Sources of systemic infection

In this webinar we will discuss where does the infection come from and how a baby gets infected?
This slides shows common bacteria that cause sepsis- in hospitalized neonates. These include Acinetobacter,Klebsiella, Escherichia coli, Staphylococcus aureus, and Coagulase negative staphylococci
Before we discuss sources of infection, Let us see this classification of NNS based on age of neonate at the onset of sepsis. If sepsis manifests at or before 72 hours of life- it is known as early onset sepsis. While the cases manifesting after 72 hours are known as late onset sepsis. This classification is important as the two types of sepsis are supposed to have different sources, causative bacteria, manifestations as well as outcomes.
Here we describe where the infection comes from in EOS. The bacteria from the rectum and perineum of mother ascends to maternal genital tract. While passing thru the birth canal, the baby picks up this infection. Alternatively, the infection can ascend to amniotic cavity especially when membrane ruptures prematurely. From there is reaches to the baby thru ingestion or aspiration and cause early onset sepsis. This is what is known as vertical transmission- from mother to baby.
EOS happens more often when one or more of these perinatal risk factors are present. These include: It is important to know that EOS on many occasions happens without any of these risk factors as well.
As opposed to EOS, LOS in hospitalized neonates also know as healthcare associated infection or HAI. It is acquired from the environment through bad care giving practices. The most important reason is inadequate hand hygiene practiced by the nurses and doctors of the unit. Their contaminated hands most often transmit infection of the babies under their care. The other methods of LOS includes- too many procedures, investigations, no asepsis during procedures, infection occurring during ventilation particularly during ET suction, overcrowding in the unit, lack of breastmilk feeding, use of IV fluids and unncessary drugs and antibiotics.
LOS in the community is acquired from bad practices in the homes and these include lack of breastfeeding, unclean cord practices, poor hygiene, many skin pustules and use of prelacteal or supplemental feeding.
This slide has very important message. While the EOS and LOS are pretty distinct in developed nations but that is not the case in developing countries. Bacterial pathogens, manifestations and antimcrobial resistance are quite similar between EOS and LOS in developing countries suggesting a similar pathogenesis. It seems that bad practices in birthing areas and during resuscitation and care giving during initial few hours of birth results in so called EOS in many babies, which actually is like LOS due to horizontal transmission.
Prevention of EOS therefore involves preventing and managing maternal risk factors as outlined in previous slide as well as following hygienic practices during birthing and resuscitation as well as during early few hours of birth. LOS would be prevented by good NICU practices in hospital, hygienic practices in homes. We have a separate webinar on this issue. Breast milk feeding would prevent both EOS as well as LOS
  • Introduction...
  • 1. Types of neonat...
  • 2. Pathogenesis of...
  • 3. Maternal risk f...
  • 4. Risk factors of...
  • 6. Risk factors of...
  • 7. In developing c...
  • 8. Preventive stra...
  • 9. Key messages...
 

Introduction

DR. RAMESH AGARWAL
MD, DM (Neonatology)

Professor
Department of Pediatrics
All India Institute of Medical Sciences
New Delhi

1. Types of neonatal sepsis

2. Pathogenesis of EOS

3. Maternal risk factors for EOS

► Rupture of membrane >24 hours
► Spontaneous preterm labor

► Chorioamnionitis
      ♦ Maternal fever (>100.4°F) and
      ♦ Two of: maternal tachycardia, fetal
         tachycardia, foul smelling liquor, uterine
         tenderness, maternal leukocytosis
         (>15,000 cells/mm3)

► Prolonged labor (>24h)
► Unclean or multiple PV examination
► Maternal UTI or diarrhea

4. Risk factors of LOS in hospitalized neonates

(Healthcare associated infections; HAI)

► Lack of adequate hand hygiene
► Procedures and investigations
► Suboptimal asepsis routines
► Infection occurring during ventilation particularly during
    ET suction
► Overcrowding in the unit and low nurse-patient ratio
► Lack of breastmilk feeding
► Use of IV fluids, unnecessary drugs and antibiotics

6. Risk factors of LOS in neonates in the community

(Community acquired infections; CAI)

► Contaminated environment
► Lack of hygiene practices
► Superficial infections such as umbilical sepsis and many
    pustules
► Lack of breastfeeding

7. In developing countries

(EOS in hospitalized neonates is like LOS)

► Perhaps due to

      ♦ Horizontal transmission due to unhygienic practices
         during birth, resuscitation and first few hours

      ♦ Colonization of maternal genital tract with resistant
         pathogens

8. Preventive strategies

► Early onset sepsis
      ♦ Must be directed towards preventing maternal risk factors
      ♦ Hygienic birthing and resuscitation and early care giving
         practices

► Late onset sepsis
      ♦ Good NICU practices in hospitals
      ♦ Hygienic practices in homes
      ♦ Breast milk feeding

9. Key messages

► Source of infection
      ♦ Early onset sepsis: maternal genital tract
        (vertical transmission)
      ♦ Late onset sepsis: environment, suboptimal care giving
         practices (horizontal transmission)

► Prevention of sepsis therefore must be directed towards
    risk factors of respective type of sepsis