BOACON, HANNY MAE A.

MD 17th Batch
UPMSHS

Objectives:
At the end of the presentation medical clerks will:
1. Gain knowledge about neonatal sepsis
2. Know the etiologic agents that causes neonatal sepsis
3. Explain the pathophysiology of the disease occurrence
4. Discuss the management of sepsis neonatorum
5. Know the prognosis of the disease

PATIENT HISTORY

Source of information:Parents
Reliability: (98%)
Source of Referral: None

Date & Time: 11/25/16 / 9:00 pm

GENERAL DATA:

J.C., 5 days old, newborn, male, Filipino, Roman Catholic, presently residing at Sto. Niño,
Tacloban City, Leyte. He was born at Eastern Visayas Regional Medical Center (EVRMC) last
11/20/2016 at 2:00 am.

HISTORY OF PRESENT ILLNESS:

Prenatal:

The patient’s mother is a 32 y/o G1P1 (1-0-0-1) who do not smoke cigarette but drank
local distillate once during pregnancy. Prenatal check-up was initiated at 3 mos. at Anibong
Health Center. She was prescribed with Ferrous Sulfate 1 tab OD with good compliance.
Succeeding visits was done monthly until 7 months at Anibong Health Center. From 8 months to
9 months prenatal visit was done City Health Center. She was prescribed with Vitamin C 500 mg
to be taken daily with good compliance. During pregnancy, her BP was 110/70 mmHg. She was
able to gain weight of 15 kg (from 48kg to 63 kg). She had undergone laboratory examinations
at City Health Center like CBC with normal result and Urinalysis which showed increased in
WBC. There was no medications given but was advised to increased fluid intake as remedy. She
received first dose of Tetanus toxoid at 5 months AOG. Second dose was given at 7 months. She
reported to have allergy to “turingan” and “bangkulis”. She experienced itchiness at 7-8 months
at both shoulders. She sought consult at City Health Center and was seen by a midwife. She was
told that it may due to her pregnancy. She also experienced fever determined by touch, cough
and colds during pregnancy that are spontaneously resolving. She has no history of abortion,
bleeding, sever vomiting and severe abdominal pain with pregnancy. She negates exposure to
X-ray.

Birth

The patient was born term, in cephalic presentation, via NSVD, to a G1P1 (1-0-0-1)
mother attended by a health professional at EVRMC last November 20, 2016 at around 2:00
am.

Neonatal

During the first 5 hours of life:

The patient was pinkish and vigorous, with a loud cry immediately at birth. Immediate
thorough drying was done and the baby was placed at the mother’s abdomen for the skin to
skin contact. Properly timed delayed cord clamping was achieved then umbilical cord was cut
using a pair of sterilized scissors and was clamped using disposable cord clamp. Sucking was
noted to be good. He was then placed at the bassinette where he was properly clothed and
injected with vaccines including BCG and Hepa B. Body weight was 3.4 kg and body length was
not recalled by the mother. The mother then started breastfeeding the newborn. The baby was
breastfed per demand, usually with a 2-3 hrs interval lasting 20 min or more for both breasts.
They were brought at the OB Ward around at around 4:00 am.

During 24 hours of life:

Pure breastfeeding was maintained. Pass out meconium and urine. They were
discharged after 24 hours. Newborn Screening was done prior to discharge.

Day 3 of life:

The mother noticed non fouling brownish discharges from umbilicus. She then started
to dress the stump with alcohol. Upon changing the baby’s clothes, she noticed pustule that
first appear on the right popliteal area. There were no fever, no redness, no inflammation
noted. There was no treatment nor consultation done.

Day 4 of life:
The mother reported that there is already foul smelling on the umbilical stump. She
continued to dress the stump with alcohol which provided temporary relief from foul odor.
Pustules now appear on the genital area and posterior neck. There is no fever as verbalized. No
consultation done.
 Day 5 of life:

Symptoms persisted. There is now reddish appearance on the periumbilical area and the
pustules increased in number, this prompted the mother to sought consult hence admitted.

Feeding

The newborn is breast fed per demand more than 8x in a day lasting 20 minutes per
breast.

Physical Examination:

Done on the 1st day of hospitalization

GENERAL SURVEY:

The patient was examined awake, and not in cardiopulmonary distress with the
following V/S and anthropometric measurements:

Temperature: 36.7 C (36.5-37.5)

Respiratory Rate: 58 cpm (<60 cpm)

Heart Rate: 121 bpm (120-160 bpm)

Weight: 3.3 kg

Recumbent Length: 49 cm

HC: 34cm

CC 33 cm

AC: 33 cm

MUAC: 11 cm

 HEAD: With short, black hair evenly distributed on scalp, symmetric head contour. With
open, diamond shaped, soft anterior fontanel about 3x4 cm in diameter and open
triangular shaped, soft posterior fontanel about 1 x 1 cm in diameter.

 SKIN: With pinkish, smooth and moist skin. With peeling of the skin. No jaundice, no
pallor.

 EYES: Anicteric sclera, pale palpebral conjunctiva. Pupils equally reactive to light. No
periorbital edema.

 EARS: Symmetrical and firm pinnae.

  NOSE: Septum at midline, no nasal flaring.

 MOUTH AND THROAT: Moist, pinkish lips and oral mucosa. Tongue and uvula at
midline. No lesion. Tonsils not inflamed.

 NECK: Supple, no supraclavicular retractions, trachea at midline, no palpable lymph

nodes, thyroid gland not palpable 

 CHEST AND LUNGS:

Inspection: Symmetrical chest expansion, no intercostal, supraclavicular and subcostal

retractions on anterior chest, no mass noted. No dilated veins. Ribs and scapula were
prominent.

Palpation: Confirmed symmetrical expansion. No mass.

Auscultation: Clear breath sounds, no wheeze, no crackles

 CARDIOVASCULAR:

Inspection: Adynamic precordium. Apical impulse not visible.

Palpation: PMI not palpable. No heave, no thrill.

Auscultation: Heart Rate: 151 bpm. No murmur heard.

 BREAST AND AXILLAE:

Inspection: Flat, with symmetrical alignment

Palpation: No palpable mass, no nipple discharge 

 ABDOMEN:  

Inspection: Globular, no visible mass. With reddish periumbical. Umbilical stump moist.

Palpation: No mass.

Percussion: Tympanic.

  Auscultation: No bruits.

 GENITALS:

Grossly male. Both testes descended with marked corrugation of scrotum, no phimosis.

 BACK AND SPINE: Spine at midline. No mass.

 MUSCULOSKELETAL: Full ROM of upper and lower extremities.

  Peripheral/Vascular: No edema. Full pulses

PRIMITIVE REFLEXES:

 Moro Reflex: The baby was held supine while supporting the head, back, and legs. Upon
abruptly lowering the entire body, the arms abducted and extended, with hands
opened, and the legs flexed.
 Palmar Grasp: Upon placing a finger into the baby’s hand and presses against the
palmar surface, the baby flexed all his finger and grasp the examiner’s finger. This was
done on both hands.
 Plantar Grasp: The toes curled when the base of his toes was touched. This was done
on both foot.
 Rooting Reflex: Upon stroking the perioral skin at the corners of the mouth, the mouth
opened and baby turned his head toward the stimulated side and sucked. This was done
on both sides.
 Assymetric Tonic Neck Reflex: As the head was turned to one side while holding the jaw
over shoulder, the arms and legs on side to which the head was turned extended while
the opposite arm and leg flexed. This was done on both while the baby was on supine.

Neurologic Examination:

No neurologic deficit upon examination.

Salient Features:

S:

 Male, 5 days old

 Inadequate care of the umbilicus

O:

 Brownish discharges from umbilicus

 Redness on periumbilical area
 Pustules on right popliteal area, genital area and posterior neck
 Admitting Impression:

Sepsis Neonatorum 20 Omphalitis

Course in the Ward:

Subjective Objective Assessment Plan

11/25/2016: Objective: Sepsis  Admit to Pedia-Nicu B

at ER T: 36.7 C Neonatorum 2°  Secure consent for admission
foul smelling HR: 121 bpm Omphaltis  BF with AP
umbilicus R: 58 cpm  IV heplock
(+) discharges on umbilical area Medications:
(+) redness on periumbilical area  -Ampicillin 11mg IVTT Q8H
Laboratory:  -Gentamycin 17 mg IVTT OD
Hematology:  -Mupirocin ointment to
RBC: 4.91 (4.7-6.1) affected area TID
WBC: 26.71 (4.8-10.8)  Cord care now then BID
Platelet: 368 (150-450)  Vital signs every 4H
Bacteriology result:  I and O every shift
Heavy growth of staphylococcus
aureus
Gram Stain result:
No microorganism seen
Blood Chemistry Result:
Na: 139.2 (135-148 mmol/L)
K: 5.32 (3.5-5.3 mmol/L)
Cl: 109.9 (98-107 mmol/L)
RBS: 3.8
11/26/2016 Moist umbilical area Sepsis  Continue BF with AP
No episodes Neonatorum 2°  Continue IVTT meds
of fever Omphalitis  Cord care
11/27/16: Moist umbilical area Sepsis  Continue BF with AP
Day Neonatorum  Burp patient every after feeding
  2° Omphalitis  Continue IVTT meds
Day 2meds  Continue Mupirocin ointment
11/28/16: Moist umbilicus Sepsis  Continue BF with AP
Neonatorum  Burp patient every after feeding
Umbilical Blood Chemistry result: 2° Omphalitis  Continue Mupirocin ointment
stump slough  
off Total Bilirubin: 131.20 (5.1-
20.1mmol/L)
 
 Direct:10.3 (0-3.4 mmol/L)

Indirect:0120.9

Bacteriology Result:

(+) for coagulase negative

staphylococcus after 15.1 hours of
incubation)

11/29/2016  Sepsis  Continue meds

Neonatorum
  2° Omphalitis  Continue Mupirocin ointment

11/30/16: Awake, active, good suck  Sepsis  Continue BF with AP

Neonatorum
Dry not foul   2° Omphalitis  Burp every after feeding
smelling
umbilicus  Continue IVTT meds. May give IM if
IV line not available
 
 Repeat Blood culture

Vital signs every 2 hours

12/01/2016 Awake  Sepsis  Continue BF

Neonatorum
Dry not foul Active 2° Omphalitis  Continue meds
smelling
umbilicus good suck  For repeat blood culture and
sensitivity

 Watch out for any signs of fever

12/02/2016 Awake  Sepsis  Continue BF

Neonatorum
Day 6 meds Active 2° Omphalitis  Continue IV meds- pls give IM if IV
line not available
Dry not foul good suck
smelling  
umbilicus  

 
Case Discussion: Infections of the Neonatal Infant

Pathogenesis and Epidemiology

1. Infectious agents can be transmitted from the mother to the fetus or newborn infant by
diverse modes.

2. The fetus and newborn infant are less capable of responding to infection because of
immunologic immaturity.

3. Coexisting conditions often complicate the diagnosis and management of neonatal

infections.

4. The clinical manifestations of newborn infections vary. The timing of exposure, inoculum
size, immune status, and virulence of the etiologic agent influence the expression of
disease.

5. Maternal infection, the source of transplacental fetal infection, is often undiagnosed

during pregnancy.

6. A wide variety of etiologic agents infect the newborn, including bacteria, viruses, fungi,
protozoa, and mycoplasmas.

Modes of transmission and

pathogenesis

PATHOGENESIS OF INTRAUTERINE
INFECTION

 CMV

 Treponema pallidum,

 Toxoplasma gondii

 rubella virus

 varicella virus, parvovirus B19

 hematogenous transplacental
transmission
PATHOGENESIS OF ASCENDING BACTERIAL PATHOGENESIS OF LATE-ONSET POSTNATAL
INFECTION INFECTIONS

Chorioamniotis:  The most common source of

postnatal infections in hospitalized
 Microbial invasion of amniotic fluid newborns is hand contamination of
often as a result of prolonged healthcare personnel, underscoring
rupture of the chorioamniotic fluid the importance of handwashing.
often as a result of prolonged
rupture of the chorioamniotic
membrane

Immunity

 Group B streptococci

 Escherichia coli

 herpes simplex virus (HSV) notable pathogens in the

 CMV early neonatal period

 varicella-zoster virus (VZV)

 respiratory syncytial virus (RSV)

 Enteroviruses

 Candida species

IMMUNOGLOBULIN

 Actively transported across the placenta, with concentrations in a full-term infant.

  In premature infants, cord IgG levels are directly proportional to gestational age

 At 18-20 wk., IgG levels are <100 mg/dL and reach 400 mg/dL by 30-32 wk. of
gestation.

 Levels of maternally derived IgG fall rapidly after birth in a process (physiologic
hypogammaglobulinemia).

 Other classes of immunoglobulins (IgA, IgM, IgD, IgE) does not cross placenta.

 A predisposition to gram negative infections in neonate may be explained by inefficiency

of neonate to produce IgM to provide opsonin to these organisms.

COMPLEMENT

 Mediates bactericidal activity against certain organisms (E. coli)

 Functions as an opsonin with antibody in the phagocytosis of GBS.
 Premature infants have lower levels of complement components and less complement
activity, and have notably reduced levels of C9

NEUTROPHILS

Neutrophil Function:

 bactericidal/permeability-increasing protein (BPI) that binds to the endotoxin in the cell

wall of Gram-negative bacteria

 BPI facilitates opsonization and prevents the inflammatory response to endotoxin.

 BPI activity may be decreased in neonates.

Neutrophil Number:

 Neonates have a 70-80% reduction in bone marrow neutrophil stores compared to

adults and therefore are impaired in their response to infectious and noninfectious
stressors

Natural Killer Cells

 Subgroup of lymphocytes that are cytolytic against cells infected with viruses.

 Lyse cells coated with antibody in a process (antibody-dependent cell-mediated

cytotoxicity)

 Appear early in gestation and are present in cord blood in numbers equivalent to those
in adults

CYTOKINES/INFLAMMATORY MEDIATORS
  The Th1 response is directed against intracellular organisms and is relatively impaired in
neonates, possibly accounting for the predisposition to severe clinical outcomes with
infections with intracellular pathogens.

Etiology of Fetal and Neonatal Infection

Epidemiology of Early- and Late-Onset Neonatal Infections:

 Early onset infections are acquired before or during delivery (vertical mother-to-child
transmission)

 Late-onset infections develop after delivery from organisms acquired in the hospital or
the community.

 The incidence of neonatal bacterial sepsis varies from 1-4/1,000 live births, with
geographic variation and changes over time.

 Studies suggest that term male infants have a higher incidence of sepsis than term
females

 The incidence of meningitis is 0.2-0.4/1,000 live births in newborn infants and is higher
in preterm infants. Bacterial meningitis may be associated with sepsis or may occur as a
local meningeal infection.

 Up to one-third of VLBW infants with late-onset meningitis have negative blood culture
results

PREMATURITY

 The most important neonatal factor predisposing to infection is prematurity or LBW.

  Possible explanations include:

 Maternal genital tract infection is considered to be an important cause of

preterm labor, with an increased risk of vertical transmission to the newborn

 The frequency of intraamniotic infection is inversely related to gestational age

 Premature infants have documented immune dysfunction

 Premature infants often require prolonged intravenous access, endotracheal

intubation, or other invasive procedures that provide a portal of entry or impair
barrier and clearance mechanisms, putting them at continued risk for hospital-
acquired infections.

Healthcare–Associated Infections (HAI)

 HAIs are responsible for significant morbidity and late mortality in hospitalized
newborns, with almost 25% of VLBW infants (<1,500 g birthweight) experiencing 1 or
more nosocomial infections.

 The most frequent HAIs are bloodstream infections associated with intravascular
catheters and ventilator-associated pneumonia

 Neonatal immunization during the birth hospitalization is the most reliable point of
healthcare contact

 The mean age at onset of the first episode of late-onset HAI sepsis occurs during 2-3 wk
of life, independent of the infecting pathogen HAIs increase the risk of adverse
outcomes, including prolonged hospitalization and mortality.

Clinical Manifestations of Transplacental Intrauterine Infections

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME

 Fever
 Rash

 Cutaneous manifestations of infection include omphalitis, cellulitis, mastitis, and

subcutaneous abscesses

 Ecthyma gangrenosum is indicative of infection with Pseudomonas species.

 The presence of small salmon-pink papules suggests L. monocytogenes infection.

 A vesicular rash is consistent with herpesvirus infection.

 Omphalitis
 Is a neonatal infection resulting from unhygienic care of the umbilical cord,
which continues to be a problem, particularly in developing countries.
 May remain a localized infection or may spread to the abdominal wall, the
peritoneum, the umbilical or portal vessels, or the liver.
 Abdominal wall cellulitis or necrotizing fasciitis, with associated sepsis and a high
mortality rate, may develop in infants with omphalitis.
 Prompt diagnosis and treatment are necessary to avoid serious complications
 Tetanus
 Is a serious neonatal infection that results from unclean delivery and unhygienic
management of the umbilical cord in an infant born to a mother who has not
been immunized against tetanus.
 The surveillance case definition of neonatal tetanus requires:
 the ability of a newborn to suck at birth and for the 1st few days of life
 followed by an inability to suck starting between 3 and 10 days of age
 difficulty swallowing, Spasms, Stiffness, seizures, Death
 Bronchopneumonia, presumably resulting from aspiration, is a common
complication and cause of death
  Pneumonia
 Early signs and symptoms of pneumonia may be nonspecific,
 Respiratory symptoms of increasing severity are grunting, tachypnea, retractions,
flaring of the alae nasi, cyanosis, apnea, and progressive respiratory failure
 The progression of neonatal pneumonia can be variable.
 Fulminant infection is most commonly associated with pyogenic organisms such as
GBS
 In nonbacterial infection the onset can be preceded by upper respiratory tract
symptoms or conjunctivitis
 Infection is generally caused by C. trachomatis, CMV, Ureaplasma urealyticum, or 1
of the respiratory viruses.
 Rhinovirus has been reported to cause severe respiratory compromise in infants,
particularly those who are preterm.

Intrapartum and Peripartum Infections

 The CDC recommends the following screening tests and treatment when indicated:

1. All pregnant women should be offered voluntary and confidential HIV testing at the
first prenatal visit, as early in pregnancy as possible.

2. A serologic test for syphilis should be performed on all pregnant women at the first
prenatal visit.

3. Serologic testing for hepatitis B surface antigen (HBsAg) should be performed at the
first prenatal visit

4. A maternal genital culture for C. trachomatis should be performed at the first

prenatal visit.

5. Maternal culture for Neisseria gonorrhoeae should be performed at the first

prenatal visit.

6. All pregnant women at high risk for hepatitis C infection should be screened for
hepatitis C antibodies at the first prenatal visit.

7. Evidence does not support routine testing for bacterial vaginosis in pregnancy.

8. The CDC recommends universal screening for rectovaginal GBS colonization of all
pregnant women at 35-37 wk. gestation, and a screening-based approach to
selective intrapartum antibiotic prophylaxis against GBS

Suspected Intrauterine Infection

  Cordocentesis can provide a sufficient sample for both total and pathogen-specific IgM
assays, for PCR, or for culture.

 The total IgM value is important because the normal fetal IgM level is<5 mg/dL

 Amniocentesis can be performed and the fluid sent for analysis.

Features that should suggest the diagnosis of an intrauterine infection (CMV, Toxoplasma,
rubella, HSV, and syphilis)

 Intrauterine growth restriction

 Hematologic involvement (anemia, neutropenia, thrombocytopenia, petechiae,

purpura)

 ocular signs (chorioretinitis, cataracts, keratoconjunctivitis, glaucoma, microphthalmos)

 CNS involvement (microcephaly, aseptic meningitis, hydrocephaly, intracranial

calcifications)

 Other organ system involvement (pneumonia, myocarditis, nephritis, hepatitis with

hepatosplenomegaly, jaundice)

 Nonimmune hydrops

PNEUMONIA AND PNEUMONITIS

 The differential diagnosis of pneumonitis in neonates is broad and includes RDS,

meconium aspiration syndrome, persistent pulmonary hypertension, diaphragmatic
hernia, transient tachypnea of the newborn, congenital heart disease, and BPD.

 The diagnosis of infectious pneumonia in a neonate is usually presumptive

 Microbiologic proof of infection is generally lacking because lung tissue is not easily
cultured.

 Giemsa stained smears of conjunctivae or nasopharyngeal mucosa may reveal inclusion

bodies confirming the diagnosis.

MENINGITIS

 The diagnosis of meningitis is confirmed by examination of CSF and identification of a

bacterium, virus, or fungus by culture, antigen, or molecular analysis.

 For term infants with suspected early-onset sepsis, many clinicians routinely obtain
blood cultures and a CBC.
  Examination and culture of CSF may subsequently be undertaken in term infants with
symptoms and/or bacteremia

 Gram staining of CSF yields an organism in most neonates with bacterial meningitis. The
leukocyte count is usually elevated, with a predominance of neutrophils (>70-90%)

Management

Complications and Prognosis

 Complications of bacteremic infections include endocarditis, septic emboli, abscess

formation, septic joints with residual disability, and osteomyelitis and bone destruction

 Recurrent bacteremia is rare (<5% of patients).

 Candidemia may lead to vasculitis, endocarditis, and endophthalmitis, as well as to

abscesses in the kidneys, liver, lungs, and brain.

 Sequelae of sepsis may result from septic shock, DIC, or organ failure.
 Mortality rates from the sepsis syndrome depend on the definitionof sepsis and
reported mortality rates in neonatal sepsis are as low as 10%

 Several studies have documented that the sepsis case fatality rate is highest for Gram-
negative and fungal infections

 The case fatality rate for neonatal bacterial meningitis is between 20% and 25%.

 Risk factors for death or for moderate or severe disability include seizure duration >72
hr, coma, need for inotropic agents, and leukopenia.

 Immediate complications of meningitis include ventriculitis, cerebritis, and brain

abscess.

 Late complications of meningitis occur in 40-50% of survivors and include hearing loss,
abnormal behavior, developmental delay, cerebral palsy, focal motor disability, seizure
disorders, and hydrocephalus.

 Advanced imaging (CT, MRI) has demonstrated cerebritis, brain abscess, infarct,
subdural effusions, cortical atrophy, and diffuse encephalomalacia in newborns
surviving meningitis.

 A number of these sequelae may be encountered in infants with sepsis but without
meningitis, as a result of cerebritis or septic shock.

 Extremely low birthweight infants (<1,000 g) with sepsis are at increased risk for poor
neurodevelopmental and growth outcomes in early childhood.