Sepsis in NYI

Learning objectives

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

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 and blood and meninges. Many NYI infections can be prevented by good hygiene at the time of birth, 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 and meningitis and all these may present alike. Sepsis is a clinical syndrome of systemic illness accompanied by septicaemia (a bacterium in the blood which is normally sterile). It is also called bacteraemia.

Maternal 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 is so great and the mortality rates are high.

Key fact for providers

Infants with sepsis may present in the first few days of life, before they have been discharged or they may go home and be readmitted with sepsis.
The management of both groups is the same.

Initial assessment and treatment of sepsis in the NYI

ABCCCD

Provide supportive care and monitoring for the sick NYI
Start empiric antibiotics; give penicillin and gentamicin – see doses in wall charts
Give flucloxacillin (if available) instead of penicillin if extensive skin pustules or abscess as these may be indications of staphylococcus infection.

Symptoms and signs of sepsis in a NYI

Symptoms

Lethargic, decreased movement

Axillary temperature 37.5°C or above (or feels hot to touch) or temperature < 35.5°C


Bulging fontanelle

Signs of respiratory distress in the newborn and in the YI: Grunting, nasal flaring, fast breathing, chest in drawing, crepitation’s in the lungs



Umbilical redness extending to the periumbilical skin or umbilicus draining pus

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

Investigations

WBC: < 5000 or > 20,000 cells/mcl (age >72 hrs)
Lumbar puncture if available, before IV antibiotics
Blood culture, if available, before IV antibiotics
Urine culture if available, before IV antibiotics

Empiric antibiotic therapy of sepsis

ANTIBIOTIC EACH DOSE FREQUENCY ROUTE
(DAYS)
Inj. Penicillin or 50,000 IU/kg < 7 days:
12 hrly		 > 7 days:
6 hrly		 IV, IM
AND
Inj. Gentamicin LBW 3mg/kg/dose
Term 5mg/kg/dose		 < 7 days:
24 hrly		 > 7 days:
24 hrly
(7.5mg/kg/dose)		 IV, IM

Key fact for providers - Supportive care for NYI with sepsis

  • Ensure warmth

  • Gentle stimulation if apnoiec, 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 apnoeas.
  • If shocked treat according to 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 IV fluids.
  • Treat convulsions if present.
  • Treat jaundice if present with phototherapy.

Key fact 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 may require longer).
  • 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).