NEONATAL SEPSIS AND NEONATAL SEPSIS AND CONGENITAL INFECTIONS CONGENITAL INFECTIONS Camille Sabella Sabella, MD , MD Camille August 28, 2012 August 28, 2012 Objectives Objectives Objectives • At the end of the presentation, the • At the end of the presentation, the participant will be able to: participant will be able to: - - List the pathogens that cause neonatal List the pathogens that cause neonatal sepsis sepsis - Discuss the epidemiology of the Discuss the epidemiology of the - common pathogens of sepsis common pathogens of sepsis - Know the agents that are responsible Know the agents that are responsible - for congenital infections for congenital infections - Discuss the clinical features of the Discuss the clinical features of the - causes of congenital infections causes of congenital infections NEONATAL INFECTIONS NEONATAL INFECTIONS • Bacterial neonatal sepsis Bacterial neonatal sepsis • • • Viral infections mimicking bacterial Viral infections mimicking bacterial sepsis sepsis • In In- -utero utero infections (congenital infections (congenital • infections) infections) 1
NEONATAL SEPSIS NEONATAL SEPSIS • • Bacterial Bacterial vs vs viral viral • Early • Early- -onset onset vs vs Late Late- -onset onset • Perinatal Perinatal vs vs Nosocomial Nosocomial vs vs Community Community • acquisition acquisition • • Clinical syndromes similar regardless of Clinical syndromes similar regardless of etiology etiology BACTERIAL NEONATAL SEPSIS BACTERIAL NEONATAL SEPSIS • • Overall incidence 1 Overall incidence 1- -5 per 1000 live births 5 per 1000 live births • • Early Early- -onset sepsis onset sepsis • symptom onset within 6 days of life • symptom onset within 6 days of life • • maternal complications common maternal complications common • vertical transmission of organisms vertical transmission of organisms • colonizing genital tract colonizing genital tract BACTERIAL NEONATAL SEPSIS BACTERIAL NEONATAL SEPSIS • • Late- Late -onset sepsis onset sepsis • symptom onset after 6th day of life symptom onset after 6th day of life • • • 2 distinct groups of neonates 2 distinct groups of neonates • • healthy newborns who have been healthy newborns who have been discharged to home discharged to home • • high high- -risk hospitalized neonates who risk hospitalized neonates who develop hospital- develop hospital -associated associated infection infection 2
QUESTION #1 QUESTION #1 Of the following, the organism LEAST • • Of the following, the organism LEAST likely to cause early likely to cause early- -onset neonatal onset neonatal sepsis is: sepsis is: A. Listeria A. Listeria monocytogenes monocytogenes B. B. Group B Streptococci Group B Streptococci C. C. Streptococcus Streptococcus pneumoniae pneumoniae D. E. coli D. E. coli E. viridans E. viridans streptococci streptococci ETIOLOGY OF EARLY ETIOLOGY OF EARLY- -ONSET ONSET BACTERIAL SEPSIS BACTERIAL SEPSIS Group B Streptococci • • Group B Streptococci • dramatic decline since implementation of dramatic decline since implementation of • intrapartum intrapartum prophylaxis prophylaxis • • Escherichia coli Escherichia coli • probably most common now probably most common now • • • Listeria monocytogenes Listeria monocytogenes Less Common • • Less Common • viridans viridans streptococci streptococci • • non • non- -typeable typeable Haemophilus Haemophilus influenzae influenzae QUESTION #2 QUESTION #2 • All of the following are important causes All of the following are important causes • of late- -onset neonatal sepsis, EXCEPT: onset neonatal sepsis, EXCEPT: of late A. A. Streptococcus Streptococcus pyogenes pyogenes B. Coagulase- -negative negative B. Coagulase Staphylococci Staphylococci C. C. Staphylococcus aureus aureus Staphylococcus D. Gram- -negative bacilli negative bacilli D. Gram E. E. Candida albicans Candida albicans 3
ETIOLOGY OF LATE- -ONSET ONSET ETIOLOGY OF LATE NEONATAL SEPSIS NEONATAL SEPSIS • Healthy newborns previously discharged from Healthy newborns previously discharged from • hospital hospital • Group B Streptococci • Group B Streptococci • L. L. monocytogenes monocytogenes • • • E. coli E. coli • • Salmonella Salmonella species species - Less frequent causes: Less frequent causes: - • H. • H. influenzae influenzae- - nontypeable nontypeable • • Neisseria Neisseria meningitidis meningitidis • Streptococcus Streptococcus pneumoniae pneumoniae • ETIOLOGY OF LATE ETIOLOGY OF LATE- -ONSET ONSET N SEPSIS* SEPSIS* High risk newborns (VLBW infants in NICU) (VLBW infants in NICU) • • High risk newborns • Coagulase Coagulase- -negative Staphylococci negative Staphylococci-- --48% 48% • • • Most common cause of late Most common cause of late- -onset onset sepsis in hospitalized high sepsis in hospitalized high- -risk risk neonates neonates • Gram Gram- -negative bacilli ( negative bacilli ( E. coli E. coli , , Klebsiella Klebsiella sp, sp, • Enterobacter Enterobacter sp, sp, Pseudomonas Pseudomonas sp) sp)— —20% 20% • • S. S. aureus aureus— —8% 8% • Candida Candida albicans albicans— —12% 12% • • Enterococci • Enterococci— —3% 3% *NICHD Neonatal Network, Pediatrics 2002;110:285 BACTERIAL NEONATAL SEPSIS: RISK BACTERIAL NEONATAL SEPSIS: RISK FACTORS FOR VLBW INFANTS FACTORS FOR VLBW INFANTS • Invasive procedures Invasive procedures • • Mechanical ventilation Mechanical ventilation • • Indwelling intravascular catheters Indwelling intravascular catheters • • Total • Total Parenteral Parenteral Nutrition Nutrition • Widespread use of broad Widespread use of broad- -spectrum spectrum • antibiotics antibiotics • H H 2 blockers • 2 blockers 4
CLINICAL MANIFESTATIONS CLINICAL MANIFESTATIONS OF NEONATAL SEPSIS OF NEONATAL SEPSIS • Signs and symptoms often subtle and Signs and symptoms often subtle and • nonspecific nonspecific • Features of neonatal meningitis often Features of neonatal meningitis often • indistinguishable from sepsis indistinguishable from sepsis • Noninfectious illnesses have similar Noninfectious illnesses have similar • features features • RDS; Congenital heart disease; • RDS; Congenital heart disease; Metabolic disorders Metabolic disorders • • Most neonatal pathogens produce similar Most neonatal pathogens produce similar symptoms symptoms GROUP B STREPTOCOCCI: GROUP B STREPTOCOCCI: MATERNAL COLONIZATION MATERNAL COLONIZATION 15- -40% of all pregnant women are colonized with 40% of all pregnant women are colonized with • • 15 GBS GBS • Genital and GI tracts • Genital and GI tracts • • Highest: African Highest: African- -Americans, <20yo Americans, <20yo • Lowest: Asian, Mexican Lowest: Asian, Mexican- -Americans Americans • • • Colonization Colonization • Constant or intermittent Constant or intermittent • • Colonization during one pregnancy does Colonization during one pregnancy does • not predict colonization in subsequent not predict colonization in subsequent pregnancy pregnancy Mother to Infant Transmission of GBS Mother to Infant Transmission of GBS Mother to Infant Transmission of GBS GBS colonized mother 50% 50% Non-colonized Colonized newborn newborn 2% 98% Early-onset sepsis, Asymptomatic pneumonia, meningitis CDC Prevention Guidelines, 2010 5
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