Initial approach to neonatal sepsis
We can identify four broad scenarios of sepsis presentation:
1.The baby is asymptomatic i.e. does not have any symptoms at all but there are one or more perinatal risk factors for EOS
2.The baby has symptoms suggestive of sepsis within 72 hours and there are risk factors as well
3.Symptoms within 72 hours but no risk factors
4.Symptoms after 72 hours
The first three scenarios pertain to EOS and last scenario pertain to LOS. In any of four scenarios- the baby could be in the hospital or at home
Let us examine what are the perinatal risk factors for eraly onset sepsis.
They are classified into two categories, namely extereme risk factors such as
Rupture of membrane for >72 hours
Chorioamnionitis, and
Foul smelling liqor
Other risk factors namely-
Spontaneous preterm labor
Prolonged labor for >24 hours
Unclean PV examination
The likelihood of sepsis is greater when the exterem risk factors are present. In next few slides, we will discuss scenario-based management of babies
So what do we do in scenario 1: If there are extreme perinatal risk factors namely chorioamnionitis, or foul smelling liqor or ROM for >72 hours: startantibiotics. If there are other risk factors: follow these babies with examination of vital parameters and for development of any sign of sepsis every 6 to 12 hours for 72 hours. If the baby develops a sign suggestive of sepsis or hemodynamic instability, antibiotics must be initiated. We should always take blood culture before starting antibiotics in both the circumstances. Perform LP if culture comes positive.
In scenario 2: If the baby is symptomatic and has one or more risk factors- the baby should be started on antibiotics. Perform blood culture before starting antibiotics. Perform LP.
Now let us examine scenario 3 or 4: a symptomatic baby before or after 72 hours of life. As indicated earlier, such baby can be in the homes or already admitted in the hospital for some other reason. These babies can have one or more of following signs: Lethargy, poor feeding Sometime a care giver- mother/nurse- may report that ‘baby does not look well’. And this can be an early sign of sepsis Respiratory distress, apnea Fever, hypothermia Vomiting, diarrhea, abdominal distension Seizures, encephalopathy Poor perfusion, shock Rare- bleeding, sclerema, renal failure
What do we do in scenario 3 &4.
Assess the level of sickness in the baby. If the baby is too sick as evidenced by presence of shock, sclerema, bleeding tendency, respiratory failure requiring ventilation, seizures in absence of HIE, severe hypothermia, or obvious signs of sepsis such as cellulitisantibiotics should initiated immediately.
However, If the baby is not too sick (such as a there is an isolated episode of apnea, ocassional vomiting, transient temperature instability, some recued activity, mild tachypnea, we need not start antibiotics immediately. We do sepsis screen and the baby is only treated with antibiotics of if sepsis screen is positive. If the sepsis screen is negative: alternate cause for symptoms should be looked for and the baby is followed up closely and again, always take blood culture before starting antibiotics.
Key message are therefore the sepsis can manifest in different ways:
1.The baby can be asymptomatic and perinatal risk factors may be present
2.Symptomatic baby: the symptoms are generally non-specific and can pertain to any organ system
In a sick baby/significant perinatal risk factor: start antibiotics
In not-so sick baby perform sepsis screen. If other perinatal risk factors: follow the baby; treat if screen positive or baby becomes symptomatic
- Introduction...
- 1. Leaning objecti...
- 2. Sepsis...
- 3. Perinatal risk ...
- 4. Symptoms sugges...
- 5. Scenarios...
- 6. What do you do ...
- 7. What do you do ...
- 8. What to do in s...
- 9. What to do in s...
- 10. Key messages...
- 11. Key messages 0...
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