Neonatal Infections May 2005 Dr Patricia Fenton Sheffield Children’s Hospital

Neonatal Infections Hazard analysis at critical control point A baby production line Uterus to push chair

The Bad News Is….. No Pictures

The Good News Is…. 994 out of every 1000 infants born in the UK survive

Some Definitions n Infant - <1 year n Neonate - < I month n “early onset” - < 7 days

Infant Deaths (Number) n E and W figures n Neonates account for 67% of deaths n Infection is NOT a major cause of neonatal death.

A Hazardous Journey n The uterus: Listeria monocytogenes n The birth canal: group B streptococcus n The unit: Acinetobacter baumanii n Devices: CNS n The attendants: Staph aureus

Three Barriers to Infection NORMAL FLORA SKIN AND MUCOUS MEMBRANES IMMUNITY

Impaired Barriers n Thin skin n Raw umbilicus n Invasive devices

Small/premature = n Poor antibody response n Poor neutrophil response n Poor complement activation n Impaired macrophage activity n Poor T cell function n Reduced placental IgG

Clinical Presentations n Not breathing well n Not feeding well n Not looking well lethargic irritable mottled n Fever and tachycardia n Seizures AND NOT A BLOOD TEST OR XRAY!

Listeria monocytogenes n 1-3 cases per million per year E&W n 17 pregnancy associated cases 2001 n >300 pregnancy assoc n Soft cheese, paté and chilled meals n All animals n 5% humans in bowel

Listeria - an interesting organism n G + rod n Flagellae-RT not BT n Tumbling motility n Haemolytic BA n Invasin (IC) n Actin tails n Listerioloysin O

Log10 bacteria per ml

Disease Spectrum n Influenza like illness (maternal) n Sepsis with stillbirth n Neonatal sepsis/meningitis n Sepsis/meningitis in impaired immunity (at any age)

Treatment, Outcome and Control n Ampicillin or amoxycillin n Plus gentamicin n One third fatal n Avoidance, food quality measures, high level of suspicion, early treatment

Early Onset GBS Disease n 376 cases in 2001 n 39 died Important because: n Identified risk factors n Preventable

Risk Factors n Previous baby affected by GBS n GBS in urine at any time this pregnancy n Preterm labour n Prolonged ROM n Fever in labour (RCOG guidelines 2003)

Screening Based Strategy n 27% carry it (rectal plus vaginal swabs) n Antibiotic prophylaxis 86% reduction n Treat 1000, prevent 1.4

Risk Factor Strategy n 25% women have one or more risk n Antibiotic prophylaxis 69% reduction n Treat 1000, prevent 2

The Disease n Early onset n Low apgar n Sepsis n Pneumonia n GBS causes 70% early onset sepsis n Low birth weight

Prevention n Choose your mother carefully (IgG) n Be big (mortality 6% vs. 18%) n Penicillin AT ONSET OF LABOUR

Christmas Day HH n Premature 35/40 n No ANC n Septic, ventilated n Extubated day 11 n Home “to die” BUT….

The Unit n 24 cots (2x6 bedded 1x12 bedded) n Zero to two cases per year for 5 years n 4 month period 11 cases clinical sepsis n All cases in one 6 bedded ward area

The Bug n Acinetobacter baumannii n Gram negative cocco-bacillus n Water-dwelling saprophyte n Long survival on dry surfaces n Mattresses, air con, ventilators n Up to 25% normal human skin flora n Dissemination via hands?

What Happened Next? Cultured everything.

Results? n Nothing n Followed each baby and everything that happened to them

And they found n Hydrocolloid dressings-large sheets n Cut and stored n Used on skin n CULTURE POSITIVE OUTBREAK STRAIN

What happened next? n Practice stopped n Outbreak ended n 3 babies died

Lessons Learnt n A knowledge of background infection rates useful (none to 11) n Susceptible patients are just that n Plastic wallets make good incubators

Devices n Initial response n Getting worse n Central line in situ n ?CNS

Coagulase negative staphylococci n Gram positive cocci n Normal skin flora n Low grade pathogen in normal host n Hydrophobic cell surface (adheres) n Polysaccharide production - biofilm n Neonatal infections

Neonatal Unit B/C n CNS234 n Stau 17 n E.coli 19 n GNB’s 32 n GBS 18

Attendants n 6 week period n 4 blistered babies n Early discharge n 14 more identified n Staph aureus n Phage type 3A/3C n Exfoliative toxin A

Outbreak Control n Swabs of all staff handling newborns n Check all hands n One individual handled 17/18 affected n Epidemic strain from nose, axilla, peri n All other staff negative n Treatment of carrier ended outbreak

Staphylococcus aureus n Looks like CNS and.. n Normal flora (30% adults) but.. n Highly pathogenic n Exfoliative toxin A - SSSS n Potential for cross infection n Treated with flucloxacillin

Control Measures Wash hands and check hands

Conclusions n Infection: significant hazard to neonate n Journey womb to push chair n Bacteria for every occasion n Smaller is frailer n Never give up on a neonate

Our Aim at SCH Family focused service Putting the needs and welfare of children first