NEONATAL SEPSIS

This term was not new to me. I had heard it so many times in my microbiology classes and it never occurred to me that I would have an experience with it ever in my life.

We were referred to knh when Princess didn’t show any improvement and we were admitted in the pediatrics emergency section. After taking the history, the doctor ordered for blood tests and indicated “?sepsis” I have done medical laboratory science and technology and when I saw that statement, a chill ran down my spine. Cold sweat ran down my face and I think I froze. Sepsis in neonates is fatal. (A neonate is a baby less than 28 days and sepsis is a serious medical condition in which the whole body is inflamed and a known or suspected infection is present). The prognosis is usually not a good one especially if not ‘caught’ early and I didn’t want to imagine what could happen. The mortality rate is 10-40%.

What is Neonatal Sepsis?

Definition from Wikipedia “Neonatal sepsis is a type of neonatal infection and specifically refers to the presence in a newborn baby of a bacterial blood stream infection (BSI) (such as meningitis, pneumonia, pyelonephritis, or gastroenteritis) in the setting of fever”

Sepsis is a severe bacterial infection that spreads throughout the body in the first month of life. It occurs in less than 1% of newborns but accounts for up to 30% of deaths in the first few weeks of life.

It is also known in other terms as sepsis neonatorum, neonatal septicemia or Sepsis-infant.

Causes of Neonatal Sepsis

Neonatal sepsis can be caused by bacteria such as Escherichia coli (E.coli), Listeria monocytogenes and GBS.

• GBS commonly known as Group B Streptococcus which includes the bacteria Streptococcus agalactiae is the most common cause of neonatal sepsis and meningitis. This bacterium normally colonizes the urogenital tract of pregnant women. It primarily occurs in newborns and is very rare after 5 months of age and causes invasive diseases in newborns. The incidence is:-
  • Overall: 2 to 4 per 1000 live births
  • Invasive: 1.8 per 1000 live births

Transmission is perinatal before or during birth from the mother to the child during delivery via a birth canal colonized with GBS. Incidence of U.S. vaginal colonization with GBS is 15-20% (Statistics for Kenya not available).

The mean onset of infection is 20 hours of life and there is early-onset infection and late-onset infection.

Early-onset neonatal disease occurs in neonates who are less than 7 days old, with transmission of the organism from the mother and manifests in the form of pneumonia or meningitis with bacteremia (bacteria in the bloodstream). This is associated with a high mortality rate. The following increases an infant’s risk of early-onset sepsis:

• Group B streptococcus infection during pregnancy
• Preterm delivery
• Water breaking (rupture of membranes) that lasts longer than 24 hours before birth
• Infection of the placenta tissues and amniotic fluid (chorioamnionitis)

 

Late-onset neonatal disease occurs between 1 week and 3 months after birth. It usually occurs in the meningitis form and the mortality rate is not as high as in the early-onset.The following increase an infant’s risk of sepsis after delivery:

• Having a catheter in a blood vessel for a long time
• Staying in the hospital for an extended period of time

 

In adults, GBS occurs in immunosuppressed patients or those with underlying disease and is also often found in a previously healthy woman who just experienced childbirth.

• Listeria monocytogenes

This microorganism is a potential pathogen for both humans and animals. Most human cases occur in patients with debilitating disease or in prenatal or neonatal infants. Sepsis, meningitis, and disseminated abscesses occur in infected patients. Meat, vegetables, and various milk products are the most common sources of infection.

Listeriosis is a serious disease for humans, with mortality greater than 25%. There are two main clinical manifestations, sepsis and meningitis. Relapses may occur after apparent recovery.

A particular property of L. monocytogenes is the ability to multiply at low temperatures. Bacteria therefore can accumulate in contaminated food stored in the refrigerator.

I also found this information useful. Listeria species are found in living and nonliving matter. Various foodstuffs of vegetable and animal origin are sources of infection. Animal and human carriers also have been described. Most human cases of listeriosis develop in immunocompromised hosts: newborns, old people, cancer patients, and transplant recipients. Reports of sporadic cases of listeriosis are becoming more frequent as the number of persons at risk, especially because of immunosuppression by medical therapy, increases. Outbreaks of listeriosis are due mainly to a common source of contaminated food.

Listeriosis also may be transmitted congenitally across the placenta. The immunocompetent mother suffers at worst a brief, flu-like febrile illness, but the fetus, whose defense system is still immature, becomes seriously ill. Depending on the stage of gestation, the fetus is either stillborn or born with signs of congenital infection. The onset of listeriosis is delayed (i.e., a few days after birth) when infection is acquired during labor by bacteria colonizing the genital tract of the mother.

Hygienic food processing and storage may reduce the risk of listeriosis. Individuals in high-risk groups (i.e., immunocompromised individuals and pregnant women) should avoid uncooked food or should at least marinate salads for a long time in a vinegar-based dressing to kill adherent bacteria.

• E. Coli

This bacterium is normally found in the gastrointestinal tract and produces vitamin K in the large intestine. It is exclusively found in the large intestines and faeces and  if found in tested water, it indicates pollution and faecal contamination.

Neonatal sepsis can occur when E. Coli from the mother’s birth canal is transmitted to the baby. The bacterium could have found its way to the birth canal through spread of fecal bacteria to the urogenital tract.

Symptoms

Infants with sepsis neonatorum may have the following symptoms; body temperature changes, breathing problems, diarrhea, low blood sugar, reduced movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting and jaundice (yellow skin and whites of the eyes).

Signs and tests

Laboratory tests can help diagnose neonatal sepsis and identify the bacterium that is causing the infection. Blood tests may include:

• Blood culture
• C-reactive protein
• Complete blood count (CBC)

A lumbar puncture (spinal tap) will be done to examine the cerebrospinal fluid for bacteria.

If the baby has a cough or problems breathing, a chest x-ray will be taken.

Urine culture tests are done in babies older than several days.

Treatment

Babies in the hospital and those younger than 4 weeks old are started on antibiotics before lab results are back. (Lab results may take 24-72 hours.) This practice has saved many lives.

Older babies may not be given antibiotics if all lab results are within normal limits. Instead, the child may be followed closely on an outpatient basis.

Babies who do require treatment will be admitted to the hospital for monitoring.

Antimicrobial agents are the mainstay of treatment.

Prognosis (Expectations)

With prompt treatment, many babies with these bacterial infections will recover completely with no remaining problems. Nevertheless, neonatal sepsis is a leading cause of infant death. The more quickly an infant receives treatment, the better the outcome.

Complications

• Disability
• Death

 **Seek immediate medical help if your infant shows symptoms of neonatal sepsis.

Prevention

Preventative antibiotics may be given to pregnant women who have chorioamnionitis, Group B strep, or who have previously given birth to an infant with sepsis due to the bacteria. Perinatal GBS Prophylaxis is available.

Preventing and treating infections in mothers, providing a clean birth environment, and delivering the baby within 24 hours of rupture of membranes, where possible, can all help lower the chance of neonatal sepsis.

Hygienic food processing and storage may reduce the risk of listeriosis.

 

References

Verani JR, McGee L, Schrag S. Prevention of Perinatal Group B Streptococcal Disease, Revised Guidelines from CDC, 2010. Morbidity and Mortality Weekly Report. 59(RR-10): 1-36, 2010.

Stoll et al. Early onset neonatal sepsis: the burden of group B streptococcal and E. coli disease continues. Pediatrics 2011: 127:817-826.