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Infection & Sepsis The NICU

Infection & Sepsis The NICU. Jason D Higginson, MD LCDR MC USN. American Board of Pediatrics Content General Pediatrics Certifying Examination. Infectious Diseases Prevention by active immunization Prevention by passive immunization Aids to the diagnosis of infectious diseases

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Infection & Sepsis The NICU

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  1. Infection & Sepsis The NICU Jason D Higginson, MD LCDR MC USN

  2. American Board of PediatricsContent General Pediatrics Certifying Examination • Infectious Diseases • Prevention by active immunization • Prevention by passive immunization • Aids to the diagnosis of infectious diseases • Appropriate specimen collecting • Antibiotic susceptibility testing • Use of the serology laboratory • Use of the virology laboratory • Antibiotics/Antivirals/ Antifungals • Principles of antibiotic use

  3. American Board of PediatricsContent General Pediatrics Certifying Examination • Fetus and Newborn Infant • Eye prophylaxis • Screening • Serologic test for syphilis • Conditions, diseases • Sepsis • TORCH infections

  4. Disclaimer • This is my take on neonatal infection • Really NICU • Much is left out or covered briefly • Think and read for yourself Far more crucial than what we know or do not know is what we do not want to know –Eric Hoffer

  5. Number 1, 2 and 3 in your differential Why?

  6. Declining Sepsis Related Mortality M. Bizzarro,Pediatrics 2005;116;595-602

  7. Definitions • Early onset = Less than 7 days old • From maternal lower genital tract • Often fulminant course • High mortality 5-20% • Late onset = Greater than 7 days old • Vertical or from postnatal environment • Often insidious • ~5% mortality

  8. NICU SepsisMost Common Encountered Bugs • Early onset sepsis • E. Coli • GBS • Listeria • Gram-negative organisms • Late onset sepsis • CONS • S aureus • GBS, E coli, gram-negative • Fungal agents

  9. Who is at Risk Prior to Delivery • Maternal GBS colonization • Maternal fever or infection • ROM greater than 18-24hrs • Maternal malnutrition or poor health • Fetal scalp electrode • Perinatal asphyxia

  10. Who is at Risk After Delivery • Low birth weight • Premature delivery • Medical intervention • Lines • Mechanical ventilation • Length of stay in hospital • Antibiotic exposure

  11. Clinical Manifestations • You name it! • Hypotonia • Temperature instability • Respiratory (apnea, cyanosis) • Feeding difficulties • Lethargy • Tachycardia • Hypotension, poor perfusion • Hypoglycemia, hyperglycemia

  12. Differential After 1, 2 and 3 • Because signs and symptoms are non-specific…….exclude other diagnoses • Respiratory distress syndrome • Meconium aspiration, PPHN • CNS insult/ malformation • Drug exposure • Metabolic disease • The list goes on……..

  13. Work up • CBC with differential • Blood Cx • Lumbar puncture • CXR • Urine Cx • Other as indicated (there are other diseases in pediatrics other than sepsis)

  14. CBC Normal Values • WBC >5K, <15-20K • ANC >1500 (<500 concerning) • Immature neutrophils <15% ANC • WBC decreased with maternal HTN • Platelets >150K Fanaroff and Martin 8th edition 2005

  15. WBC Count Not Sensitive nor Specific

  16. Do I Need To Do LP?

  17. CSF Normal Ranges Preterm Term Fanaroff and Martin 8th edition 2005

  18. Pediatrics 2006;117;1094-1100

  19. CSF Results Somewhat Useful:Keep This In Mind Even If ABX Onboard Pediatrics 2006;117;1094-1100

  20. Just Tint The Media Red For The Blood Culture?

  21. Draw A Reasonable Amount of Blood For Culture Isaacman: J Pediatr, Volume 128(2).February 1996.190-195

  22. Treatment Considerations • Timing of Suspected Infection • Setting of disease • Infants medical circumstances • Local Infection patterns and resistance

  23. NNMC NICU 2007

  24. Early Onset Sepsis • Most common encountered bugs • E. Coli • GBS • Listeria • Gram-negative organisms • Ampicillin-> GBS and Listeria, maybe E coli • Gentamicin (Aminoglycoside)-> gram negative coverage as well as synergy with Ampicillin for GBS and Listeria • Consider addition or replacement of Gentamicin with 3rd generation Cephalosporin in Gm neg meningitis

  25. Late Onset Sepsis • In the NICU • CONS • S aureus • GBS, E coli, gram-negative • Fungal agents • Vancomycin- virtually all CONS and skin flora produce penicillinase • Cefotaxime- gram-negative coverage with CSF penetration • Not covered: Listeria, enterococci, pseudomonas or ESBL’s

  26. Other Concerns • Check levels if therapy beyond 48hrs • Minimize toxicity • Ensure efficacy • Gentamicin • Peak 5-12mcg/ml • Trough 0.5-1mcg/ml • Vancomycin • Target trough 5-10 mcg/ml

  27. Other Concerns • Narrow therapy once sensitivity known • Failure to respond to therapy? • Gaps in coverage • Hard to treat nidus • Alternative diagnoses • Re-culture • Remove your hardware

  28. Prevention: A Pediatrician’s Real Job

  29. “Soap and water and common sense are the best disinfectants”  William Osler • 1846Vienna General Hospital • Neonatal mortality due to puerperal fever of 13% • Jakob Kolletschka dies from infection contracted while performing a postmortem examination: similar pathology to puerperal fever • Semmelweis institutes hand washing policy and Neonatal mortality decreases to 2% • Is he heralded as a hero?

  30. Scorn "After some years of mental deterioration, Semmelweis was committed to a private asylum in Vienna. There he became violent and was beaten by asylum personnel and died from the injuries received."

  31. One NICU’s Experience Infect Control Hosp Epidemiol 2004;25:742-746

  32. Who Needs Prophylaxis? • All Women Screened 35-37weeks (rectal &vaginal culture) • Need intrapartum ABX • + Culture (unless C/S without labor) • GBS bacteriuria this pregnancy • Previous infant w/ GBS Dz • GBS unknown and • Preterm, ROM>18hr, Maternal temp (>100.4) MMWR 2002;51(No. RR-11)

  33. Preterm And No GBS Cx? MMWR 2002;51(No. RR-11)

  34. After Delivery? MMWR 2002;51(No. RR-11)

  35. Prevention At Work MMWR 2002;51(No. RR-11)

  36. The Remaining Highlights

  37. Fetal/ Neonatal Immunology • Passive Immunity In Infants • Active placental transport of IgG • majority of circulating antibodies at birth IgG • increased transport activity 20-24wk • Levels reach nadir at 3-4months after birth • Breast Milk contains many antibodies- importance is debated but likely confer some benefit

  38. Fetal/ Neonatal Immunology • Active Immunity • Little perinatal antibody production in reality • IgM production 8th week • IgG production 10-15th week • IgA production 30th week • Antibody responsiveness is slow in infants • Adult levels reached in early childhood (4-6yrs)

  39. Neonatal Opthalmia • Neonatal Opthalmia- Conjunctivitis first 4 weeks • Bacterial, Viral, Chemical • Eye Prophylaxis is for Neisseriagonorrhoeae • Not effective against Chlamydia trachomatis, HSV • Should be given within 1 hour of birth • Eyes should be wiped with sterile cotton prior to administration • Agents: erythromycin, tetracycline, silver nitrate

  40. Neonatal Opthalmia • Will a simple culture help diagnose these? • Chlamydia trachomatis- obligate intracellular organism culture must contain epithelial cells • If mother untreated- 25-50% conjunctivitis, 5-20% pneumonia • Tx 14day erythromycin PO • Neisseriagonorrhoeae- quickly to lab / chocolate agar CO2 enriched • Tx Cefotaximie x1, eye irrigation

  41. TORCH Infections • Toxoplasmosis • Other (T. pallidum, VZV, Parvovirus) • Rubella • CMV • HSV & HIV

  42. Hepatitis B • HBsAg + Mom • HBV within 12hrs of birth • This alone is 70-95% effective in transmission prevention • HBIG within 12hrs of birth • HBsAg unknown • Send maternal studies • HBV within 12hrs of birth • If Mom + HBIG within 7days of delivery • <2000g give HBIG if test not known at 12hrs • HBV <2000g birth dose not counted in series completion

  43. Varicella • Exposure (significant) • Usually protected by maternal antibodies • VariZIG + Acyclovir indicated : • <28wks • <1000g • no maternal Dz Hx • Maternal Dz onset 5days befor-2days after delivery (not zoster)

  44. Serologic Tests For Syphilis • Non-treponemal test- • Venereal Disease Research Laboratory (VDRL), Rapid Plasma Reagin (RPR) • Detection of non-specific antibodies • High false positive rate • Can miss early infection • Cheap screening test also good for following response to Tx • Treponemal test- • Fluorescent Treponemal Antibody Absorption (FTA-ABS), Treponema pallidum particle agglutination (TP-PA) • Detect specific treponemal monoclonal-antibodies • High false positive rate • Used to confirm infection • Once positive usually positive for life

  45. Serologic Tests For Syphilis • Important Caveats • Maternal status unknown (screening infant not enough-> may be non-reactive despite Dz) • Clinical Manifestations- huge list but >2/3 are asymptomatic • Maternal titer increase fourfold worrisome for active Dz • Infant titer is fourfold greater than the mothers worrisome • No or poor maternal Tx (ie not penicillin, <1mo prior to delivery) • No serologic follow-up for Dz Tx prior to pregnancy

  46. Questions? The greater the ignorance the greater the dogmatism  -William Osler

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