Sepsis in NYI (Chapter 15)

Learning Objectives

After completion of this chapter the participant should be able to:

See investigations in case of suspicion of sepsis
See for assessment and management of meningitis

Risk factors for Sepsis

NYI have immature immune systems and have just been colonised with bacteria during their recent delivery. They are therefore prone to infections which are likely to cross barriers, for example between the lungs and blood, the gut and blood and meninges. Many NYI infections can be prevented by good hygiene at the time of birth, early and exclusive breastfeeding, appropriate umbilical cord care, appropriate eye care, using KMC and avoiding separation of the mother and infant.

Common systemic bacterial infections in young infants include sepsis, pneumonia, urinary tract infection, and meningitis and all these may present alike. Sepsis is a clinical syndrome of systemic illness accompanied by septicaemia (bacteria in the blood). It is also called bacteraemia.

Risk Factors for Sepsis and Clues to Infection

The risk factors for sepsis in the NYI are:

The babies born to mothers with these risk factors may be symptomatic or asymptomatic. Both symptomatic and asymptomatic should be treated as having sepsis with IV antibiotics as the risk for neonatal infection and the mortality rates are high.

Initial Assessment and Treatment of Sepsis in the NYI

ABCCCD

Assess ABCCD and manage the problems identified.

Provide supportive care and monitoring for the sick NYI.

Start empiric antibiotics; give penicillin and gentamicin – see doses in wall charts. Give (flu) cloxacillin instead of penicillin if extensive skin pustules or abscesses are present as these may indicate a staphylococcus infection.

Symptoms and Signs of sepsis in a NYI:

Look for these risk factors and do a septic screen. If the sepsis screen is negative and the infant remains asymptomatic, antibiotics may be discontinued after five days.

Investigations

A sepsis screen should be done in such infants before IV antibiotics:

Empiric antibiotic therapy and dose for sepsis:

Note: If a baby develops a fever after being in the neonatal unit for >72hrs it is likely to be a hospital acquired infection. These infections need treatment with the addition of ceftriaxone.

If less than 72 hours Benzyl penicillin in combination with Gentamicin are the drugs of choice.
ANTIBIOTIC EACH DOSE FREQUENCY ROUTE
Age < 7 days Age > 7 days
Benzyl
penicillin		 50,000 IU/kg 12 hrly. 6 hrly. IV, IM
AND
Gentamicin LBW:
3 mg/kg
Term:
5 mg/kg
>7 days:
7,5 mg/kg		 24 hrly. 24 hrly.
(7,5 mg/kg/dose) 		IV, IM
Ceftriaxone
[2nd line drug] 		50-100 mg/kg 24 hrly. 24 hrly. IV
If Benzyl penicillin is not available, Ampicillin or (Fluc)cloxacilin can be used as an alternative
Inj. Ampicillin 25 mg/kg <2kg: 12hrly <1.2kg: 12hrly
1.2-2kg: 8 hrly.		 IV/IM
>2kg: 8hrly >2kg: 6hrly IV/IM
(Flu)Cloxacillin 50 mg/kg 12 hrly. 6 hrly. IV

Key Facts for Providers:
Supportive Care for NYI with Sepsis
  • Ensure warmth.
  • Gentle stimulation if apnoeic, consider aminophylline if premature and current age is estimated to be < 37 weeks gestation.
  • Respiratory support with oxygen or CPAP if there is severe respiratory distress or apnoea.
  • If shocked treat according to the impaired circulation protocol.
  • If hypoglycaemic, infuse 2mls/kg of 10% dextrose stat and recheck in 30 minutes, continue maintenance 10% dextrose.
  • If they have not received Vitamin K, give 1mg intramuscularly as septic NYI may have an increased tendency to bleed.
  • If very sick, e.g., continuous convulsions, avoid oral feeds, give maintenance fluids. Treat convulsions if present.
  • Treat jaundice if present with phototherapy

Key Facts for Providers:
Empiric Antibiotics and Duration
  • Empiric antibiotics means that the organism causing the sepsis has not yet been identified and the antibiotics selected will treat the organisms most likely to cause this presentation in this age group.
  • If there is no blood culture or the blood culture is negative and even if the baby is well, continue to treat with the empiric antibiotics for a minimum of 5 days.
  • If the baby was clinically septic - treat for 7-10 days (except meningitis and bone/joint infection which will require longer duration antibiotics).
  • If not improving in 48 hours the antibiotic treatment may need to be changed from the first line (penicillin and gentamicin) to second line, which is often ceftriaxone but this depends where you work).

How to Prevent Sepsis in a NYI