(Sepsis neonatorum)

Neonatal sepsis is an invasive, usually bacterial, infection that occurs during the neonatal period. The signs are numerous, non-specific and include decreased spontaneous activity, drinking and Saugunlust, apnea, bradycardia, temperature instability, difficulty breathing, vomiting, diarrhea, stomach tense, tremors, seizures and jaundice. The diagnosis is clinical and based on the cultural detection of the pathogen. The initial treatment is performed with ampicillin plus gentamicin or cefotaxime and adapted to the antibiogram.

Neonatal sepsis is an invasive, usually bacterial, infection that occurs during the neonatal period. The signs are numerous, non-specific and include decreased spontaneous activity, drinking and Saugunlust, apnea, bradycardia, temperature instability, difficulty breathing, vomiting, diarrhea, stomach tense, tremors, seizures and jaundice. The diagnosis is clinical and based on the cultural detection of the pathogen. The initial treatment is performed with ampicillin plus gentamicin or cefotaxime and adapted to the antibiogram.

(Sepsis and septic shock.) Neonatal sepsis is an invasive, usually bacterial, infection that occurs during the neonatal period. The signs are numerous, non-specific and include decreased spontaneous activity, drinking and Saugunlust, apnea, bradycardia, temperature instability, difficulty breathing, vomiting, diarrhea, stomach tense, tremors, seizures and jaundice. The diagnosis is clinical and based on the cultural detection of the pathogen. The initial treatment is performed with ampicillin plus gentamicin or cefotaxime and adapted to the antibiogram. The incidence is 0.5 to 8.0 / 1000 live births. The highest rates occur in infants with very low birth weight infants with depressed function at birth, such as by a low Apgar score manifested infants with maternal perinatal risk factors (eg. As low socioeconomic status, premature rupture of membranes) minority men Etiology The neonatal sepsis start early (? 3 days after birth) or late (after 3 days). Early sepsis Early onset neonatal sepsis (within 7 days after birth) is usually caused by germs intra partum. Most children have symptoms within 6 hours after birth. Most cases of early sepsis caused by group B streptococci (GBS) and gram-negative enteric pathogens (mainly Escherichia coli). With up to 35% of women vaginal and rectal swabs at term show a colonization with group B streptococci At least 35% of newborns are also colonized. A decisive factor for early-onset invasive disease is the colonization density (high density the risk by 40 times increased). In one out of 100 newborns, in which GBS can be detected, there will be a streptococcal-induced invasive disease caused by group B streptococci; > 50% of which manifest themselves within the first 6 hours of life. Increasingly, a non typifizierbarer Haemophilus influenzae can be identified in preterm infants as sepsis cause. The other cases are mostly by other gram-negative enteric pathogens (eg Klebsiellasp.) And gram-positive organisms – Listeria monocytogenes, Enterococcus (e.g., Enterococcus faecalis, E faecium..), Group D streptococci (for example Streptococcus bovis.) , ?-hemolytic streptococci and staphylococci – caused. can be detected S. pneumoniae, H. less frequently influenzae type B and Neisseria meningitidis. Asymptomatic gonorrhea occurs in 5-10% of pregnancies, N. gonorrhoeae can therefore potentially pathogenic sein.Spätsepsis late-onset (late-onset) neonatal sepsis (7 days after birth) is often a nosocomial infection (hospital-acquired infections in newborn). Staphylococci are responsible for 30-60% of Spätsepsen and are particularly associated with intravascular plastic catheters before (especially arterial catheter). E. coli is also increasingly recognized as a major cause of late sepsis, especially in infants with very low birth weight (LBW). The isolation of cloacae Enterobacter or Cronobacter (formerly Enterobacter) sakazakii (Enterobacter formerly) sakazakii from blood or cerebrospinal fluid can indicate contaminated food. Contamination of the ventilation accessories should be suspected in a nosocomial infection with Pseudomonas aeruginosa, which can cause pneumonia or sepsis. Although a generalized screening and intrapartum Antibiotikaprophylase for the group B streptococci, the number of early-onset disease due to this pathogen significantly reduced the number of late-onset GBS sepsis remains the same. This can be seen in line with the hypothesis that the cause must be sought for the late-onset disease usually in the area. The role of anaerobes (particularly Bacteroides fragilis) in late sepsis is unclear, although neonatal deaths with a Bacteroides bacteremia have been associated. Candida is becoming more common cause of late sepsis. It occurs in 12-18% of infants with low birth weight vor.Frühsepsis and late sepsis (simplex z. B. disseminated herpes, enteroviruses, adenoviruses, RSV) Some viral infections can manifest as early sepsis or late sepsis. Pathophysiology early sepsis Certain maternal perinatal and obstetric factors increase the risk, especially neonatal sepsis early. These include: Premature rupture of membranes (PROM) time ? 18 hours before birth Maternal chorioamnionitis occurs (most often manifests simply as maternal fever before or during birth with maternal leukocytosis, tachycardia, uterine compliance and / or foul-smelling amniotic fluid) colonization with GBS prematurity the hematogenous transplacental dissemination and a maternal infection occurs in the transmission of some viruses (eg. as rubella, cytomegalovirus), protozoa (eg. as Toxoplasma gondii) and Treponema (z. B. Treponema pallidum) ago. A few bacterial pathogens (eg. As L. monocytogenes, Mycobacterium tuberculosis) reach the fetus transplacental. but most pathogens reach the fetus in utero or ascending passes through the birth canal during the fetus. The density of the maternal colonization directly correlated with disease risk of the fetus. However, also can be detected a large density of nuclei with many children of only slightly colonized mothers. Fruit water, which is contaminated with vernix or meconium, promotes the growth of group B streptococci and E. coli. Therefore, the few pathogens are in the fornix able to multiply quickly after premature rupture, which may contribute to this paradox. They usually reach the bloodstream by aspiration or ingestion of amniotic fluid and cause bacteremia. Various phenomena speak for an ascending infection, such as the high incidence of neonatal infection in a premature rupture of membranes, the importance of pelvic inflammatory disease (a amnionitis is rather associated with a neonatal sepsis as the central placental infection), the increased risk of infection for the closer to the birth canal located Twin and the microbiological findings in early onset neonatal sepsis of which is the maternal vaginal flora widerspiegelt.Spätsepsis the most important risk factor for late sepsis, preterm delivery. Other risk factors include Prolonged use of intravascular catheters sequelae (but which can only be an indication for the use of invasive procedures) Exposure to antibiotics (aimed at specific resistant strains of bacteria) Prolonged hospitalization contaminated equipment or intravenous or enteral solutions Gram-positive bacteria (eg . as coagulase-negative staphylococci and Staphylococcus aureus) are introduced from the environment or the patient’s skin. Gram-negative enteric bacteria almost always come from the individual endogenous bacterial flora that has either changed by previous antibiotic treatments or was resistant germs by the hands of staff (common distribution) settled or transferred by contaminated equipment. Consequently, it is in situations that promote exposure of the infant to these germs (z. B. overcrowding, inadequate care key or inconsistent washing hands), an increased incidence of nosocomial infections. Risk factors of sepsis with Candida include long lying (> 10 days), central venous catheters, hyperalimentation, the use of antibiotics (especially 3rd generation cephalosporins) and a pathology of the abdomen. The primary focus of infection urinary tract, paranasal sinuses, the middle ear, lungs and gastrointestinal tract apply; from here it comes then to a spread to the meninges, kidneys, bones, joints, the peritoneum and skin. Symptoms and signs The early signs of neonatal sepsis are often non-specific and can not be a single pathogen assign (including viruses). Among the most frequent early signs Decreased spontaneous activity less powerful suction anorexia apnea bradycardia temperature instability include (hypothermia or hyperthermia) fever is only present in 10-15% of infants, but if it persists> 1 h hour, this is an indication of infection , Other symptoms include shortness of breath, neurological abnormalities (excitability, seizures), jaundice (esp. In the first 24 hours of life without Rh or AB0 incompatibility, but with an unexpectedly high concentration of direct bilirubin), vomiting, diarrhea and flatulence of the abdomen. Organ-specific symptoms give indications of the primary or secondary Absiedlungsort infection. Most infants with a late onset (and many with L. monocytogenes) infection of the streptococcus group B fall on with shortness of breath, which is difficult distinguishable from respiratory distress syndrome. A Omphalitis must be presumed for periumbilical erythema with secretions or blood secretions (infection preventing the obliteration of the umbilical vessels). Coma, seizures, opisthotonos, or a bulging fontanelle let meningitis suspected encephalitis or brain abscess. Decreased spontaneous movements of a limb or a joint, calor, rubor or swelling over a joint indicate osteomyelitis or purulent arthritis. An abdominal distension should suggest peritonitis or necrotizing enterocolitis (especially if the symptoms with bloody stools and leukocytes in the stool accompanied). Note factor on disseminated herpes simplex infection are cutaneous sores, ulcerations of the oral mucosa and hepatosplenomegaly (in particular together with disseminated intravascular coagulation [DIC]). The early onset infection with group B streptococci manifests as fulminant pneumonia. It is often a result of a gynecological complications (premature labor, premature rupture of membranes or chorioamnionitis). > 50% of newborns to infection with group B streptococci within 6 hours after birth manifested. In 45% of newborns Apgarzahl of <5 is observed. Meningitis can also be present, but is not common. In the late-onset GBS infection (> 3 days to 12 weeks) meningitis is commonly found. The late-onset GBS infection is largely not dependent on perinatal risk factors or maternal colonization. It arises primarily partum post. Diagnosis Profound suspected blood, cerebrospinal fluid, and sometimes urine culture Early diagnosis of neonatal sepsis is of great importance and requires a good knowledge of risk factors (especially in children with low birth weight) and a high degree of attention when a newborn during the first weeks of life is striking. In neonates with clinical signs of sepsis should as soon as possible, a complete blood count, differential diagnosis with smear, blood culture, urine culture (not necessary for the evaluation of early sepsis) get and, if possible, lumbar puncture. In newborns with respiratory distress, a chest radiograph should be initiated. The diagnosis is confirmed by the isolation of the pathogen. Other tests may be pathological, but not necessarily contribute to the diagnosis. Infants should be given a broad empirical antimicrobial therapy. Newborns who appear to be in good shape, are treated depends on several factors, as discussed below prevention. Complete blood count and smear The total leukocyte count is not suitable in newborns for detection of early sepsis. However, an increased ratio of immature to mature polymorphonuclear leukocytes> 0.16 is sensitive, and values ??below that limit speak for a diagnosis of exclusion. However, the specificity is low; up to 50% of newborns have an increased ratio. Values ??that have arisen after the first 6 hours of life, are abnormal with a higher probability and clinically productive as values ??that were collected immediately after birth. The platelet count may fall hours or several days before the clinical manifestation of sepsis, but in the majority of cases it remains an increased to about 2 days after onset of disease. The decrease in platelets is sometimes with other signs of disseminated coagulation associated (z. B. increased fibrin degradation, decreased fibrinogen or prolonged prothrombin time). Since the timing of these changes, the platelet count is usually not helpful in assessing a newborn sepsis. Because of the high number of circulating bacterial pathogens can often be seen by appropriate Gram, methylene blue or acridine coloring in or on the polymorphonuclear leukocytes. Whatever the outcome of the CSF or the LP immediate antibiotic treatment should at newborns with suspected sepsis, but particularly in those who are sick or febrile or hypothermic be initiated after crops (eg., Blood and cerebrospinal fluid) wurden.Lumbalpunktion created by a previously hypoxic newborn is an increased risk of a further deterioration during the lumbar puncture. However, there is a high degree of suspicion of CSF should be obtained as soon as the child’s condition stabilized (neonatal bacterial meningitis diagnosis). An additional O2 administration before and after the LP can prevent hypoxia. Since a GBS infection in the first days of life often proceeds very similar to the respiratory distress syndrome, in these children LP are often routinely durchgeführt.Blutkulturen The umbilical vessels via the umbilical stump, in particular after a few hours, often contaminated with germs, so that the blood samples from these venous vessels often does not provide reliable results. Therefore, blood for culture should be collected by venipuncture, preferably at two peripheral locations. Although there are no set rules for the optimal preparation of the skin prior to drawing blood in newborns, doctors can use an iodine-containing liquid to clean the skin. Then the body should dry. Alternatively, blood may soon be removed after placement of an arterial umbilical catheter and used as needed for culture. It should be applied in each case an aerobic and anaerobic blood culture However, the minimum amount of blood per blood culture flask at 1.0 ml; if <2 ml is obtained everything should be placed in a single aerobic blood culture bottle. Suspicion of catheter-associated infection in addition to the peripheral blood sample, a blood through the catheter must be done. > 90% of positive bacterial blood cultures growth occurs within 48 hours after incubation. Data on capillary blood cultures are of little relevance to recommend them. Although Candida grow in blood cultures and blood agar plates for suspected another fungal infection but special culture media are required. Other fungal cultures as Candida must, possibly 4-5 days are incubated before a finding can be collected and may remain negative despite disseminated infestation. It is useful to early detect colonization in the mouth, stool or on the skin before culture results are available. Newborns with candidemia should be subjected to a record to identify a Candida meningitis. An indirect ophthalmoscopy with far dripped pupil is performed to detect retinal lesions. Renal mycetomas can werden.Urinanalyse detected sonographically and culture urine tests are only required for the evaluation of late sepsis. Urine samples should by catheterization or suprapubic puncture and not be recovered from urine bags. In the detection of ? 5 leukocytes at a high magnification in the centrifuged urine or any nucleus in fresh, centrifuged urine is a urinary tract infection must be assumed. A missing Pyuria includes urinary tract infections not aus.Andere ignition tests Numerous studies have been evaluated pathologically and as a possible early marker in sepsis. In general, however, the sensitivity to a later disease score low and the specificity is less than optimal. Acute phase proteins are formed under the influence of IL-1 and the liver, if inflammation is present. Most important is the quantitative C-reactive protein (CRP). A concentration of ? 1 mg / dl (measured by nephelometry) is abnormal. Elevated values ??occur within 6-8 h after the onset of sepsis. The highest value is measured after one day. The sensitivity of the C-reactive protein is higher when the measurements are performed after 6-8 hours of life. Two normal values ??of between 8 and 24 hr after birth and then 24 h later reaches a negative predictive value of 99.7%. Procalcitonin is examined as an acute phase protein marker for sepsis in newborns. Although procalcitonin appears more sensitive than C-reactive protein, it is less specific. Prognosis The mortality rate of neonatal sepsis in underweight newborns 2-4 times higher than for term infants. In the early sepsis Gesamtletalitätsrate is 3-40% (GBS sepsis 2-10%) and the late sepsis 2-20% (GBS sepsis 2%). The mortality rate in the late sepsis is highly dependent on the etiology of infection; Infections caused by gram-negative bacilli or Candida, have a rate of 32-36%. In addition to mortality have infants with very low birth weight, develop a bacterial or candida sepsis, a significantly higher risk of poor neurological outcome. Treatment antibiotic therapy Supportive treatment The drugs are later adapted to the antibiogram and the site of infection. As a neonatal sepsis often initially manifests with non-specific symptoms, but the consequences can be catastrophic, rapid diagnosis and early initiation of treatment are essential, (overview of antibacterials: Selection and use of antibiotics). In general, if not a source of infection is clinically identified, the child appears healthy and cultures are negative, antibiotics can be stopped (up to 72 hours in small premature infants) after 48 h. General supportive measures, including therapy for respiratory failure and hemodynamic instability, combined with antibiotic therapy. Antimicrobial drugs Recommended dosages selected pareneraler antibiotics for newborns. In the early sepsis therapy with ampicillin plus aminoglycoside should be started. Cefotaxime can supplement the treatment or replace the aminoglycoside, if it is suspected that the meningitis is caused by a Gram-negative pathogens. The antibiotics can, once the pandemic is identified, to be adjusted. Previously healthy infants who were taken from an environment with suspected late sepsis should receive therapy with ampicillin plus gentamicin or ampicillin plus cefotaxime. When Gram-negative meningitis is suspected, ampicillin, cefotaxime and an aminoglycoside can be used. In the late nosocomial sepsis, initial therapy should be initiated with vancomycin (against methicillin-resistant S. aureus) and an aminoglycoside. When P. aeruginosa has spread in the pediatric ward, ceftazidime, cefepime or piperacillin / tazobactam to be used in addition to or instead of an aminoglycoside depending on local sensitivities. Newborns who were already treated for 7-14 days with an aminoglycoside should receive another aminoglycoside or cephalosporin of the third generation at a re-treatment. If coagulase-negative staphylococci (z. B. for more than 72 h lying vascular catheter at a) are suspected, or the germ detected in a blood culture or other otherwise sterile body fluids and has been classified as pathogenic, already should be initially treated with vancomycin. Is the causative agent, however, sensitive to nafcillin, cefazolin should or nafcillin replace vancomycin. An elimination of the suspected source of infection (usually vascular catheter) may be necessary to anneal the infection, as coagulase-negative staphylococci may be protected by a biofilm (coating which promotes adhesion of the germs to the catheter). Since Candida cultures need 2-3 days to grow in a blood culture, an empirical initiation of amphotericin B treatment and the removal of the infected catheter can before the cultures confirm a fungal infection lifesaving sein.Andere treatment options exchange transfusions are particularly hypotonic in critically ill ( and metabolically acidotic) newborn with the aim carried out to increase the level of circulating immunoglobulins, to reduce the concentration of circulating endotoxin, to increase the hemoglobin level (to improve with higher 2,3-diphosphoglycerate levels) and the perfusion. Prospective studies on this topic does not yet exist, however. Fresh frozen plasma (fresh frozen plasma) to the lack of heat-stable and heat-labile opsonin, which is typical of underweight newborns diminish. Here, too, there are no controlled studies, and the potential benefits must be weighed against the risks of transfusion. Granulocyte transfusions (blood products: granulocytes) were carried out in septic and granulocytopenic newborn, but could not convincingly improve the disease outcome. Recombinant G-CSF (granulocyte-colony stimulating factors) and GM-CSF (granulocyte-macrophage colony-stimulating factors) increase the neutrophils and improve their function in neonates with suspected sepsis. Newborns with severe neutropenia do not seem to benefit from routine use. This requires further study. Prevention newborns who appear healthy, the risk of streptococcal infection group B may have. You will be treated depending on various factors (1.2), including the presence of chorioamnionitis Whether was a prophylaxis for streptococci maternal group B displayed and administered as required gestational age and duration of membrane rupture If neither chorioamnionitis nor an indication of streptococcal prophylaxis of group B is present, no examination or treatment is indicated. If chorioamnionitis is present or strongly suspected premature and newborn infants should get a blood culture at birth and begin an empirical broad-spectrum antibiotic therapy. The tests should cover after 6-12 hours of life and leukocyte count and differential diagnosis as well as C-reactive protein. The further procedure depends on the clinical course and the results of laboratory tests. If a maternal prophylaxis of group B streptococci displayed and administered in a suitable manner (i.e., penicillin, ampicillin or cefazolin i v given for ? 4 hr….) Should be observed infants in hospital for 48 h; Testing and treatment are performed only when symptoms develop. Selected patients ? 37 SSW, reliable caregivers and easy access to follow-up studies have, can go home after 24 hours. If appropriate prophylaxis for streptococcus group B took place, infants are hours in the hospital for 48 observed without antimicrobial therapy. If the amniotic sac ? 18 h before birth or <37 SSW bursts, blood culture, blood count with differential and perhaps a C-reactive protein at birth and / or 6 to 12 hours thereafter, are recommended. The clinical course and the results of laboratory tests to determine how to proceed. The benefit of an i.v. Immunoglobulin administration to enhance the immune response of the newborn and thus prevent sepsis or treat, could not be confirmed. Maternal indications for GBS prophylaxis All pregnant women should be tested late in pregnancy for GBS colonization. Women with a positive GBS screening should receive intrapartum antibiotic prophylaxis, unless they get a cesarean section before labor starts and before the waters break. Women with a negative GBS screening should receive intrapartum antibiotics if they have previously delivered a baby with GBS disease. Women whose GBS status is unknown (eg because they have not been tested or because the results are not available.) Should receive intrapartum an antibiotic if ? 1 of the following factors are present: <37 wk gestation rupture at ? 18 hours body temperature> 38 ° C to the antibiotics that are commonly used include penicillin, ampicillin, or cefazolin and they should ? 4 hours before delivery iv are given. The selection should antimicrobial resistance patterns of local GBS berücksichtigen.Hinweis for prevention 1. Brady MT, Polin RA: Prevention and management of infants with Suspected or proven neonatal sepsis. Pediatrics 132: 166-8, 2013. 2. Polin RA and the Committee on Fetus and Newborn: Management of neonates with Suspected or proven early-onset bacterial sepsis. Pediatrics 129: 1006 to 1015, 2012. Summary Neonatal sepsis early (? 3 days after birth) or late use (after 3 days). An early sepsis is typically caused by pathogens that are intra partum acquired. Symptoms appear within 6 hours after birth. A late sepsis typically results from infection by the environment and more likely to occur in premature infants, particularly those with longer hospitalization, use of i.v. Catheters or both. Early signs are often non-specific and subtle. Fever only occurs in 10-15% of newborns. It should blood and Liquorkulturen and, for the late sepsis, and urine cultures are created. The initial treatment of sepsis with early onset is with ampicillin plus gentamicin (and / or cefotaxime when suspected gram-negative meningitis) introduced and adapted to the antibiogram.

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