Neonatal infections

Infection in Neonates

Newborn babies are at higher risk of infection because of their weak

immune systems related to their age.
Most infections in newborn babies are caused by bacteria, and some by
viruses.
A mother’s birth canal contains bacteria, especially if she has an active
infection.
During childbirth, the baby can swallow or breathe in the fluid in the birth
canal, and bacteria or viruses can get into his lungs and blood.
Infection in newborn babies can progress fast and early diagnosis and
treatment is important for improved outcome.
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 Bacterial Sepsis
Neonatal sepsis is defined as a clinical syndrome of bacteraemia
with systemic signs and symptoms of infection in the first 4 weeks
of life.
 Neonatal infection is one of the major causes of mortality and
morbidity.
Bacterial sepsis and meningitis often are linked closely in
neonates; meningitis is present with Early-onset sepsis (in 30% of
cases), late onset sepsis (in 75% of cases).
Considering the high mortality rates, there must be a high index of
suspicion for neonatal sepsis.

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Classification of Infections

What is an early infection?

What is a late onset infection?

What is a minor or local infection?

What is considered a major infection?

Essential Newborn Care Ethiopian FMoH, 2016

 Classification
Early-onset infections are acquired before or during delivery.
 Late-onset infections are acquired after delivery in the
normal newborn nursery, neonatal intensive care unit (NICU),
or the community.
1. Early Sepsis (Birth to 7 days, usually less than 72 hrs )
2. Late Onset Sepsis (7 - 30 days)

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Etiology:

Commonest organisms causing bacterial neonatal sepsis in

developing countries include;

 Klebsiella, Staphylococcus Aureus, and Escherichia coli.

 Clinical features
• - Signs and Symptoms of infection in newborn infants could be
non-specific or focal signs of infection may be seen.
• Neonates may show one or more of the following signs.
- Suspect bacterial infection if the infant has one or more of the
following danger signs:
 Abnormal vital signs
 Fever (temp >38 ºC), hypothermia (temp <36 ºC) or
temperature instability
Tachycardia (HR > 180) or bradycardia (HR <80)
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Tachypnea (RR > 60) or bradypnea (RR < 30) including
apnea

 Poor perfusion: capillary refill time > 3 seconds,

hypotension

 Abnormal breathing: gasping, grunting, severe chest in-

drawing, nasal flaring or apnea

Abnormal color: cyanotic, pale, grey, mottled, jaundiced,

erythematous including umbilical flare 8
Abnormal activity: tremors, irritability, seizures, floppiness,
stiffness or minimal response to stimulation, lethargy

Abnormal feeding: poor feeding, abdominal distention, recurrent

vomiting, diarrhea, otherwise unexplained hypo- or hyperglycemia

 History of convulsions

Severe Jaundice

Bulging fontanel
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 Maternal risk factors for infection
• Maternal fever (temp >38ºC) during labor or within 24 hours after delivery
- Maternal urinary tract infection in current pregnancy or bacteriura
- Duration of membrane rupture > 18 hours before delivery
- Uterine tenderness or foul smelling amniotic fluid
- Obstetric diagnosis of chorioamnionitis
- Meconium stained amniotic fluid
- Resuscitation at birth
- Invasive procedures
- Home delivery 10
Septic workup
- Consider blood culture and sensitivity whenever possible and
modify that treatment accordingly.
- CBC (Complete Blood Count with differential). Concern for
sepsis if:
o Total WBC is abnormal (<5,000 or >20,000)
o Differential with granulocytes >70%.
- ESR or CRP. Concern for sepsis if positive.
- Consider urinalysis and gram stain if symptoms of urinary
tract infection or more general concerns for sepsis in infant >1
week old

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• Consider lumbar puncture if concern for meningitis
(lethargy, irritability, convulsions, bulging fontanel).
- Consider chest x-ray if respiratory distress or
oxygen desaturation

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 CSF glucose /blood glucose ratio <50%
 Protein>150 mg/dl in Terms and >175 in preterm
 Presence of microorganisms
 If the CSF not clear may also suggest abnormality.

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What is Meningitis?
• Membranes that surround the
brain and spinal cord are
called the meninges
• Meningitis is the inflammation
of the meninges
• Bacteria may spread through
the bloodstream to the
meninges and cause
meningitis
• Neonatal meningitis is
meningitis that occurs in the
first 28 days of life
 Sepsis with meningitis
- A diagnosis of meningitis should be made based on clinical evidence
(abnormal neurological exam: seizures, abnormal tone and full fontanels) and
risk of infection for babies less than 72 hours of age ,

- for babies age greater than 72 hours of age diagnosed with sepsis CSF
analysis should be done to rule out meningitis despite absence of overt signs
of meningitis

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CSF analysis suggestive of meningitis:

- Identification of organism on gram stain or culture

- WBC count ≥20,000 cells/mm3
- Low glucose (less than two third of serum value)
- Protein greater than 150 mg/dl

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Treatment

• General supportive measures, including respiratory and

hemodynamic management, are combined with antibiotic
treatment.

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 For early onset (less than 7 days)
• Antibiotic – Ampicillin and Gentamycin
Duration: If positive cultures – minimum 7 days.
- If negative cultures, and clinically well, with normal CRP or ESR–
stop after 48 hours
- If negative cultures, but not clinically well, abnormal CXR or
elevated CRP – treat as confirmed sepsis.
- If no improvement after 48 hours, or worsens, after repeating
blood cultures ( if possible) and considering further investigations,
consider changing to: Ceftriaxone and gentamicin
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 For late onset (7-30 days)
• Antibiotic – Ampicillin and Gentamicin
- In certain cases were patient is critically sick or staphylococcal
infection is likely (pustular skin rash, osteomyelitis…) start with
triple antibiotics (cloxacillin, ampicillin and gentamycin)
- If no improvement after 48 hours, or the infant’s condition
worsens.
• Consider changing antibiotics to: Cloxacillin, ceftriaxone and
gentamicin or vancomycine and gentamicin

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• Treatment of neonatal sepsis with meningitis
- Antibiotics the same as for sepsis but with higher dose and
prolonged duration (Gentamycin for two weeks the rest for
three weeks)

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 Prevention of Neonatal Sepsis & Meningitis

• Clean delivery
• Infection prevention
• Hand washing
• Prompt treatment of
maternal infection
Neonatal Pneumonia
 Congenital Neonatal Pneumonia

Definition and Cause:

• An inflammatory condition of the lung—affecting the alveoli.

• Caused by infection with viruses, bacteria, or by certain other

conditions such as autoimmune diseases.

• Can cause difficulties with the transition from intrauterine to

extrauterine life
 Transmission occurs via 1 of 3 routes:

1. Hematogenous: mother with bacterial or viral accumulation

in blood.

2. Ascending:  acquired from birth canal

3. Aspiration:  amniotic fluid causes inflammation

Signs and Symptoms:

• Elevated respiratory rate, heart rate, BP

• Increased work of breathing (chest indrawing, nasal flaring,
tracheal tug)
• Grunting
• Increased secretions (mucous—green, yellow, thick)
• Unstable body temperature
• Poor feeding
• Abdominal distention
• Cyanosis
• Oliguria
 Treatment:

Increased monitoring
Respiratory support (supplemental oxygen if required)
Antibiotics
Isolation precautions
IV hydration
Seek advanced care
What is this?
 Herpes Simplex Virus
• Commonly transmitted during birth
• Can be transmitted intrauterine and post-
natally
• 75% of infants with HSV infection are born to
mothers with no history or clinical findings

APA, 2015; SOGC, 2008

 Risk of transmission

• Primary maternal genital infection: 25% to 60%.

• Primary infection occurs when the individual encounters either HSV-1 or
HSV-2 and has no prior exposure (i.e., HSV-1 and HSV-2 antibody
negative) to either viral type.
• Recurrent maternal genital infection: 2% to 5%. Non-primary first episode
is the first clinically recognized episode, but the individual has HSV-1 or
HSV-2 antibodies from a prior exposure.
• Primary infection in third trimester highest infant risk
Intrauterine transmission: can be caused by ascending
infection through ruptured or apparently intact amniotic
membranes.

Intrauterine infections causing congenital malformations

have been implicated in rare cases

Post-natal transmission from parent or caregiver (non-

genital infection via e.g. mouth or hands)
 Signs and symptoms of HSV in a newborn
• Usually between birth to approximately 6 weeks of age
• Again, clinical presentation can be unspecific; this highlights the
importance of maternal screening
• Skin: presentation of rash with fluid filled vesicles, although it is common
(50%) for infants not to have skin lesions
• Sepsis presentation, particularly if accompanied by liver dysfunction
• Fever
• Poor feeding
• Behavior: lethargic, irritable
• Neurological: abnormal CSF findings particularly when accompanied by
seizures
 diagnose HSV in your settings
• Through laboratory culture of blood, cerebrospinal fluid, urine
and fluid from eyes, nose and mucous membranes
• If not laboratory capabilities – diagnosis will be through clinical
suspicion and a thorough history

Treatment
• IV acyclovir used because oral acyclovir has limited
bioavailability in neonates resulting in inadequate drug levels
What is Wrong with this Baby?
Signs and Symptoms of Omphalitis
General Specific

Fever Skin redness

Tachycardia Purulent or foul-smelling

discharge
Tachypnea Abdominal distension

Poor feeding

Irritability
Umbilical Cord:
Normal Drying and Separation
1 2

3 4

Just after falling off

Diagnosis?

[Link]

Gonococcal ophthalmitis
Signs, Symptoms & Treatment
Mild Moderate Severe
Mucoid discharge Increasing discharge Purulent discharge
with conjunctivitis with severe
conjunctivitis

Caregiver education Erythromycin Syrup Erythromycin Syrup

on eye care
Antibiotic eye Antibiotic eye
ointment ointment

Ceftriaxone IM X1

ALWAYS wash hands before and after providing eye care!

Diagnosis??

(Roper & Vandelaer, 2007)

 Neonatal Tetanus
Usually presents at 2-14 days but can occur later

Risk Factors

• Unimmunized pregnant women

• Cutting of cord with unsterilized instruments
• Tying or dressing the cord with unhygienic materials
• Omphalitis (common entry site)
Sign and symptom
• Fever
• Poor feeding
• Irritability
• Convulsions or muscle spasms
• Muscle rigidity (lock jaw, facial grimace, rigid abdomen)
• Maintains consciousness
• Thanks