Neonatal Emergencies 1 (through EOS)

Question 1

The neonate and infection (6)

Answer 1

1. Diverse modes of transmission
2. Immunologic immaturity of the newborn –> Immune system isn’t as active/mature as an older child
3. Can be complicated by coexisting conditions
   * Ex: congenital defects, prematurity, etc, can cause decrease immune system
4. Variable clinical manifestations –> Although variable, there is a limited repertoire that they can present with
5. Often a mystery
6. Wide variety of agents can infect the neonate

Question 2

Early onset sepsis

Answer 2

Onset: birth to one week

Infection from birth canal

Question 3

Congenital infection

Answer 3

present at birth; infection directly from mother

Question 4

Late onset sepsis

Answer 4

Onset: beyond 1 week

Maternal or external source of inrfection

Question 5

Congenital infection manifestations (3)

Answer 5

1. Growth retardation: LBW
2. Congenital malformations
3. Fetal loss (stillbirth)
   - Rubella, CMV, HIV, Toxoplasma, Parvo B19, HSV, VZV

Question 6

Prenatal Infection Manifestations (4)

Answer 6

1. Meningitis
2. Septicemia
3. Pneumonia
4. Preterm labor

Question 7

Postnatal Infection Manifestations (4)

Answer 7

1. Meningitis
2. Septicemia
3. Conjunctivitis
4. Pneumonitis

Question 8

Maternal Risk Factors for Neonatal Sepsis (4)

Answer 8

a. GBS status
b. Malnutrition
c. Recently acquired STI
d. Lower socioeconomic status

Question 9

Postpartum Risk Factors for Neonatal Sepsis (6)

Answer 9

a. Untreated or incomplete treatment
b. Maternal fever >/= 100.4F
c. UTI, vaginal, cervical, systemic infections without identified foci
d. ROM > 12-18 hours
e. Chorioamnionitis and ROM >24 hours increases the risk of neonatal infection 4 fold
f. Prematurity

Question 10

Neonatal Risk Factors for Neonatal Sepsis (4)

Answer 10

a. Males > females (may be X-linked)
b. Immaturity of immune system in the newborn host
c. Late onset infection related to exposures – in and out of hospitalization
d. Co-existing conditions

Question 11

Clinical Manifestations of Neonatal Sepsis (7)

Answer 11

1. Respiratory distress (#1)
2. Fever
3. Neurologic findings –
   Seizures, full fontanelle, sunken fontanelle, lethargy, hypotonia
4. GI symptoms – HSM, abdominal distention, vomiting, gastric aspirate, bloody stools, jaundice (early or prolonged) •
5. Metabolic – Prolonged jaundice, hypoglycemia
6. General Activity or Appearance – BABY IS JUST NOT LOOKING WELL!
   * Is it different from baseline? – caretaker judgment
7. Complications – Shock, DIC

Question 12

Suspected sepsis work-up (7)

Answer 12

1. CBC w/ dif
2. Blood culture (gold standard)
3. Urine culture
4. Lumbar puncture
5. CMP
6. CXR
7. HSV PCR

Question 13

Work-up for Fever less then 30 days: CBC with dif results to suspect sepsis (4)

Answer 13

1. WBC (total exceptionally high >30,000 or low <5,000)
2. ANC (<1750)
3. I/T ratio (elevated > 0.2)
4. Platelet count – nonspecific, late indicator of sepsis (<100,000 concerning)
   * Thrombocytopenia may be present in newborn sepsis
   * Abnormally low platelet and no technique that was done that caused it then consider sepsis/raised suspicion of sepsis

Question 14

Blood culture for suspected sepsis (6)

Answer 14

1. Gold Standard
2. Aerobic and anaerobic cultures
   * Anaerobic is especially important in neonates who may have abscess, bowel involvement, hemolysis
3. 48 hours is the standard rule – if suspicious then follow that blood culture and know where the baby is for 48 hours
   * Don’t release them after 24 hours and the culture grows positive
   * Keep a close eye on the baby for 48 hours
4. Low sensitivity and specificity
5. Often false negative if inadequate amount of blood
6. False positives due to break in aseptic technique

Question 15

Urine culture for suspected sepsis

Answer 15

Catheterize = best

Mainly done for late onset sepsis, after 7 days

Question 16

LP for suspected sepsis

Answer 16

Only if stable and highly suspicious of sepsis

Question 17

CMP for suspected sepsis (3)

Answer 17

Hydration status and anion gap

• Anion gap to differentiate if it’s a metabolic problem such as inborn metabolism
• Large anion gap raises suspicion

Question 18

CXR for suspected sepsis

Answer 18

Only if respiratory symptoms

Question 19

HSV PCR for suspected sepsis (2)

Answer 19

1. Swab the presenting parts

2. HSV in newborn period may not present with initial lesions but does cause high fever

Question 20

CRP (3)

Answer 20

1. CRP takes 12-24 hours to rise and remains elevated for up to 3 to 7 days.
2. Can’t do it right away, at minimum do it at 12 hours
3. Any tissue injury/hypoxia can cause CRP to rise, so be careful only looking at this

Question 21

Procalcitonin (3)

Answer 21

1. Hyperprocalcitoninemia in systemic inflammation or infection occurs within 2-4 hours
2. Reaches peak concentrations in 8-24 hours and persists for as long as the inflammatory process continues.
3. PCT concentrations increase earlier and normalize more rapidly than CRP, PCT has the potential advantage of earlier disease diagnosis, as well as better monitoring of disease progression

Question 22

ESR (2)

Answer 22

1. Traditional markers of systemic inflammation
2. Erythrocyte sedimentation rate (ESR) have proven to be of limited utility in neonates due to their poor sensitivity and specificity for bacterial infection

Question 23

Initial Management for Suspected Sepsis (5 with antibiotic details)

Answer 23

1. Airway first
2. Assess hydration status (IV insertion, fluids)
3. Check blood glucose (heelstick); Hypoglycemia in neonatal period is an emergency! (brain function, etc)
4. Start empiric antibiotics after blood cultures are sent if stable
   a. Ampicillin and Gentamicin –
   Ampicillin is preferred aminoglycoside
   b. Ampicillin and Cefotaxime– If suspicious about meningitis; Cef has better penetration
   c. Add Vancomycin if greater 7 days of life

• Wait 48 hours to discharge, just to be safe
  5. Start Acyclovir if high index of suspicion for HSV – Assess for skin lesions and swab

Question 24

Ampicillin Dosing for Neonates <28 days

Answer 24

<7 days:
<2 kg: 50-100 mg/kg/day IV/IM divided q12hr

> 2 kg: 75-150 mg/kg/day IV/IM divided q8hr

> 7 days:
<1.2 kg: 50-100 mg/kg/day IV/IM divided q12hr

1.2-2 kg: 75-150 mg/kg/day IV/IM divided q8hr

> 2 kg: 100-200 mg/kg/day IV/IM divided q6hr

Question 25

Gentamicin Dosing (3)

Answer 25

1. 0-7 days: 5 mg/kg/day IV/IM divided q12hr 2. >7 days: 7.5 mg/kg/day IV/IM divided q8hr 3. Monitor drug levels – ototoxic

Question 26

Cefotaxime Dosing

Answer 26

1. Neonates 0-7 days old, (>2000 g) Dose: 100-150 mg/kg/day IM/IV divided q8-12h 2. Neonates >7 days old, (>2000 g) Dose: 150-200 mg/kg/day IM/IV divided q6-8h

Question 27

Acyclovir dosing

Answer 27

30 mg/kg/day IV divided q8hr for 14-21 day

Question 28

Early onset sepsis general information (5)

Answer 28

1. 0-7 days of life 2. First week 3. 85% present in first 24 hours a. Many will not have left the hospital yet or have just left the hospital and will need to be readmitted b. Be aware of when/where they were born and where they are in their cycle 4. GBS a. Can also think about this with LOS (GBS & Meningitis) 5. Listeria

Question 29

GBS General Info (5)

Answer 29

1. Gram positive, beta hemolytic bacteria -- #1 offender! 2. Common colonizer of GI and GU tracts; Can get GBS UTI 3. Emerged as most common cause of sepsis and meningitis in infants less than 3 months of age in the 1970s 4. Before prevention efforts – EOS majority of cases 5. With prevention efforts – LOS and EOS equal

Question 30

GBS Facts (7)

Answer 30

1. In the United States, group B strep bacteria are the leading cause of meningitis and sepsis - in a newborn’s first week of life (EOS) IF EOS → GET GBS STATUS! 2. About 1 out of every 4 pregnant women carry group B strep bacteria in the rectum or vagina. Group B strep bacteria may come and go in people’s bodies without symptoms. 3. Pregnant woman should be tested for group B strep bacteria when they are 35 to 37 weeks pregnant. * Significant because if baby was born before this time period or if mother missed appointment during this time, it’s considered unknown and POSITIVE 4. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby who will develop group B strep disease, compared to a 1 in 200 chance if she does not. 5. Any pregnant woman who had a baby with group B strep disease in the past, or who has had group B strep in their urine during this pregnancy caused by group B strep should get antibiotics during labor. 6. Newborns are at increased risk for a group B strep disease if their mother tests positive for group B strep bacteria during pregnancy. 7. The antibiotics used to prevent early-onset group B strep disease in newborns only help during labor — they can’t be taken before labor, because the bacteria can grow back quickly

Question 31

Early-Onset GBS Sepsis Clinical Presentations

Answer 31

1. Typically symptoms appear on day 0 or day 1 of life 2. Respiratory distress and apnea are the most common signs * Increased work of breathing, tachypnic, etc. 3. Bacteremia most common form of disease (~ 80% of cases) 4. Pneumonia and meningitis less common; these are more of late onset presentations

Question 32

GBS Colonization (6)

Answer 32

1. GBS Carriers: ~ 85% of women (CDC) * GBS usually lives in GI tract but can spread to GU * No symptoms or signs on examination * Not a sexually transmitted infection 2. Risk Factors for Early Onset Disease: GBS colonization during labor and delivery a. Prenatal cultures late in pregnancy can predict delivery status 3. Obstetric Risk Factors a. Prolonged rupture of membranes b. Infection of placenta or amniotic fluid c. Fever during labor (100.4 or greater, twice, within an hour after delivery) 4. GBS in maternal urine during pregnancy is a marker for heavy colonization a. Lives in GI tract but if it spreads to the GU, there is a significant amount of GBS there 5. Previous infant with GBS disease 6. Low maternal levels of anti-GBS antibodies

Question 33

Prevention of EOGBS Strategies (2)

Answer 33

Universal screening of pregnant women for GBS at 35-37 weeks gestation *Vaginal and rectal swab

Question 34

Who gets Intrapartum antibiotic prophylaxis?

Answer 34

a. GBS positive screening test b. GBS colonization status unknown with i. Delivery at < 37 weeks ii. Temperature in labor > 100.4 (38C) iii. ROM >18 hours iv. Previous infant with GBS Disease v. GBS in Maternal urine during current pregnancy (UTI)

Question 35

IAP (4)

Answer 35

1. Penicillin first line drug for intrapartum antibiotic * Dosage 5 million IU then 2.5-3.0 IV every 4 hours * No need to memorize, but make sure the mother got it every 4 hours and at least 4 hours before delivery to be considered adequate treatment * Optimal if administered at least 4 hours before delivery – this is considered adequate treatment 2. Ampicillin is acceptable alternative to PCN allergic 3. Cefazolin preferred for PCN –allergic (if not high risk for anaphylaxis) 4. If High Risk for anaphylaxis: a. Clindamycin b. Erythromycin c. Vancomycin

Question 36

Revised Neonatal Algorithm (4)

Answer 36

1. Aims to reduce unnecessary evaluations and antibiotics in newborns at relatively low risk 2. Applies to all newborns 3. Management based on clinical appearance, risk factors and adequacy of IAP if indicated 4. Adequate IAP clarified 5. > 4 hours of IV abx before delivery

Question 37

Treatment of EOS

Answer 37

1. Antimicrobial Therapy – Early Onset 2. GBS, Listeria, E-coli * Ampicillin for Listeria and GBS * Less reliable for E-coli * Aminoglycosides for most Gram Negative organisms * Work synergistically with Ampicillin against GBS and Listeria 3. Amp and Gent is #1 combo unless suspicious of meningitis, then do Amp and Cef