Doctor123.org

Neonatal Sepsis, Emergency Medicine

Basics

Description

- Occurs in 3 " пїЅ5 newborns per 1,000 live births - Risk factors: - Perinatal: - History of recent fever (>37.5 пїЅ пїЅC) - UTI - Chorioamnionitis - Prolonged rupture of membranes (>18 hr) - Foul lochia - Uterine tenderness - Intrapartum asphyxia

- Neonatal: - Prematurity - Fetal tachycardia (>180 beats/min) - Male - Twinning (especially 2nd twin) - Developmental or congenital immune defects - Administration of IM iron - Galactosemia - Congenital anomaly (urinary tract, asplenia, myelomeningocele, sinus tract) - Omphalitis

- Viral: - Herpes simplex is a common viral etiology. - Enterovirus - Adenovirus

- Bacterial: - Group B Streptococcus - E. coli type K1 - L. monocytogenes - Other streptococci - Nontypeable Haemophilus influenzae - Coagulase-positive and coagulase-negative Staphylococcus - Less commonly: Klebsiella, Enterobacter - Pseudomonas, T. pallidum, and Mycobacterium tuberculosis - Citrobacter diversus (important cause of brain abscess) - Additional pathogens: Mycoplasma hominis and Ureaplasma urealyticum

- Nonspecific history: - "Not acting normal " пїЅ - Feeding poorly - Irritable or lethargic

- General: - Toxic appearing - Altered mental status: Irritable or lethargic - Apnea or bradycardia - Mottled, ashen, cyanotic, or cool skin

- Vital signs: - Hyperthermia/hypothermia - Tachypnea - Tachycardia - Prolonged capillary refill time

- Bedside glucose determination - CBC: - WBCs elevated or suppressed - Shift to the left - Thrombocytopenia

- Lumbar puncture: - May need to delay if hemodynamically unstable - Cell count, protein, glucose, culture, Gram stain

- Metabolic disorders: - Hypoglycemia - Adrenal insufficiency (congenital adrenal hyperplasia) - Organic acidoses - Urea cycle disorders

Mechanism

  • Life-threatening infection of the newborn, rarely occurring as late as 3 mo of age
  • Overwhelmingly bacterial:Rarely viral or fungal infectionOrganisms usually present in the maternal perineal flora
  • Occurs in 3 " пїЅ5 newborns per 1,000 live births
  • Risk factors:Perinatal:History of recent fever (>37.5 пїЅ пїЅC)UTIChorioamnionitisProlonged rupture of membranes (>18 hr)Foul lochiaUterine tendernessIntrapartum asphyxiaNeonatal:PrematurityFetal tachycardia (>180 beats/min)MaleTwinning (especially 2nd twin)Developmental or congenital immune defectsAdministration of IM ironGalactosemiaCongenital anomaly (urinary tract, asplenia, myelomeningocele, sinus tract)Omphalitis

Etiology

Sepsis

  • Bacterial:Group B StreptococcusEscherichia coliListeria monocytogenesCoagulase-negative StaphylococcusTreponema pallidum
  • Viral:Herpes simplex is a common viral etiology.EnterovirusAdenovirus
  • Fungi:
  • Protozoa:

Meningitis

  • Bacterial:Group B StreptococcusE. coli type K1L. monocytogenesOther streptococciNontypeable Haemophilus influenzaeCoagulase-positive and coagulase-negative StaphylococcusLess commonly: Klebsiella, EnterobacterPseudomonas, T. pallidum, and Mycobacterium tuberculosisCitrobacter diversus (important cause of brain abscess)Additional pathogens: Mycoplasma hominis and Ureaplasma urealyticum
  • Viral:EnterovirusesHerpes simplex virus (type 2 more commonly)CytomegalovirusesToxoplasma gondiiRubellaHIV
  • Fungi:Candida albicans and other fungi

Diagnosis

Signs and Symptoms

History

  • Nonspecific history: "Not acting normal " пїЅFeeding poorlyIrritable or lethargic
  • General:Toxic appearingAltered mental status: Irritable or lethargicApnea or bradycardiaMottled, ashen, cyanotic, or cool skin

Physical Exam

  • Vital signs:Hyperthermia/hypothermiaTachypneaTachycardiaProlonged capillary refill time
  • Abdominal distention
  • Jaundice
  • Bruising or prolonged bleeding
  • Sepsis syndrome in the neonate:Septic shockHypoglycemiaSeizuresDisseminated intravascular coagulation (DIC)If untreated, cardiovascular collapse and death

Essential Workup

  • Sepsis evaluation followed by empiric antibiotics and support
  • Determine a source for the infection.
  • Identify metabolic abnormalities.

Diagnosis Tests & Interpretation

Lab

  • Bedside glucose determination
  • CBC:WBCs elevated or suppressedShift to the leftThrombocytopenia
  • C-reactive protein (CRP)
  • Urinalysis
  • Cultures as soon as the diagnosis is entertained:Blood, CSF, catheterized or suprapubic urine, stool
  • Lumbar puncture:May need to delay if hemodynamically unstableCell count, protein, glucose, culture, Gram stain
  • Serum glucose needed to exclude hypoglycemia
  • Arterial blood gas and oximetryMetabolic acidosis is common.
  • Electrolytes and calcium:
  • DIC panel:Coagulopathy is a late complication.Monitor PT, PTT and fibrinogen-split products

Imaging

CXR to rule out pneumonia пїЅ пїЅ

Differential Diagnosis

  • Heart disease:Hypoplastic left heart syndromeMyocarditis
  • Metabolic disorders:HypoglycemiaAdrenal insufficiency (congenital adrenal hyperplasia)Organic acidosesUrea cycle disorders
  • Intussusception
  • Child abuse
  • CNS:Intracranial hemorrhagePerinatal asphyxia
  • Neonatal jaundice
  • Hematologic emergencies:Neonatal purpura fulminansSevere anemiaMethemoglobinemiaMalignancy (congenital leukemia)

Treatment

Pre-Hospital

Cautions

  • Ventilatory support if obtunded, apneic, or respiratory distress
  • IV access
  • Continuous monitoring

Ed Treatment/Procedures

  • Implement empiric treatment for neonatal sepsis if presentation at all consistent, particularly if any risk factors are present.
  • Administer antibiotics:Ampicillin and gentamicin or cefotaximeAdd vancomycin if the patients condition continues to deteriorate or any suggestion of Streptococcus pneumoniae.Cefotaxime may be substituted for gentamicin.
  • Support for septic shock if present

Medication

  • Ampicillin: 200 mg/kg/d q6h IV/IM for infant >2 kg birth weight and >2 wk old; 150 mg/kg/d q8h if <7 days old
  • Cefotaxime: 150 mg/kg/d q6h IV/IM for infants >2 kg birth weight and >1 wk old; 150 mg/kg/d q8h IV/IM if 8 " пїЅ28 days old; 100 mg/kg/d IV/IM q12h if 0 " пїЅ7 days old
  • Gentamicin: 2.5 mg/kg/dose q8h IV/IM if postconceptual age >37 wk and >7 days old; 2.5 mg/kg/dose q12h if <7 days old
  • Vancomycin: 15 mg/kg/dose IV q8h if postconceptual age >37 wk and >7 days old; 15 mg/kg IV q12h if <7 days old

Follow-Up

Disposition

Admission Criteria

  • All patients with suspected sepsis are admitted to the hospital for supportive care, IV antibiotic therapy, and close monitoring.
  • All children <1 mo with a fever are generally admitted even in the absence of significant suspicion of sepsis. Older children are admitted based upon the clinical presentation.

Initial Stabilization

  • Airway management indicated if obtundation, apnea, or respiratory distress
  • IV access to administer fluids and pressors as needed
  • Continuous monitoring

Additional Reading

  • American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
  • Edwards пїЅ пїЅMS. Postnatal bacterial infections. In: Martin пїЅ пїЅRJ, Fanaroff пїЅ пїЅAA, Walsh пїЅ пїЅMC, eds. Neonatal-Perinatal Medicine. Diseases of the Fetus and Infant. 9th ed. St. Louis, MO: Mosby; 2011:793 " пїЅ829.
  • Ferrieri пїЅ пїЅP, Wallen пїЅ пїЅLD. Neonatal bacterial sepsis. In: Taesch пїЅ пїЅHW, Ballard пїЅ пїЅRA, Gleason пїЅ пїЅCA. Averys Diseases of the Newborn. 9th ed. Philadelphia, PA: Elsevier Saunders; 2012:538 " пїЅ550.
  • Shapiro пїЅ пїЅNI, Zimmer пїЅ пїЅGD, Barkin пїЅ пїЅAZ. Sepsis syndromes. In: Marx пїЅ пїЅJA, Hockberger пїЅ пїЅRS, Walls пїЅ пїЅRM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2010:1848 " пїЅ1858.
  • Van de Hoogen пїЅ пїЅA, Gerards пїЅ пїЅLJ, Verboon-Maciolek пїЅ пїЅMA, et al. Long-term trends in the epidemiology of neonatal sepsis and antibiotic susceptibility of causative agents. Neonatology. 2010;97(1):22 " пїЅ28.
  • Young пїЅ пїЅTE, Mangum пїЅ пїЅB. Neofax 2011: A Manual of Drugs Used in Neonatal Care.24th ed. Montvale, NJ: Physicians 'Desk Reference; 2011:2 " пїЅ105.

Codes

ICD9

  • 038.0 Streptococcal septicemia
  • 038.42 Septicemia due to escherichia coli [E. coli]
  • 771.81 Septicemia [sepsis] of newborn
  • 771.2 Other congenital infections specific to the perinatal period
  • 038.3 Septicemia due to anaerobes
  • 054.5 Herpetic septicemia
  • 771.4 Omphalitis of the newborn
  • 771.7 Neonatal Candida infection

ICD10

  • P36.0 Sepsis of newborn due to streptococcus, group B
  • P36.4 Sepsis of newborn due to Escherichia coli
  • P36.9 Bacterial sepsis of newborn, unspecified
  • P37.2 Neonatal (disseminated) listeriosis
  • P36.39 Sepsis of newborn due to other staphylococci
  • P36.5 Sepsis of newborn due to anaerobes
  • P36.8 Other bacterial sepsis of newborn
  • P37.5 Neonatal candidiasis
  • P38.9 Omphalitis without hemorrhage

SNOMED

  • 276669000 Bacterial sepsis of newborn (disorder)
  • 403842002 Neonatal streptococcal infection (disorder)
  • 206379003 sepsis of newborn due to Escherichia coli (disorder)
  • 359646002 Neonatal disseminated listeriosis (disorder)
  • 403000003 Neonatal systemic candidosis (disorder)
  • 42052009 Omphalitis of the newborn (disorder)
  • 448784003 Sepsis due to herpes simplex (disorder)
  • 449505005 Sepsis due to coagulase negative Staphylococcus (disorder)