1. Nov 2007 ACoRN © 2005-07 Infection Sequence

2. Nov 2007ACoRN © 2005-07

3. Nov 2007ACoRN © 2005-07 A lerting signs C ore steps O rganization of care R esponse N ext steps S pecific management S pecific diagnosis Infection Sequence

4. Nov 2007ACoRN © 2005-07 Alerting Signs

5. Nov 2007ACoRN © 2005-07 Risk factors for infection AntepartumAntepartum –previous baby with GBS –positive maternal GBS screen –GBS bacteriuria –maternal infection –previous unexplained stillborn at term

6. Nov 2007ACoRN © 2005-07 Risk factors for infection IntrapartumIntrapartum –preterm labor –PPROM < 37 weeks –rupture of membranes > 18 hours –maternal temperature ≥ 38 o C –signs and symptoms of chorioamnionitis NeonatalNeonatal –need for resuscitation or invasive procedures –prematurity

7. Nov 2007ACoRN © 2005-07 Infection Risk Factors

8. Nov 2007ACoRN © 2005-07

9. Nov 2007ACoRN © 2005-07 Clinical signs of infection Signs of infection are non-specific.Signs of infection are non-specific. Newborns have poor immunity. Infection can lead to rapid dissemination and deterioration.Newborns have poor immunity. Infection can lead to rapid dissemination and deterioration.

10. Nov 2007ACoRN © 2005-07 Core Steps

11. Nov 2007ACoRN © 2005-07 Organization of Care

12. Nov 2007ACoRN © 2005-07 Response

13. Nov 2007ACoRN © 2005-07 Next Steps

14. Nov 2007ACoRN © 2005-07 Specific Diagnosis Sepsis without a focusSepsis without a focus Sepsis with one or more fociSepsis with one or more foci –pneumonia –meningitis –urinary tract infection

15. Nov 2007ACoRN © 2005-07 Organisms Early onset GBS E. Coli Listeria H. Flu Strep A and DEarly onset GBS E. Coli Listeria H. Flu Strep A and D Late onset Staph epi aureaus Gram Neg Candida GBSLate onset Staph epi aureaus Gram Neg Candida GBS

16. Nov 2007ACoRN © 2005-07 Presentation Early onset First 72 hours of ageEarly onset First 72 hours of age Pneumonia / sepsis High mortality rate Pneumonia / sepsis High mortality rate Late onset More frequently after one week of age Frequently associated with meningitis Significant neurological morbidityLate onset More frequently after one week of age Frequently associated with meningitis Significant neurological morbidity

17. Nov 2007ACoRN © 2005-07 Specific Management

18. Nov 2007ACoRN © 2005-07 Specific Management Modify antibiotic choices to optimize coverage – – dependent on site of infection – – dependent on isolated organism from cultures – – dependent on antibiotic sensitivity Therapeutic drug monitoring to optimize treatment Duration of antibiotic therapy Need for additional tests and interventions – – surgical consultation and intervention – – consultation with Infectious Disease specialist

19. Nov 2007ACoRN © 2005-07 Specific Management Observe for and treat complications of infection:Observe for and treat complications of infection: –shock –hypoglycemia –thrombocytopenia and coagulopathy Repeat Primary Survey at regular intervals.Repeat Primary Survey at regular intervals.

20. Nov 2007ACoRN © 2005-07 Treatment ANTIBIOTICSANTIBIOTICS Supportive CareSupportive Care –Ventilation, oxygen –IV fluids, volume, pressor –Transfusion if indicated –Thermal regulation –NPO or NG suction if needed –FFP/ Cryo if clotting disorders

21. Nov 2007ACoRN © 2005-07 Other conditions that may present like severe sepsis Ductal dependent CHDDuctal dependent CHD Congenital adrenal hyperplasiaCongenital adrenal hyperplasia Inborn errors of metabolismInborn errors of metabolism Abdominal catastrophesAbdominal catastrophes

22. Nov 2007ACoRN © 2005-07 A lerting signs C ore steps O rganization of care R esponse N ext steps S pecific management S pecific diagnosis Infection Sequence

23. Nov 2007ACoRN © 2005-07 Questions?

24. Nov 2007ACoRN © 2005-07 What about the CBC?

25. Nov 2007ACoRN © 2005-07 Indications Complete blood count (CBC) with white count and differentialComplete blood count (CBC) with white count and differential –Is infection suspected? Platelet countPlatelet count –Infection? Maternal ITP? –Alloimmunization? TORCH?

26. Nov 2007ACoRN © 2005-07 White blood cells

27. Nov 2007ACoRN © 2005-07 White blood cells Variable WBC countVariable WBC count Stress  neutrophil demarginationStress  neutrophil demargination Limited storage pool  neutropeniaLimited storage pool  neutropenia Immature formsImmature forms

28. Nov 2007ACoRN © 2005-07 WBC is insensitive and nonspecificWBC is insensitive and nonspecific –normal in 50% proven sepsis Low neutrophil count or increased band count is more usefulLow neutrophil count or increased band count is more useful White blood cells

29. Nov 2007ACoRN © 2005-07 sometimes expressed as immature/total (I/T) ratiosometimes expressed as immature/total (I/T) ratio > 0.25 suggestive of sepsis> 0.25 suggestive of sepsis bands (immature) bands (immature) segmented + band (total) segmented + band (total) Mature vs. Immature

30. Nov 2007ACoRN © 2005-07 White blood cells Infection?Infection? WBC < 5.000 Neutrophils < 1.750 Bands > 2.000 I/T > 0.25Caution! Decision to treat sepsis in sick babies is a clinical one.Decision to treat sepsis in sick babies is a clinical one. Do not delay antibiotic treatment while waiting for results.Do not delay antibiotic treatment while waiting for results.

31. Nov 2007ACoRN © 2005-07 Kevin 34 weeks’ gestation34 weeks’ gestation PPROM – leaking for 5 daysPPROM – leaking for 5 days SVD two hours agoSVD two hours ago Apgars 5 1, 7 5Apgars 5 1, 7 5 Birth weight 2400 gramsBirth weight 2400 grams Grunting and requiring oxygenGrunting and requiring oxygen CPAP startedCPAP started

32. Nov 2007ACoRN © 2005-07 CBC result WBCHgbHctPlatelets Segmented neutrophils Band neutrophils Monocytes Normal Normal 4.0 x 10 9 /L (5.0-25.0) 145 g/L (135-195) 0.47 (0.45-0.66) 180 x 10 9 /L (150-450) 0.9 x 10 9 /L (5.0-25.0) 0.6 x 10 9 /L (<1.20) 1.5 x 10 9 /L (0.5-1.8)

33. Nov 2007ACoRN © 2005-07 What is Kevin’s IT ratio?What is Kevin’s IT ratio? bands (immature) segmented + band (total) 0.6 0.6 (0.9 + 0.6) IT ratio = 0.4 Kevin

34. Nov 2007ACoRN © 2005-07 Kevin Blood culture results at 12 hours:Blood culture results at 12 hours: –Gram positive cocci in chains Next dayNext day –Streptococcus group B (GBS)

35. Nov 2007ACoRN © 2005-07 Questions?