially useful when maternal antibiotics given pretreatment interferes with cultures
Duration:
Rule out sepsis
Pneumonia
Sepsis
Meningitis
48 - 72 hours
5 - 7 days
7 - 10 days
14 - 21 days
Ventilation
BP support - fluids, Dopamine/Dobutamine/HCTZ
TPN
FFP - clotting factors, C3, antibodies
G-CSF - stimulate WBC production/release
Steroids not indicated as anti-inflammatory
Duration(fromfirstnegativeculture)
Uncomplicated sepsis
Meningitis
10 - 14 days
14 days minimum
Duration(fromfirstnegativeculture)
Uncomplicated sepsis
Meningitis
10 -14 days
21 days minimum
Treatment of Listeria
Monocytogenes Infections
Ampicillin and an Aminoglycoside IV
Duration(fromfirstnegativeculture)
Uncomplicatedsepsis
1014days
Meningitis
14daysminimum
Prognosis
Neonatal Sepsis
Mortality 20 - 30% overall - highest in premature infants
Morbidity ?? 25% ??
Organism
Mortality for
BW <1500g
Mortality for
BW 1500-2500g
Mortality for
BW >2500g
Group B
Streptococci
73%
20%
10%
Escherichia coli
73%
42%
13%
Staphylococcus
aureus
44%
15%
5%
Other
67%
33%
13%
Total
67%
28%
10%
Term or preterm
Bacterial: GBS, Chlamydia
Viral: HSV, CMV, HepB, HIV
Fungal: Candida
Nosocomial acquisition
Health care associated infections
Preterm or sick term infant
or neonatal treatment of early onset disease does not decrease risk of late
onset disease
Symptoms -
Transmission
5-8% transplacental (congenital)
85-90% perinatally
Primary infection (risk 30-50%)
Secondary infection (risk <5%)
Impossible to distinguish 1o vs 2o
5-10% postnatally
Parent, caregiver
Usually non-genital - hand, mouth
Multi-organ involvement
Sepsis syndrome, DIC
Liver, CNS, lung predominance
Severe liver & CNS dysfunction common
Wide temp variations characteristic
Seizures common
HSV Diagnosis
Patients(%)Death(%)
OutcomeinInfant(%)Normal(%)
Sequelae
Disseminated
withoutCNSinvolvement
withCNSinvolvement
38(16)
78(33)
87
71
3
15
10
14
Localized
CNS
skin
eye
mouth
61(26)
39(17)
13(5)
4(2)
37
10
0
0
51
26
31
0
12
64
69
100
2(1)
100
235(100)
49
25
26
Asymptomatic
TOTAL
*ModifiedfromNahmiasetal.
265
Primarysevereneurologicsequelae.
Noapparentsequelaefromavailablefollowupinformation.
Feigen&Cherry,FifthEdition,2004
Prematurity
ELBW > VLBW
Increased LOS
Abdominal surgery / NEC
Hyperalimentaion / Intralipids
Neutropenia, Thrombocytopenia
Catheters
UAC, UVC, ETT, Foley, CT, Peritoneal drains, etc
Neonatal Infections
Sepsis
Meningitis
Pneumonia
Otitis Media
Diarrheal Disease
UTI
Osteomyelitis
Suppurative Arthritis
Conjunctivitis
Orbital Cellulitis
Cellulitis - - Omphalitis
Gram-negative bacteria
Enterococcus spp, Enterobacter spp, E. coli
Pseudomonas spp, Klebsiella spp, Seratia spp
Source:
Infant GI tract
Person-to-person transmission from Nursery personnel
Nursery environmental sites: sinks, multiple use solutions, countertops, respiratory
therapy equipment
Duration(fromfirstnegativeculture):
Rule out sepsis
Pneumonia
Sepsis
Meningitis
48 - 72 hours
5 - 7 days
10 -14 days
14 - 21 days
Methicillin-resistant
Staphylococcus
aureus (MRSA)
Real risk on NICU
Community /
maternal acquired
Vanco use required
Strict contact
isolation
1014days
Meningitis
1421days
Removalofindwellingintravascularcatheters
AminoglycosideIV+something(basedonsensitivities)
Duration(fromfirstnegativeculture)
Uncomplicatedsepsis
1014days
Meningitis
1421days
Removalofindwellingintravascularcatheters
Prognosis
Dependent upon organism and early initiation of
appropriate therapy
LOS increased in all cases
Morbidity also variable dependent upon organ
involvement - worse with meningitis
Common Manifestations of
Viral Infections in the Newborn Infant
Specific Features (acute)
Hyper- or hypothermia
General: irritability, lethargy, jitters, poor feeding, vomiting
CNS: seizures, hyper- or hypotonia, full fontanelle,
meningitis, encephalitis
Skin: icterus, petechiae, purpura, vesicle, maculopapular
rash
Eye: conjunctivitis, keratitis
Heart: myocarditis, hypotension
Abdomen: hepatosplenomegaly, hepatitis
Lung: pneumonitis, respiratory distress, cyanosis
+
+
+
++
+(rare)
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+