Neonatal Sepsis
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Neonatal Sepsis
Self-Learning Packet 2004 This self-learning packet is approved for 2 contact hours for the following professionals: 1. Registered Nurses 2. Licensed Practical Nurses
Orlando Regional Healthcare, Education & Development
© Copyright 2004 Rev. 10/31/2004
Neonatal Sepsis
Table of Contents Purpose.......................................................................................................................3 Objectives...................................................................................................................3 Instructions.................................................................................................................3 Introduction ................................................................................................................4 Immunity ....................................................................................................................4 Immune System Development ................................................................................................... 4 Immune System Physiology....................................................................................................... 5
Risk Factors................................................................................................................7 Trends in Neonatal Sepsis..........................................................................................8 Frequency................................................................................................................................... 8 Mortality/Morbidity ................................................................................................................... 8 Race, Sex, & Age ....................................................................................................................... 8
Early versus Late Onset Infections ............................................................................9 Clinical Signs of Sepsis ...........................................................................................10 Diagnostic Evaluations ............................................................................................10 Types of Pathogens ..................................................................................................12 Group B Strep .......................................................................................................................... 12 Staphylococcus......................................................................................................................... 13 Escherichia Coli ....................................................................................................................... 13
Management.............................................................................................................14 Nursing Considerations............................................................................................14 Family Implications .................................................................................................15 Summary ..................................................................................................................16 Post Test ...................................................................................................................17 References ................................................................................................................21 Orlando Regional Healthcare, Education & Development © Copyright 2004
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Neonatal Sepsis
Purpose The purpose of this self-learning packet is to educate nurses who care for infants and to satisfy the continuing education requirements of Orlando Regional Healthcare employees. Orlando Regional Healthcare is an Approved Provider of continuing nursing education by Florida Board of Nursing (Provider No. FBN 2459) and the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation (AP 085).
Objectives After completing this packet, the learner will be able to: 1. Match immune system development with appropriate week of gestation. 2. Identify the definition of neonatal sepsis. 3. Label the correct immunoglobulin with its definition. 4. Identify the cost of care related to neonatal sepsis. 5. Identify the risk factors for neonatal infections. 6. Describe trends in neonatal sepsis. 7. Differentiate between congenital and acquired infections. 8. Identify the signs and symptoms of a septic neonate. 9. Describe different types of neonatal infections. 10. Match treatment options with appropriate infection. 11. Identify nursing considerations when taking care of a sick infant. 12. Describe family implications when a newborn becomes ill.
Instructions In order to receive 2.0 contact hours, you must: • • •
Complete the posttest at the end of this packet Submit the posttest to Education & Development with your payment Achieve an 84% on the posttest
Be sure to complete all the information at the top of the answer sheet. You will be notified if you do not pass, and you will be asked to retake the posttest.
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Neonatal Sepsis
Introduction Newborn infants are at much higher risk for developing sepsis than children and adults because of their immature immune system—especially premature infants, where 1 out of every 250 will be diagnosed with sepsis. Sepsis is one of the major leading causes of death in the first few months of a newborn’s life. Infections can contribute up to 13-15% of all deaths during the neonatal period with the mortality rate reaching as high as 50% for infants who are not treated timely. The combination of an immature and slow responding immune system increases the risk of infection in the neonate. One reason for the increased risk is that antibodies, which help protect mothers from infections, do not cross through the placenta to the fetus until approximately 30 weeks of gestation. The antibodies present at birth take time to reach optimum levels, which also affects the protection provided. After reading this packet, the learner will have a better understanding of the physiology of the neonatal immune system, current trends in the diagnosis and treatment of infections, risk factors, signs and symptoms of sepsis, and implications for nurses who provide care for the septic newborn.
Immunity Immune System Development The immune system begins very early in fetal development with the origin of blood formation in the third week of gestation. In the fourth week of gestation the thymus forms. The thymus helps to mature and develop white blood cells so that they can play a key role in fighting infections. By the eighth week of gestation, T cells, B cells, and natural killer cells can all be found in the thymus. T cells, which make an important component in cell-mediated immunity, are formed solely in the thymus. B cells, which are the precursors of antibody producing cells, are first produced in the liver but by 12 weeks gestation move into the bone marrow where it remains. Natural killer cells, which are cytotoxic cells that have the ability to attack viruses, mature in the thymus. Interestingly, greater concentrations of natural killer cells are found in the peripheral blood of newborns and the newborn usually has adult levels of these cells at birth, but they diminish rapidly. Neutrophils are relatively numerous in both the term and pre-term infant. A neutrophil is a type of white blood cell that defends the body from organisms that cause infection. The stages of neutrophil development, from immature to mature, are myeloblast, promyelocyte, myelocyte, metamyelocte, band, and segmented neutrophil. When an infection is present, the neutrophils migrate out of the capillaries and into the infected site, where they ingest and destroy the Orlando Regional Healthcare, Education & Development © Copyright 2004
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Neonatal Sepsis pathogens causing the infection. The amount of circulating neutrophils in the newborn peaks around 12 hours after birth and then starts to decline to normal levels. Even though a large number of circulating neutrophils can be found in the newborn, the bone marrow storage pool of neutrophils at birth is only 20% to 30% of the circulating pool in adults.
Immune System Physiology Despite the immune system and immune system components, early development during gestation the newborn still remains vulnerable to infections after they are born because of the immaturity of their immune system.
Differences in Immune Responses in Full and Preterm Infants Immune System Component
Full Term Infant
Preterm Infant
Immunoglobulin G
Complete placental transfer, concentrations comparable to mother
Incomplete placental transfer, concentrations decreased
Lymphocytes
Concentrations of T and B cells comparable to those in adults with normal response to antigens
Concentrations of T and B cells comparable to those in adults with normal response to antigens
Complement
50%-75% of concentration in adult
Decreased concentration
Neutrophils
Elevated numbers at birth, with impaired functional ability
Elevated numbers at birth, with impaired functional ability
Monocytes
Normal number at birth but have impaired chemotaxis
Normal number at birth but have impaired chemotaxis
Macrophages
Normal number at birth
Normal number at birth
but decreased function but decreased function A newborn has a poor response to invading pathogens. This Natural Killer Cells Concentration similar to Concentration similar to immune response will gradually adult level, but have adult level, but have improve with age. During the diminished cytotoxic diminished cytotoxic initial postpartum phase, the effects effects infant relies on maternal antibodies and the mother’s breast milk, which is rich with immunoglobulins. When a pathogenic organism overcomes the infant’s defenses, infection and sepsis result. Sepsis is defined as the presence of microorganisms or their toxins in blood or other tissues. Newborn sepsis is still one of the most significant causes of neonatal disability and death today.
Reviewing the functions of the infant’s immune system will help provide a better understanding of the interaction between the pathogenic organisms and the newborn’s susceptibility to infection. Infections occur when the infant comes in contact with a pathogenic organism. The organism, whether it is a virus, fungus, or bacteria, enters into the infant’s body system and begins to multiply. The infant’s immune system response to an organism is divided into three phases. The first phase is the primary or nonspecific phase, which occurs immediately following the infant’s inoculation with a pathogenic organism. During this phase, there is a migration of the neutrophils
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Neonatal Sepsis to the primary site of the infection. The neutrophils enter into the cells through membrane filters and adhere to the pathogen. Ingestion and destruction of the invading organism then takes place. The next phase in the immune response is called the secondary phase or the specific response phase. During this phase, there is interaction of T and B cells to help develop immunoglobulins or antibodies to protect the infant from the infection. There are three major types of immunoglobulins: Immunoglobulin G (IgG), Immunoglobulin M (IgM), and Immunoglobulin A (IgA). Immunoglobulin G is the major immunoglobulin of the serum and interstitial fluid. It provides immunity against both bacterial and viral pathogens. It starts to cross the placenta and enter into fetal circulation around 30 weeks’ gestation and continues until the 40th week. Term infants have IgG levels that are equal to or exceed maternal levels. Since IgG is not transferred until around the 30th week of gestation, the preterm infant does not have this protective barrier. Preterm infants are thus at higher risk for infections. Research has shown that there are also decreased levels of IgG in post-term and small for gestation age infants, which suggest that there may be some inhibition of transfer with placental damage. Immunoglobulin M does not cross the placenta thus, little or no IgM is transferred to the fetus. This lack of IgM increases the infant’s susceptibility to gram negative infections. The infant does however begin synthesis of this immunoglobulin very early in their fetal life. Levels of IgM have been detected around 30 weeks’ gestation with higher levels detected when there is an intrauterine infection present. Immunoglobulin A is the most common immunoglobulin found in the gastrointestinal tract, respiratory tract, human colostrum, and breast milk. IgA does not cross the placenta, and intrauterine synthesis is minimal. Levels of IgA are usually not detected until the infant is around 2 to 3 weeks old. The last immune response is the tertiary phase. This phase provides long-term immunity against the organism. During the second phase, the B cells produce memory cells that recognize the invading pathogen on subsequent exposures. These memory cells recognize the invading organism and cause them to be neutralized, preventing the infant from becoming sick again. Although adequate numbers of B cells are present at birth, antibody production is diminished in the neonate due to a lack of uterine exposure to foreign pathogens.
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Neonatal Sepsis
Risk Factors Causes of infections in newborns can be divided into three main groups: intrauterine, intrapartum, and postnatal infections. All three groups include factors that increase the infant’s risk of coming in contact with an organism that can cause an infection.
Source
Risk Factors
Maternal
Poor prenatal care Poor nutrition Substance abuse
Intrapartum
Premature rupture of membranes Maternal fever Prolonged labor Maternal UTI
Intrauterine or factors that increase the risk before birth include the following: poor prenatal care, poor nutrition, Neonatal Male recurrent abortions, and substance Birth asphyxia abuse. Intrauterine infections occur Low birth weight when pathogenic organisms cross the placenta into the fetal circulatory system. The organisms, such as cytomegalovirus (CMV), can reside in the amniotic fluid,. Other organisms ascend from the vaginal track, infecting the membranes and causing them to rupture. This rupture of membranes can lead to infections of the respiratory and gastrointestinal tract of a newborn. Intrapartum or factors that increase the infants chance of becoming infected during the birthing process include: prolonged rupture of membranes (>12 to 18 hours), urinary tract infections, preterm labor, prolonged or difficult labor, maternal fever, colonization with Group B Streptococcus (GBS), and maternal infections. Most infections during the birthing process are related to the infant coming into unavoidable contact with an infected birth canal. The birth canal can host bacteria that an infant’s immune system cannot defend against. Postnatal infections may be contracted after delivery, as in the case with infections contracted during resuscitation, or as a result of a nosocomial infection due to improper hand washing. Infections in the postnatal period are more common in those infants who require foreign objects be introduced into their systems. Items like endotracheal tubes or indwelling catheters increase the risk of an infant becoming septic. The single most important risk factor for infection in the neonate is prematurity. Neonatal factors that increase the infant’s chance of becoming sick include: low birth weight, prematurity, birth asphyxia, meconium staining, and resuscitation. There is a direct correlation between gestational age and the infants risk for infection. Infants born at less then 32 weeks gestation have a 4 to 25 times higher risk of developing an early onset infection. Reasons for this include immature immune system, thinner skin, and the frequent need for insertion of foreign objects. Also, premature infants are likely to develop chronic lung disease requiring prolonged ventilator support. Corticosteroids are often used to help treat their lung disease, but these drugs may leave the infant at an increased risk of infection.
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Neonatal Sepsis It is important to note that in an otherwise healthy-appearing, term-gestation infant none of these factors by themselves should lead to an assumption that the infant will suffer an infection. However, a combination of these risk factors greatly increases the infant’s chance for infection and therefore should heighten the suspicion of sepsis. Studies have shown that incidence of infection increases to greater than 15% when two or more risk factors are present. An infant who appears sick should heighten clinical suspicion of sepsis, and an evaluation for infection should be performed immediately.
Trends in Neonatal Sepsis Frequency Sepsis identified by the results of cultures, such as blood, CSF, urine, occurs in approximately 2 out every 1000 live full term births. Of the 7-13% infants who undergo evaluation for sepsis only 3-8% have culture-proven sepsis. Since the early signs of sepsis are often nonspecific a high percentage of newborns are subjected to a septic workup and administration of antibiotics before the diagnosis has been made. The American Academy of Pediatrics (AAP), American Academy of Obstetrics and Gynecology (AAOG) and the Centers for Disease Control and Prevention (CDC) all have recommendations for sepsis screening and/or treatment for various risk factors, thus a higher percentage of newborns are subjected to diagnostic tests. Since the mortality rate of untreated sepsis is as high as 50%, most healthcare providers believe that the hazard of not treating or delaying treatment to wait for positive cultures is too high, and therefore treatment is initiated while awaiting the test results. As a result, the annual treatment cost for sepsis in neonates here in the United States is approximately $800 million.
Mortality/Morbidity Sepsis is a major cause of death during the first few months of life causing 13-15% of all neonatal deaths. The mortality rate of neonatal sepsis can be as high as 50% for infants who are not treated or when treatment is not begun quickly. A serious morbidity of neonatal sepsis is neonatal meningitis. Research has shown that neonatal meningitis occurs in 2-4 per 10,000 infants and of those infants diagnosed with neonatal meningitis their chance of survival significantly decreases. It is responsible for 4% of all neonatal deaths.
Race, Sex, & Age Current research has shown that African-American infants have an increased incidence of Group B Strep (GBS) disease as well as acquired or late sepsis. To help counter this many professional healthcare groups have recommend guidelines for controlling risk factors in this race. Despite these changes in screening and treatments, African-American infants still remain at the highest risk for sepsis. Male infants have a higher incidence of sepsis than their female counterparts. This higher rate of sepsis is especially true for gram negative infections. Orlando Regional Healthcare, Education & Development © Copyright 2004
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Neonatal Sepsis Premature newborns also have a higher rate of infection than full term infants. The incidence of sepsis is significantly higher in infants with very low birth weight. Infants weighing less than 1000g are at the highest risk for sepsis.
Early versus Late Onset Infections Neonatal bacterial infections are classified into two different categories depending on the time of their presentation. Congenital infections or early onset infections occur when an infant presents with signs and symptoms of the illness within the first week of life. Acquired or late onset infections occur after the infant is greater than a week old. Congenital infections or early onset Characteristics of Congenital vs. Acquired Sepsis sepsis occurs within the first few days of life, and are typically Characteristic Congenital Acquired acquired during the intrapartum period, often from organisms in the maternal genital tract. Eighty-five Time of Onset: Birth - 4 Days > 7 Days percent of newborns with early onset sepsis begin to show OB Complications: Frequent Unusual symptoms within the first 24 hours of life, 5% have symptoms between Source: Mother’s Postnatal 24 and 48 hours, a very small Genital Tract Environment percentage of infants show Clinical Multisystem Focal symptoms between 48 hours and 6 Presentation: days of life. Premature infants have the most rapid onset. A sudden Mortality Rate 5-50 2-6 onset and rapid progression to septic (%): shock often characterize these Usual Group B Strep Staph Epi infections. The main clinical feature Organisms: E. Coli Candida of a newborn with early onset sepsis is respiratory distress, which often presents as mild nasal flaring and tachypnea. The respiratory distress can quickly progress to multisystem failure and shock if not caught early. With early onset sepsis, there is a high mortality rate of 15% to 50%. The most common organism for early onset bacterial infection is Group B Strep (GBS). In addition to GBS, Escherichia Coli, Enterococcus, and Chlamydia are also common causes of congenital infections in the newborn. Acquired or late onset infections can occur anywhere from 7 days to 2 months following birth. These infections are normally seen after the first week of life and usually are contracted from organisms in the postnatal environment. The clinical manifestations may be acute physiological deterioration or manifestations of a more localized infection that has progressed to sepsis. Acquired infections have slower onsets and have a decreased mortality rate of around 10% to 20%. Common pathogens responsible for late onset infections include Candida Albicans, Coagulase Negative Staphylococci, Serratia, GBS, and Pseudomonas.
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Neonatal Sepsis
Clinical Signs of Sepsis Few neonatal infections are easy to recognize. Since infants are unable to speak and vocalize when they are not feeling well, it is important for the staff caring for the infant to be observant of signs and symptoms of sepsis. These signs range from mild symptoms to a rapidly deteriorating infant, who may need resuscitation. Early onset infections often present with nonspecific, vague symptoms because of neonate’s inability to mount an inflammatory response. Often the only sign is that the infant does not “look right”. See the box to the right for a list of the signs and symptoms.
Signs of Sepsis − − − − − − − − −
Pallor Poor temperature control Grunting Flaring Apnea & Bradycardia Lethargy Hypoglycemia Poor feeding Abdominal distention
Signs of infection may be exhibited even as early as the mother’s labor. Often infants demonstrate profound tachycardia before birth, or they may show decreased beat-to-beat variability on a fetal monitoring strip. Newborns who have congenital infections may be depressed at delivery, have low apgars, and/or require resuscitation.
Common nonspecific, early signs of infection seen most often include: hypothermia, accompanied by a change in the infant’s color, tone, activity, and/or feeding behavior. During this time, there may also be sudden episodes of apnea. Gastrointestinal symptoms include feeding intolerance or a lack of interest in feeding. Because these nonspecific signs of sepsis also characterize the onset of numerous noninfectious processes, it makes the diagnosis difficult.
Diagnostic Evaluations Since sepsis can be easily confused with other neonatal conditions such as hypoglycemia or CNS disorders, laboratory and radiographic tests are performed. These tests can help confirm when an infant is truly septic. Septic work-ups will usually be performed on those infants who are displaying signs of sepsis. Work-ups may include a peripheral blood culture, complete blood cell count (CBC) with differential, chest x-ray, urine culture, and lumbar puncture with blood being the principle fluid assessed for suspected sepsis. Ideally, all cultures should be obtained before antibiotics are started. However, 20% to 30% of women in labor receive antibiotics before delivery of the infant, and therefore the infant may have already been exposed to the antimicrobials, which may affect the results of the blood cultures. Positive CSF, urine, and bacterial blood cultures are lab results that confirm the infant has an infection. Other abnormal results to observe in an infant suspected of sepsis are hypoglycemia,
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Neonatal Sepsis hyperglycemia, metabolic acidosis, thrombocytopenia, or hyperbilirubinemia. The blood culture and CBC are the most helpful tests to identify an infection and which pathogen is the causative organism. CBC findings that indicate an infection is present include: an elevated or decreased white blood count (WBC), a low platelet count, and a high I:T ratio. The I:T ratio is a calculation which is done to show the percentage of immature to total I:T Ratio Calculation white blood cells. When the I:T ratio is greater than 0.2, this indicates that there is a “left shift.” Immature cells This left shift means that there are more immature I:T ratio = Total (mature + immature) neutrophils than mature neutrophils circulating around in the bloodstream. A neutrophil is a type of white blood cell that defends the body against organisms that cause infection. When infection is present the neutrophils migrate out of the capillaries and into the infected site, where they ingest and destroy the pathogens causing the infection. When the demand for the neutrophils exceeds the supply in circulation, immature neutrophils are released into the blood to help fight off the infection. This is labeled a “left shift” and indicates that an infection may be present. As the infection diminishes and neutrophils are replenished, a “shift to the right” occurs, indicating that everything is back to normal.
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Neonatal Sepsis
Types of Pathogens Over the past 70 years, there have been changes in the predominant bacteria that cause both early onset and late onset infections. The fluctuating pattern is due to the development and use of new drugs, the mobile population of families, and the prolonged survival of infants who would have died previously. In the 1930’s most neonatal infections were the results of Group A BetaHemolytic Streptococci. This pathogen continued to be the cause of most infections until the 1950’s when most infections were then caused by the pathogen Staphylococcus Aureus. From 1966 to 1978, either Escherichia Coli or Group B Strep caused the majority of infections. Group B Strep remains one of the major causes of infections today.
Group B Strep (GBS) Although any pathogenic organism can cause serious problems for the newborn, GBS is by far the most serious cause of neonatal infection and mortality. GBS is a normal flora found in the vagina and gastrointestinal tract of 15% to 20% of women. It is not a sexually transmitted disease and normally does not cause any problems for the women who are colonized with it. For infants though, GBS can cause serious health problems and even death. Of the 20% of women colonized with GBS, 50% of them give birth to infants colonized with GBS. 1% to 2% of those infants become clinically ill with a GBS infection. One risk factor for women who are colonized with GBS is that they have a higher chance for premature labor because of the elevated amniotic fluid level of phospholipase A2. This phospholipase produces prostaglandin, which is a potent labor stimulatant. Other risk factors that increase the infant’s chance of becoming infected with GBS include maternal temperature > 38 Celsius (100.4 F), prolonged rupture of membranes, premature delivery, multiple births, and a previous sibling with a GBS infection. Because of the severity of a GBS infection in the newborn, treatment guidelines have been established by the governing bodies involved in newborn health. The main focus of the guidelines is to promote GBS screening of all pregnant women late in their pregnancy. This is partly due to the fact that upwards of 25% of GBS infections occur in term infants who are born to mothers without any risk factors. When the pregnant woman is tested and is positive for colonization of GBS, she should be treated with antibiotics during labor. GBS infections can either be an early or late onset infection. The early onset infection is a result of transmission of the GBS bacteria from the mother to the fetus, usually during delivery. The infant will begin to present symptoms during the first 24-48 hours of life. At first, the symptoms may be very subtle and nonspecific. The infant may present with pallor, tachypnea, tachycardia, or decreased activity. If these first symptoms go undetected, the infant will progress to signs of infection that are more obvious. These may include temperature instability and/or respiratory distress, such as grunting, nasal flaring, retractions, and apnea. GBS infections are progressive and the symptoms worsen if treatment is not initiated. Within hours, an infant can deteriorate from grunting with slight retractions to septic shock and death. The mortality rate in infants less then 36 weeks of gestation is 30% to 50%.
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Neonatal Sepsis Late onset GBS infections can occur anywhere after the first week of life up to 2 months of age. Late onset infections seem to be caused by nosocomial transmission rather than maternal transmission. This form of GBS infection can be less severe than the early onset form but still carries a mortality rate of 25%. Infants with this late form will often present with meningitis as their main symptom. Treatment of GBS often begins when the mother is in labor. For women who test positive, ampicillin is needed at least 4 hours before delivery for the treatment to be successful. If the mother does not receive the ampicillin, the infant may have to undergo blood tests to rule out the presence of the GBS bacteria. For those newborns who do acquire a GBS infection, treatment starts with supportive care. This includes antibiotics, such as ampicillin and gentamicin, fluid and volume support, and respiratory support, usually in the form of a ventilator. Treatment against meningitis-induced seizure activity may also be required. Long term outcomes for infants with GBS infections are dependent upon the type of infection, whether it is early onset or late onset, and how soon treatment was started. Neonates who present with early onset GBS and receive treatment quickly have a better prognosis then those who acquire late onset GBS infections where 25% to 50% of those infants may have permanent neurological damage.
Staphylococcus Staphylococcal pathogens can cause mild to severe infections. Transmission may result in a localized infection from a scalp electrode, to more widespread infections such as osteomyelitis resulting in overwhelming sepsis. The major source of this infection from staphylococcus comes from improper hand washing by the hospital staff. It is also associated with infections arising from umbilical catheters, endotracheal tubes, and central lines. Other causes of nosocomial infections are improper staffing, lack of space between infants, and lack of sterile technique when caring for invasive catheters. Colonization of the pathogen occurs in 40% to 90% of infants, usually by the fifth day of life. It is most often treated with vancomycin.
Escherichia Coli E. Coli is the most common cause of gram negative neonatal infection in the United States. This pathogen infects 1 to 2 out of every 1,000 live births and is responsible for up to 45% of neonatal infections. This bacterium is found in the mother’s genital tract with a high incidence of colonization in the neonate. The pathogen can cause severe infections that may lead to respiratory distress, cardiovascular collapse, meningitis, multiorgan failure, and even death. E. Coli is usually treated with gentamicin.
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Neonatal Sepsis
Management To increase the infant’s chance of survival, early recognition of signs and symptoms of sepsis is imperative. Often the diagnosis of sepsis is based upon suspicion of the presenting clinical signs and symptoms. Antibiotic therapy is usually started before lab results confirm and identify the pathogen causing the infection. In addition to antibiotic treatment, therapy consists of circulatory, respiratory, nutritional, and developmental support. Treatment begins with careful monitoring of the infant’s vital signs and regulation of the thermal environment. Supportive therapy for a septic infant starts with the administration of oxygen when respiratory distress or hypoxia becomes present. The infant may also need more invasive respiratory support such as continuous positive airway pressure (CPAP) or to be placed on a ventilator if they are suffering from apneic episodes. Infants who are sick may also develop electrolyte abnormalities. These infants will need careful, ongoing monitoring and adjustment of the fluid and electrolyte balance, especially when the infants are NPO. Antibiotic therapy is continued for 7 to 21 days if the cultures are positive, or it is discontinued in 3 days if cultures are negative. The infant’s outcome is variable. Before the availability of antibiotics, mortality rates for infected infants were greater than 95%. In the 1970s and 1980s, the mortality rate decreased to 20% to 40%. Today, with the use of antibiotics along with early recognition and supportive care, mortality has reduced to 13% to 45 %, depending on the causative agent. However, approximately 1,500 neonates in the United States still die annually from systemic infections.
Nursing Considerations Nursing care for the infant with sepsis involves skilled observation and ongoing assessments. Recognition of a problem is paramount in importance. It is most often the nurse who observes and identifies that something “just isn’t right” with the infant. This is due to the fact that the nurse maintains constant assessment and documentation of subtle changes in the infant’s vital signs, physical assessments, feeding tolerance, responsiveness, and/or general behavior. Awareness of the potential routes for transmission of infectious pathogens will also help identify those infants at risk for developing sepsis. Much of the care for infants with infections involves the medical treatment of the illness. Nurses must be aware of the side effects of the specific antibiotics and the proper administration guidelines. Prolonged antibiotic therapy poses additional hazards for affected infants. Antibiotics predispose the infant to growth of resistant organisms and superinfections from fungal agents such as candida. The nurse must be alert for signs of such complications.
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Neonatal Sepsis Another challenge in caring for a sick infant is starting and maintaining IV access for drug therapy. Common sites in the infant include the hand and arm, as well as the veins found in the scalp and foot. If the infant is going to require extensive antibiotic therapy, a peripherally inserted central catheter (PICC) may be considered. Total care of infants with sepsis involves decreasing any additional physiologic and/or environmental stress. This includes providing an optimum thermoregulated environment and anticipating potential problems, such as dehydration or hypoxia. Precautions need to be implemented to prevent the spread of infections to other newborns. To be effective, precautions must be carried out by all caregivers that come in contact with the sick infant. Proper handwashing, use of disposable equipment, disposing of excretions, and adequate housekeeping of the environment and equipment are essential. Since nurses are the most constant caregivers involved with sick infants, it is usually their responsibility to oversee that everyone maintains all phases of isolation.
Family Implications Maternal attachment is a cumulative process that begins before conception. It is strengthened by significant events during pregnancy, and matures through maternal-infant contact during the neonatal period. When an infant becomes sick, the necessary physical separation appears to be accompanied by an emotional detachment on the part of the parents, which may seriously damage the capacity for parenting their infant. During pregnancy, and sometimes even before conception occurs, mothers develop an ideal or fantasy image of their unborn child. To the mother, the unborn child has an imagined appearance, pattern of behavior, and expected accomplishments. Anything that alters this image can alter the bonding between the mother and her new child. Therefore nursing care does not stop with providing medical care to a sick infant. The nurse needs to encourage and facilitate parental involvement, rather than isolating the parents from their infant and associated care. Nurses should be cognitive of the fact that the parent’s worry associated with a sick infant can go way beyond the infant’s actual state of illness. Often parents ask themselves, “Can I care for this infant?” The nurse needs to provide constant teaching and supply the family with continual updates on the infant’s condition to help them through this frightening time. It is important for the nurse to use simple and basic vocabulary. When medical language is used, it increases the parent’s anxiety level, and teaching if less effective. Some mothers feel guilty that they may have done something to cause the infant’s condition. The nursing staff needs to provide constant reassurance that this is a common feeling and that she did not cause the infant to become ill. The
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Neonatal Sepsis nurse needs to remember the goals of his/her care. Goals cannot be only patient orientated, but need to be family orientated as well. It is important to remember that it is the infant to who we provide care, but it is the family who will take the baby home. The nurse needs to provide the family with the knowledge and skills they need to take care of their infant once the baby is discharged from the hospital.
Summary Despite the major advances in neonatal medicine, many infants still develop life-threatening infections during the first month of life. Identifying and caring for an infant with a possible infection starts with a skilled nurse who is proficient in performing neonatal assessments. The assessment begins with a nurse’s innate knowledge of the many different risk factors for newborn infection. The nurse needs to be observant for any sign that may indicate sepsis. It cannot be overemphasized that prompt recognition, early diagnosis, and immediate treatment of sepsis can dramatically improve the infant’s outcome and limit any potential disability. Once sepsis has been identified, treatment must be initiated promptly, and the infant reassessed for their response to the therapy. Hours can make the difference of an infant surviving the infection, or succumbing to its systemic devastation. Because of the nonspecific manifestations of impending sepsis, any changes in the physical and/or behavioral state of an infant should raise the suspicion of sepsis. Above all else, nursing assessment and interventions are the most important tool in the prevention, prompt recognition, and effective management of newborn infections.
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D O O O O O O O O O O O O O O O O O O O O O O O O O
E O O O O O O O O O O O O O O O O O O O O O O O O O
Please also complete the self-learning packet evaluation at the end of the packet. In order to receive 2.0 contact hours, you must: • Submit the answer sheet and payment ($5.00 for Orlando Regional Healthcare employees / $10.00 for non-employees) to: Orlando Regional Healthcare Education & Development, MP 14 1414 Kuhl Ave. Orlando, FL 32806 •
Achieve an 84% on the posttest. (You will be notified if you do not pass and will be asked to retake the posttest.)
Neonatal Sepsis
Post Test Directions: Do NOT write on this test. Complete this test using the bubble sheet provided. 1.
All of the following define sepsis in the newborn EXCEPT: A. The pathogen overcomes the infant’s defenses B. The presence of microorganisms in the infant’s blood C. The presence of the pathogen in the infant’s stool D. The presence of microorganisms in the infant’s tissues
2.
Which of the following are maternal risk factors for developing neonatal infections? A. Regular wellness check ups B. Poor nutrition C. Multiple births D. First pregnancy
3.
T Cells are first found in the fetus at what week gestation? A. 4 weeks B. 6 weeks C. 8 weeks D. 10 weeks
4.
The annual cost of treatment of neonatal sepsis in the United States is __________. A. $600 million B. $700 million C. $800 million D. $900 million
5.
Infants that have a higher risk for developing infection are A. Male infants B. Female infants C. Full term infants D. Post term infants
6.
An infant is 6 hours old and is starting to show signs of respiratory distress such as grunting and retraction. Which of the following accurately describes the type of infection the infant has? A. Acquired B. Congenital C. Nosocomial D. Periodic
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Neonatal Sepsis 7.
A mother brings in her 2-week-old infant to the doctor and reports that the infant has been lethargic and not eating very well. Which of the following accurately describes the type of infection the infant has? A. Acquired B. Congenital C. Intrapartum D. Maternal
8.
The most common type of organism that causes a congenital bacterial infection is: A. Candida Albicans B. Pseudomonas C. Group beta strep D. Serratia
9.
All of the following are signs of infection in the newborn EXCEPT: A. Pallor B. Apnea C. Hypoglycemia D. Choking
10.
Which statement best describes signs and symptoms of an infant with suspected sepsis? A. Infants with infections will have a fever. B. The infant’s appetite is unaffected by sepsis. C. Infants with infections are easy to recognize because of the obvious symptoms. D. Infants with infections are hard to recognize because of the vague symptoms.
11.
When taking care of a sick infant the nurse should: A. Decrease any physiologic or environmental stress B. Have blood ordered and waiting C. Perform frequent linen changes D. Perform frequent lab draws
12.
In general when assisting the family with coping with the hospitalized infant, the nurse should recognize that: A. Mothers often feel capable and ready to jump in and help with the care of the sick infant. B. Fathers often are ready to jump in and help with the care of the sick infant. C. Mothers often feel guilty when their infant becomes sick, blaming themselves for the infant’s illness. D. Parental involvement is a low priority in the care of an infant.
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Neonatal Sepsis Match the correct immunoglobulin with its description 13.
14.
15.
Does not cross the placenta, levels are higher when an infection is present. Most common immunoglobulin found in the gastrointestinal tract. Levels not detected until the infant is 2-3 weeks old.
A. Immunoglobulin A B. Immunoglobulin G C. Immunoglobulin M
Crosses the placenta and enters into fetal circulation around 30 weeks of gestation.
Match the correct pathogen with its description 16.
This pathogen is a major source of infection from hospital personnel with improper hand washing.
17.
Most common cause of gram negative infections.
18.
Infection can be either early or late in its onset and is one of the most serious causes of mortality in the newborn.
A. Escherichia Coli B. Group B Strep C. Staphylococcus
Match the correct pathogen with its common treatment 19.
Escherichia Coli
A. Ampicillin
20.
Group B Strep
B. Gentamicin
21.
Staphylococcus
C. Vancomycin
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Neonatal Sepsis
References Bellig, L. (2004, June 23). Neonatal sepsis. Emedicine. Retrieved July 12, 2004 from http://www.emedicine.com/ped.topic2630.htm CDC. Group B Strep. Retrieved July 23, 2004, from http://www.cdc.gov/ncidod/dbmd/gbs/ Deacon, J. & O’Neill, P. (1999). Core Curriculum for Neonatal Intensive Care Nursing (2nd ed.). Philadelphia, PA: W.B. Saunders Company. Gardner, S. & Merenstein, G. (2002). Handbook of Neonatal Intensive Care (5th ed.). St. Louis, MI: Mosby. Haw, P. (2003). Care of the Sick Neonate: A Quick Reference for Health Care Providers. New York, NY: Lippincott Williams & Wilkins. Huether, E. S. & McCance, L. K. (2000) Understanding Pathophysiology (2nd ed.). St. Louis, MI: Mosby. Ladewig, P., London, M., Moberly, S., & Olds, S. (2001). Contemporary Maternal-Newborn Nursing Care (5th ed.). New York, NY: Prentice Hall. Lowdermilk, L. D., Perry, E. S., & Bobak, M. (2000). Maternity & Women’s Health Care (7th ed.). St. Louis, MI: Mosby. McKenney, W. M. (2001, December). Neonatal nursing. Understanding the neonatal immune system: high risk for infection. Critical Care Nurse, 21(6), 35-47. Mullaney. D. (2001). Group B streptococcal infections in newborns. JOGNN, 30(6), 649-658. Neonatology on the Web. Neonatal Infections. Retrieved July 14, 2004, from http://www.neonatology.org/syllabus/sepsis/index.htm Oddie, S. & Emblrton, N. (2002). Risk factors for early onset neonatal group B streptococcal sepsis: case control study. British Medical Journal, 325(7539), 308-311. Polinski, C. (1996, October). The value of the white blood cell count and differential in the prediction of neonatal sepsis. Neonatal Network, 15 (7), 13-22. Sater, J. K. (1998, September / October). Treatment of sepsis in the neonate. The Journal of Intravenous Nursing, 21 (5), 275-281. Sinha, A, Yokoe, D. & Platt R. (2003). Intrapartum antibiotics and neonatal invasive infections caused by organisms other than group B streptococcus. The Journal of Pediatrics, 145 (5), 492-497. Wong, J. D. (2003). Whaley & Wong’s Nursing Care of Infants and Children (7th ed.). St. Louis, MI: Mosby.
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Neonatal Sepsis
Self-Learning Packet Evaluation Name of Packet: Employee
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_______________________________________________________ _______________________________________________________ _______________________________________________________ Thank you for your input. Please return this evaluation to Education & Development, either in person or by mail: Mailpoint #14, 1414 Kuhl Avenue, Orlando, FL 32806
Self-Learning Packet 2004 This self-learning packet is approved for 2 contact hours for the following professionals: 1. Registered Nurses 2. Licensed Practical Nurses
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© Copyright 2004 Rev. 10/31/2004
Neonatal Sepsis
Table of Contents Purpose.......................................................................................................................3 Objectives...................................................................................................................3 Instructions.................................................................................................................3 Introduction ................................................................................................................4 Immunity ....................................................................................................................4 Immune System Development ................................................................................................... 4 Immune System Physiology....................................................................................................... 5
Risk Factors................................................................................................................7 Trends in Neonatal Sepsis..........................................................................................8 Frequency................................................................................................................................... 8 Mortality/Morbidity ................................................................................................................... 8 Race, Sex, & Age ....................................................................................................................... 8
Early versus Late Onset Infections ............................................................................9 Clinical Signs of Sepsis ...........................................................................................10 Diagnostic Evaluations ............................................................................................10 Types of Pathogens ..................................................................................................12 Group B Strep .......................................................................................................................... 12 Staphylococcus......................................................................................................................... 13 Escherichia Coli ....................................................................................................................... 13
Management.............................................................................................................14 Nursing Considerations............................................................................................14 Family Implications .................................................................................................15 Summary ..................................................................................................................16 Post Test ...................................................................................................................17 References ................................................................................................................21 Orlando Regional Healthcare, Education & Development © Copyright 2004
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Neonatal Sepsis
Purpose The purpose of this self-learning packet is to educate nurses who care for infants and to satisfy the continuing education requirements of Orlando Regional Healthcare employees. Orlando Regional Healthcare is an Approved Provider of continuing nursing education by Florida Board of Nursing (Provider No. FBN 2459) and the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation (AP 085).
Objectives After completing this packet, the learner will be able to: 1. Match immune system development with appropriate week of gestation. 2. Identify the definition of neonatal sepsis. 3. Label the correct immunoglobulin with its definition. 4. Identify the cost of care related to neonatal sepsis. 5. Identify the risk factors for neonatal infections. 6. Describe trends in neonatal sepsis. 7. Differentiate between congenital and acquired infections. 8. Identify the signs and symptoms of a septic neonate. 9. Describe different types of neonatal infections. 10. Match treatment options with appropriate infection. 11. Identify nursing considerations when taking care of a sick infant. 12. Describe family implications when a newborn becomes ill.
Instructions In order to receive 2.0 contact hours, you must: • • •
Complete the posttest at the end of this packet Submit the posttest to Education & Development with your payment Achieve an 84% on the posttest
Be sure to complete all the information at the top of the answer sheet. You will be notified if you do not pass, and you will be asked to retake the posttest.
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Neonatal Sepsis
Introduction Newborn infants are at much higher risk for developing sepsis than children and adults because of their immature immune system—especially premature infants, where 1 out of every 250 will be diagnosed with sepsis. Sepsis is one of the major leading causes of death in the first few months of a newborn’s life. Infections can contribute up to 13-15% of all deaths during the neonatal period with the mortality rate reaching as high as 50% for infants who are not treated timely. The combination of an immature and slow responding immune system increases the risk of infection in the neonate. One reason for the increased risk is that antibodies, which help protect mothers from infections, do not cross through the placenta to the fetus until approximately 30 weeks of gestation. The antibodies present at birth take time to reach optimum levels, which also affects the protection provided. After reading this packet, the learner will have a better understanding of the physiology of the neonatal immune system, current trends in the diagnosis and treatment of infections, risk factors, signs and symptoms of sepsis, and implications for nurses who provide care for the septic newborn.
Immunity Immune System Development The immune system begins very early in fetal development with the origin of blood formation in the third week of gestation. In the fourth week of gestation the thymus forms. The thymus helps to mature and develop white blood cells so that they can play a key role in fighting infections. By the eighth week of gestation, T cells, B cells, and natural killer cells can all be found in the thymus. T cells, which make an important component in cell-mediated immunity, are formed solely in the thymus. B cells, which are the precursors of antibody producing cells, are first produced in the liver but by 12 weeks gestation move into the bone marrow where it remains. Natural killer cells, which are cytotoxic cells that have the ability to attack viruses, mature in the thymus. Interestingly, greater concentrations of natural killer cells are found in the peripheral blood of newborns and the newborn usually has adult levels of these cells at birth, but they diminish rapidly. Neutrophils are relatively numerous in both the term and pre-term infant. A neutrophil is a type of white blood cell that defends the body from organisms that cause infection. The stages of neutrophil development, from immature to mature, are myeloblast, promyelocyte, myelocyte, metamyelocte, band, and segmented neutrophil. When an infection is present, the neutrophils migrate out of the capillaries and into the infected site, where they ingest and destroy the Orlando Regional Healthcare, Education & Development © Copyright 2004
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Neonatal Sepsis pathogens causing the infection. The amount of circulating neutrophils in the newborn peaks around 12 hours after birth and then starts to decline to normal levels. Even though a large number of circulating neutrophils can be found in the newborn, the bone marrow storage pool of neutrophils at birth is only 20% to 30% of the circulating pool in adults.
Immune System Physiology Despite the immune system and immune system components, early development during gestation the newborn still remains vulnerable to infections after they are born because of the immaturity of their immune system.
Differences in Immune Responses in Full and Preterm Infants Immune System Component
Full Term Infant
Preterm Infant
Immunoglobulin G
Complete placental transfer, concentrations comparable to mother
Incomplete placental transfer, concentrations decreased
Lymphocytes
Concentrations of T and B cells comparable to those in adults with normal response to antigens
Concentrations of T and B cells comparable to those in adults with normal response to antigens
Complement
50%-75% of concentration in adult
Decreased concentration
Neutrophils
Elevated numbers at birth, with impaired functional ability
Elevated numbers at birth, with impaired functional ability
Monocytes
Normal number at birth but have impaired chemotaxis
Normal number at birth but have impaired chemotaxis
Macrophages
Normal number at birth
Normal number at birth
but decreased function but decreased function A newborn has a poor response to invading pathogens. This Natural Killer Cells Concentration similar to Concentration similar to immune response will gradually adult level, but have adult level, but have improve with age. During the diminished cytotoxic diminished cytotoxic initial postpartum phase, the effects effects infant relies on maternal antibodies and the mother’s breast milk, which is rich with immunoglobulins. When a pathogenic organism overcomes the infant’s defenses, infection and sepsis result. Sepsis is defined as the presence of microorganisms or their toxins in blood or other tissues. Newborn sepsis is still one of the most significant causes of neonatal disability and death today.
Reviewing the functions of the infant’s immune system will help provide a better understanding of the interaction between the pathogenic organisms and the newborn’s susceptibility to infection. Infections occur when the infant comes in contact with a pathogenic organism. The organism, whether it is a virus, fungus, or bacteria, enters into the infant’s body system and begins to multiply. The infant’s immune system response to an organism is divided into three phases. The first phase is the primary or nonspecific phase, which occurs immediately following the infant’s inoculation with a pathogenic organism. During this phase, there is a migration of the neutrophils
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Neonatal Sepsis to the primary site of the infection. The neutrophils enter into the cells through membrane filters and adhere to the pathogen. Ingestion and destruction of the invading organism then takes place. The next phase in the immune response is called the secondary phase or the specific response phase. During this phase, there is interaction of T and B cells to help develop immunoglobulins or antibodies to protect the infant from the infection. There are three major types of immunoglobulins: Immunoglobulin G (IgG), Immunoglobulin M (IgM), and Immunoglobulin A (IgA). Immunoglobulin G is the major immunoglobulin of the serum and interstitial fluid. It provides immunity against both bacterial and viral pathogens. It starts to cross the placenta and enter into fetal circulation around 30 weeks’ gestation and continues until the 40th week. Term infants have IgG levels that are equal to or exceed maternal levels. Since IgG is not transferred until around the 30th week of gestation, the preterm infant does not have this protective barrier. Preterm infants are thus at higher risk for infections. Research has shown that there are also decreased levels of IgG in post-term and small for gestation age infants, which suggest that there may be some inhibition of transfer with placental damage. Immunoglobulin M does not cross the placenta thus, little or no IgM is transferred to the fetus. This lack of IgM increases the infant’s susceptibility to gram negative infections. The infant does however begin synthesis of this immunoglobulin very early in their fetal life. Levels of IgM have been detected around 30 weeks’ gestation with higher levels detected when there is an intrauterine infection present. Immunoglobulin A is the most common immunoglobulin found in the gastrointestinal tract, respiratory tract, human colostrum, and breast milk. IgA does not cross the placenta, and intrauterine synthesis is minimal. Levels of IgA are usually not detected until the infant is around 2 to 3 weeks old. The last immune response is the tertiary phase. This phase provides long-term immunity against the organism. During the second phase, the B cells produce memory cells that recognize the invading pathogen on subsequent exposures. These memory cells recognize the invading organism and cause them to be neutralized, preventing the infant from becoming sick again. Although adequate numbers of B cells are present at birth, antibody production is diminished in the neonate due to a lack of uterine exposure to foreign pathogens.
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Neonatal Sepsis
Risk Factors Causes of infections in newborns can be divided into three main groups: intrauterine, intrapartum, and postnatal infections. All three groups include factors that increase the infant’s risk of coming in contact with an organism that can cause an infection.
Source
Risk Factors
Maternal
Poor prenatal care Poor nutrition Substance abuse
Intrapartum
Premature rupture of membranes Maternal fever Prolonged labor Maternal UTI
Intrauterine or factors that increase the risk before birth include the following: poor prenatal care, poor nutrition, Neonatal Male recurrent abortions, and substance Birth asphyxia abuse. Intrauterine infections occur Low birth weight when pathogenic organisms cross the placenta into the fetal circulatory system. The organisms, such as cytomegalovirus (CMV), can reside in the amniotic fluid,. Other organisms ascend from the vaginal track, infecting the membranes and causing them to rupture. This rupture of membranes can lead to infections of the respiratory and gastrointestinal tract of a newborn. Intrapartum or factors that increase the infants chance of becoming infected during the birthing process include: prolonged rupture of membranes (>12 to 18 hours), urinary tract infections, preterm labor, prolonged or difficult labor, maternal fever, colonization with Group B Streptococcus (GBS), and maternal infections. Most infections during the birthing process are related to the infant coming into unavoidable contact with an infected birth canal. The birth canal can host bacteria that an infant’s immune system cannot defend against. Postnatal infections may be contracted after delivery, as in the case with infections contracted during resuscitation, or as a result of a nosocomial infection due to improper hand washing. Infections in the postnatal period are more common in those infants who require foreign objects be introduced into their systems. Items like endotracheal tubes or indwelling catheters increase the risk of an infant becoming septic. The single most important risk factor for infection in the neonate is prematurity. Neonatal factors that increase the infant’s chance of becoming sick include: low birth weight, prematurity, birth asphyxia, meconium staining, and resuscitation. There is a direct correlation between gestational age and the infants risk for infection. Infants born at less then 32 weeks gestation have a 4 to 25 times higher risk of developing an early onset infection. Reasons for this include immature immune system, thinner skin, and the frequent need for insertion of foreign objects. Also, premature infants are likely to develop chronic lung disease requiring prolonged ventilator support. Corticosteroids are often used to help treat their lung disease, but these drugs may leave the infant at an increased risk of infection.
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Neonatal Sepsis It is important to note that in an otherwise healthy-appearing, term-gestation infant none of these factors by themselves should lead to an assumption that the infant will suffer an infection. However, a combination of these risk factors greatly increases the infant’s chance for infection and therefore should heighten the suspicion of sepsis. Studies have shown that incidence of infection increases to greater than 15% when two or more risk factors are present. An infant who appears sick should heighten clinical suspicion of sepsis, and an evaluation for infection should be performed immediately.
Trends in Neonatal Sepsis Frequency Sepsis identified by the results of cultures, such as blood, CSF, urine, occurs in approximately 2 out every 1000 live full term births. Of the 7-13% infants who undergo evaluation for sepsis only 3-8% have culture-proven sepsis. Since the early signs of sepsis are often nonspecific a high percentage of newborns are subjected to a septic workup and administration of antibiotics before the diagnosis has been made. The American Academy of Pediatrics (AAP), American Academy of Obstetrics and Gynecology (AAOG) and the Centers for Disease Control and Prevention (CDC) all have recommendations for sepsis screening and/or treatment for various risk factors, thus a higher percentage of newborns are subjected to diagnostic tests. Since the mortality rate of untreated sepsis is as high as 50%, most healthcare providers believe that the hazard of not treating or delaying treatment to wait for positive cultures is too high, and therefore treatment is initiated while awaiting the test results. As a result, the annual treatment cost for sepsis in neonates here in the United States is approximately $800 million.
Mortality/Morbidity Sepsis is a major cause of death during the first few months of life causing 13-15% of all neonatal deaths. The mortality rate of neonatal sepsis can be as high as 50% for infants who are not treated or when treatment is not begun quickly. A serious morbidity of neonatal sepsis is neonatal meningitis. Research has shown that neonatal meningitis occurs in 2-4 per 10,000 infants and of those infants diagnosed with neonatal meningitis their chance of survival significantly decreases. It is responsible for 4% of all neonatal deaths.
Race, Sex, & Age Current research has shown that African-American infants have an increased incidence of Group B Strep (GBS) disease as well as acquired or late sepsis. To help counter this many professional healthcare groups have recommend guidelines for controlling risk factors in this race. Despite these changes in screening and treatments, African-American infants still remain at the highest risk for sepsis. Male infants have a higher incidence of sepsis than their female counterparts. This higher rate of sepsis is especially true for gram negative infections. Orlando Regional Healthcare, Education & Development © Copyright 2004
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Neonatal Sepsis Premature newborns also have a higher rate of infection than full term infants. The incidence of sepsis is significantly higher in infants with very low birth weight. Infants weighing less than 1000g are at the highest risk for sepsis.
Early versus Late Onset Infections Neonatal bacterial infections are classified into two different categories depending on the time of their presentation. Congenital infections or early onset infections occur when an infant presents with signs and symptoms of the illness within the first week of life. Acquired or late onset infections occur after the infant is greater than a week old. Congenital infections or early onset Characteristics of Congenital vs. Acquired Sepsis sepsis occurs within the first few days of life, and are typically Characteristic Congenital Acquired acquired during the intrapartum period, often from organisms in the maternal genital tract. Eighty-five Time of Onset: Birth - 4 Days > 7 Days percent of newborns with early onset sepsis begin to show OB Complications: Frequent Unusual symptoms within the first 24 hours of life, 5% have symptoms between Source: Mother’s Postnatal 24 and 48 hours, a very small Genital Tract Environment percentage of infants show Clinical Multisystem Focal symptoms between 48 hours and 6 Presentation: days of life. Premature infants have the most rapid onset. A sudden Mortality Rate 5-50 2-6 onset and rapid progression to septic (%): shock often characterize these Usual Group B Strep Staph Epi infections. The main clinical feature Organisms: E. Coli Candida of a newborn with early onset sepsis is respiratory distress, which often presents as mild nasal flaring and tachypnea. The respiratory distress can quickly progress to multisystem failure and shock if not caught early. With early onset sepsis, there is a high mortality rate of 15% to 50%. The most common organism for early onset bacterial infection is Group B Strep (GBS). In addition to GBS, Escherichia Coli, Enterococcus, and Chlamydia are also common causes of congenital infections in the newborn. Acquired or late onset infections can occur anywhere from 7 days to 2 months following birth. These infections are normally seen after the first week of life and usually are contracted from organisms in the postnatal environment. The clinical manifestations may be acute physiological deterioration or manifestations of a more localized infection that has progressed to sepsis. Acquired infections have slower onsets and have a decreased mortality rate of around 10% to 20%. Common pathogens responsible for late onset infections include Candida Albicans, Coagulase Negative Staphylococci, Serratia, GBS, and Pseudomonas.
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Neonatal Sepsis
Clinical Signs of Sepsis Few neonatal infections are easy to recognize. Since infants are unable to speak and vocalize when they are not feeling well, it is important for the staff caring for the infant to be observant of signs and symptoms of sepsis. These signs range from mild symptoms to a rapidly deteriorating infant, who may need resuscitation. Early onset infections often present with nonspecific, vague symptoms because of neonate’s inability to mount an inflammatory response. Often the only sign is that the infant does not “look right”. See the box to the right for a list of the signs and symptoms.
Signs of Sepsis − − − − − − − − −
Pallor Poor temperature control Grunting Flaring Apnea & Bradycardia Lethargy Hypoglycemia Poor feeding Abdominal distention
Signs of infection may be exhibited even as early as the mother’s labor. Often infants demonstrate profound tachycardia before birth, or they may show decreased beat-to-beat variability on a fetal monitoring strip. Newborns who have congenital infections may be depressed at delivery, have low apgars, and/or require resuscitation.
Common nonspecific, early signs of infection seen most often include: hypothermia, accompanied by a change in the infant’s color, tone, activity, and/or feeding behavior. During this time, there may also be sudden episodes of apnea. Gastrointestinal symptoms include feeding intolerance or a lack of interest in feeding. Because these nonspecific signs of sepsis also characterize the onset of numerous noninfectious processes, it makes the diagnosis difficult.
Diagnostic Evaluations Since sepsis can be easily confused with other neonatal conditions such as hypoglycemia or CNS disorders, laboratory and radiographic tests are performed. These tests can help confirm when an infant is truly septic. Septic work-ups will usually be performed on those infants who are displaying signs of sepsis. Work-ups may include a peripheral blood culture, complete blood cell count (CBC) with differential, chest x-ray, urine culture, and lumbar puncture with blood being the principle fluid assessed for suspected sepsis. Ideally, all cultures should be obtained before antibiotics are started. However, 20% to 30% of women in labor receive antibiotics before delivery of the infant, and therefore the infant may have already been exposed to the antimicrobials, which may affect the results of the blood cultures. Positive CSF, urine, and bacterial blood cultures are lab results that confirm the infant has an infection. Other abnormal results to observe in an infant suspected of sepsis are hypoglycemia,
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Neonatal Sepsis hyperglycemia, metabolic acidosis, thrombocytopenia, or hyperbilirubinemia. The blood culture and CBC are the most helpful tests to identify an infection and which pathogen is the causative organism. CBC findings that indicate an infection is present include: an elevated or decreased white blood count (WBC), a low platelet count, and a high I:T ratio. The I:T ratio is a calculation which is done to show the percentage of immature to total I:T Ratio Calculation white blood cells. When the I:T ratio is greater than 0.2, this indicates that there is a “left shift.” Immature cells This left shift means that there are more immature I:T ratio = Total (mature + immature) neutrophils than mature neutrophils circulating around in the bloodstream. A neutrophil is a type of white blood cell that defends the body against organisms that cause infection. When infection is present the neutrophils migrate out of the capillaries and into the infected site, where they ingest and destroy the pathogens causing the infection. When the demand for the neutrophils exceeds the supply in circulation, immature neutrophils are released into the blood to help fight off the infection. This is labeled a “left shift” and indicates that an infection may be present. As the infection diminishes and neutrophils are replenished, a “shift to the right” occurs, indicating that everything is back to normal.
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Neonatal Sepsis
Types of Pathogens Over the past 70 years, there have been changes in the predominant bacteria that cause both early onset and late onset infections. The fluctuating pattern is due to the development and use of new drugs, the mobile population of families, and the prolonged survival of infants who would have died previously. In the 1930’s most neonatal infections were the results of Group A BetaHemolytic Streptococci. This pathogen continued to be the cause of most infections until the 1950’s when most infections were then caused by the pathogen Staphylococcus Aureus. From 1966 to 1978, either Escherichia Coli or Group B Strep caused the majority of infections. Group B Strep remains one of the major causes of infections today.
Group B Strep (GBS) Although any pathogenic organism can cause serious problems for the newborn, GBS is by far the most serious cause of neonatal infection and mortality. GBS is a normal flora found in the vagina and gastrointestinal tract of 15% to 20% of women. It is not a sexually transmitted disease and normally does not cause any problems for the women who are colonized with it. For infants though, GBS can cause serious health problems and even death. Of the 20% of women colonized with GBS, 50% of them give birth to infants colonized with GBS. 1% to 2% of those infants become clinically ill with a GBS infection. One risk factor for women who are colonized with GBS is that they have a higher chance for premature labor because of the elevated amniotic fluid level of phospholipase A2. This phospholipase produces prostaglandin, which is a potent labor stimulatant. Other risk factors that increase the infant’s chance of becoming infected with GBS include maternal temperature > 38 Celsius (100.4 F), prolonged rupture of membranes, premature delivery, multiple births, and a previous sibling with a GBS infection. Because of the severity of a GBS infection in the newborn, treatment guidelines have been established by the governing bodies involved in newborn health. The main focus of the guidelines is to promote GBS screening of all pregnant women late in their pregnancy. This is partly due to the fact that upwards of 25% of GBS infections occur in term infants who are born to mothers without any risk factors. When the pregnant woman is tested and is positive for colonization of GBS, she should be treated with antibiotics during labor. GBS infections can either be an early or late onset infection. The early onset infection is a result of transmission of the GBS bacteria from the mother to the fetus, usually during delivery. The infant will begin to present symptoms during the first 24-48 hours of life. At first, the symptoms may be very subtle and nonspecific. The infant may present with pallor, tachypnea, tachycardia, or decreased activity. If these first symptoms go undetected, the infant will progress to signs of infection that are more obvious. These may include temperature instability and/or respiratory distress, such as grunting, nasal flaring, retractions, and apnea. GBS infections are progressive and the symptoms worsen if treatment is not initiated. Within hours, an infant can deteriorate from grunting with slight retractions to septic shock and death. The mortality rate in infants less then 36 weeks of gestation is 30% to 50%.
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Neonatal Sepsis Late onset GBS infections can occur anywhere after the first week of life up to 2 months of age. Late onset infections seem to be caused by nosocomial transmission rather than maternal transmission. This form of GBS infection can be less severe than the early onset form but still carries a mortality rate of 25%. Infants with this late form will often present with meningitis as their main symptom. Treatment of GBS often begins when the mother is in labor. For women who test positive, ampicillin is needed at least 4 hours before delivery for the treatment to be successful. If the mother does not receive the ampicillin, the infant may have to undergo blood tests to rule out the presence of the GBS bacteria. For those newborns who do acquire a GBS infection, treatment starts with supportive care. This includes antibiotics, such as ampicillin and gentamicin, fluid and volume support, and respiratory support, usually in the form of a ventilator. Treatment against meningitis-induced seizure activity may also be required. Long term outcomes for infants with GBS infections are dependent upon the type of infection, whether it is early onset or late onset, and how soon treatment was started. Neonates who present with early onset GBS and receive treatment quickly have a better prognosis then those who acquire late onset GBS infections where 25% to 50% of those infants may have permanent neurological damage.
Staphylococcus Staphylococcal pathogens can cause mild to severe infections. Transmission may result in a localized infection from a scalp electrode, to more widespread infections such as osteomyelitis resulting in overwhelming sepsis. The major source of this infection from staphylococcus comes from improper hand washing by the hospital staff. It is also associated with infections arising from umbilical catheters, endotracheal tubes, and central lines. Other causes of nosocomial infections are improper staffing, lack of space between infants, and lack of sterile technique when caring for invasive catheters. Colonization of the pathogen occurs in 40% to 90% of infants, usually by the fifth day of life. It is most often treated with vancomycin.
Escherichia Coli E. Coli is the most common cause of gram negative neonatal infection in the United States. This pathogen infects 1 to 2 out of every 1,000 live births and is responsible for up to 45% of neonatal infections. This bacterium is found in the mother’s genital tract with a high incidence of colonization in the neonate. The pathogen can cause severe infections that may lead to respiratory distress, cardiovascular collapse, meningitis, multiorgan failure, and even death. E. Coli is usually treated with gentamicin.
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Neonatal Sepsis
Management To increase the infant’s chance of survival, early recognition of signs and symptoms of sepsis is imperative. Often the diagnosis of sepsis is based upon suspicion of the presenting clinical signs and symptoms. Antibiotic therapy is usually started before lab results confirm and identify the pathogen causing the infection. In addition to antibiotic treatment, therapy consists of circulatory, respiratory, nutritional, and developmental support. Treatment begins with careful monitoring of the infant’s vital signs and regulation of the thermal environment. Supportive therapy for a septic infant starts with the administration of oxygen when respiratory distress or hypoxia becomes present. The infant may also need more invasive respiratory support such as continuous positive airway pressure (CPAP) or to be placed on a ventilator if they are suffering from apneic episodes. Infants who are sick may also develop electrolyte abnormalities. These infants will need careful, ongoing monitoring and adjustment of the fluid and electrolyte balance, especially when the infants are NPO. Antibiotic therapy is continued for 7 to 21 days if the cultures are positive, or it is discontinued in 3 days if cultures are negative. The infant’s outcome is variable. Before the availability of antibiotics, mortality rates for infected infants were greater than 95%. In the 1970s and 1980s, the mortality rate decreased to 20% to 40%. Today, with the use of antibiotics along with early recognition and supportive care, mortality has reduced to 13% to 45 %, depending on the causative agent. However, approximately 1,500 neonates in the United States still die annually from systemic infections.
Nursing Considerations Nursing care for the infant with sepsis involves skilled observation and ongoing assessments. Recognition of a problem is paramount in importance. It is most often the nurse who observes and identifies that something “just isn’t right” with the infant. This is due to the fact that the nurse maintains constant assessment and documentation of subtle changes in the infant’s vital signs, physical assessments, feeding tolerance, responsiveness, and/or general behavior. Awareness of the potential routes for transmission of infectious pathogens will also help identify those infants at risk for developing sepsis. Much of the care for infants with infections involves the medical treatment of the illness. Nurses must be aware of the side effects of the specific antibiotics and the proper administration guidelines. Prolonged antibiotic therapy poses additional hazards for affected infants. Antibiotics predispose the infant to growth of resistant organisms and superinfections from fungal agents such as candida. The nurse must be alert for signs of such complications.
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Neonatal Sepsis Another challenge in caring for a sick infant is starting and maintaining IV access for drug therapy. Common sites in the infant include the hand and arm, as well as the veins found in the scalp and foot. If the infant is going to require extensive antibiotic therapy, a peripherally inserted central catheter (PICC) may be considered. Total care of infants with sepsis involves decreasing any additional physiologic and/or environmental stress. This includes providing an optimum thermoregulated environment and anticipating potential problems, such as dehydration or hypoxia. Precautions need to be implemented to prevent the spread of infections to other newborns. To be effective, precautions must be carried out by all caregivers that come in contact with the sick infant. Proper handwashing, use of disposable equipment, disposing of excretions, and adequate housekeeping of the environment and equipment are essential. Since nurses are the most constant caregivers involved with sick infants, it is usually their responsibility to oversee that everyone maintains all phases of isolation.
Family Implications Maternal attachment is a cumulative process that begins before conception. It is strengthened by significant events during pregnancy, and matures through maternal-infant contact during the neonatal period. When an infant becomes sick, the necessary physical separation appears to be accompanied by an emotional detachment on the part of the parents, which may seriously damage the capacity for parenting their infant. During pregnancy, and sometimes even before conception occurs, mothers develop an ideal or fantasy image of their unborn child. To the mother, the unborn child has an imagined appearance, pattern of behavior, and expected accomplishments. Anything that alters this image can alter the bonding between the mother and her new child. Therefore nursing care does not stop with providing medical care to a sick infant. The nurse needs to encourage and facilitate parental involvement, rather than isolating the parents from their infant and associated care. Nurses should be cognitive of the fact that the parent’s worry associated with a sick infant can go way beyond the infant’s actual state of illness. Often parents ask themselves, “Can I care for this infant?” The nurse needs to provide constant teaching and supply the family with continual updates on the infant’s condition to help them through this frightening time. It is important for the nurse to use simple and basic vocabulary. When medical language is used, it increases the parent’s anxiety level, and teaching if less effective. Some mothers feel guilty that they may have done something to cause the infant’s condition. The nursing staff needs to provide constant reassurance that this is a common feeling and that she did not cause the infant to become ill. The
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Neonatal Sepsis nurse needs to remember the goals of his/her care. Goals cannot be only patient orientated, but need to be family orientated as well. It is important to remember that it is the infant to who we provide care, but it is the family who will take the baby home. The nurse needs to provide the family with the knowledge and skills they need to take care of their infant once the baby is discharged from the hospital.
Summary Despite the major advances in neonatal medicine, many infants still develop life-threatening infections during the first month of life. Identifying and caring for an infant with a possible infection starts with a skilled nurse who is proficient in performing neonatal assessments. The assessment begins with a nurse’s innate knowledge of the many different risk factors for newborn infection. The nurse needs to be observant for any sign that may indicate sepsis. It cannot be overemphasized that prompt recognition, early diagnosis, and immediate treatment of sepsis can dramatically improve the infant’s outcome and limit any potential disability. Once sepsis has been identified, treatment must be initiated promptly, and the infant reassessed for their response to the therapy. Hours can make the difference of an infant surviving the infection, or succumbing to its systemic devastation. Because of the nonspecific manifestations of impending sepsis, any changes in the physical and/or behavioral state of an infant should raise the suspicion of sepsis. Above all else, nursing assessment and interventions are the most important tool in the prevention, prompt recognition, and effective management of newborn infections.
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Neonatal Sepsis Education & Development Answer Sheet
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Please also complete the self-learning packet evaluation at the end of the packet. In order to receive 2.0 contact hours, you must: • Submit the answer sheet and payment ($5.00 for Orlando Regional Healthcare employees / $10.00 for non-employees) to: Orlando Regional Healthcare Education & Development, MP 14 1414 Kuhl Ave. Orlando, FL 32806 •
Achieve an 84% on the posttest. (You will be notified if you do not pass and will be asked to retake the posttest.)
Neonatal Sepsis
Post Test Directions: Do NOT write on this test. Complete this test using the bubble sheet provided. 1.
All of the following define sepsis in the newborn EXCEPT: A. The pathogen overcomes the infant’s defenses B. The presence of microorganisms in the infant’s blood C. The presence of the pathogen in the infant’s stool D. The presence of microorganisms in the infant’s tissues
2.
Which of the following are maternal risk factors for developing neonatal infections? A. Regular wellness check ups B. Poor nutrition C. Multiple births D. First pregnancy
3.
T Cells are first found in the fetus at what week gestation? A. 4 weeks B. 6 weeks C. 8 weeks D. 10 weeks
4.
The annual cost of treatment of neonatal sepsis in the United States is __________. A. $600 million B. $700 million C. $800 million D. $900 million
5.
Infants that have a higher risk for developing infection are A. Male infants B. Female infants C. Full term infants D. Post term infants
6.
An infant is 6 hours old and is starting to show signs of respiratory distress such as grunting and retraction. Which of the following accurately describes the type of infection the infant has? A. Acquired B. Congenital C. Nosocomial D. Periodic
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Neonatal Sepsis 7.
A mother brings in her 2-week-old infant to the doctor and reports that the infant has been lethargic and not eating very well. Which of the following accurately describes the type of infection the infant has? A. Acquired B. Congenital C. Intrapartum D. Maternal
8.
The most common type of organism that causes a congenital bacterial infection is: A. Candida Albicans B. Pseudomonas C. Group beta strep D. Serratia
9.
All of the following are signs of infection in the newborn EXCEPT: A. Pallor B. Apnea C. Hypoglycemia D. Choking
10.
Which statement best describes signs and symptoms of an infant with suspected sepsis? A. Infants with infections will have a fever. B. The infant’s appetite is unaffected by sepsis. C. Infants with infections are easy to recognize because of the obvious symptoms. D. Infants with infections are hard to recognize because of the vague symptoms.
11.
When taking care of a sick infant the nurse should: A. Decrease any physiologic or environmental stress B. Have blood ordered and waiting C. Perform frequent linen changes D. Perform frequent lab draws
12.
In general when assisting the family with coping with the hospitalized infant, the nurse should recognize that: A. Mothers often feel capable and ready to jump in and help with the care of the sick infant. B. Fathers often are ready to jump in and help with the care of the sick infant. C. Mothers often feel guilty when their infant becomes sick, blaming themselves for the infant’s illness. D. Parental involvement is a low priority in the care of an infant.
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Neonatal Sepsis Match the correct immunoglobulin with its description 13.
14.
15.
Does not cross the placenta, levels are higher when an infection is present. Most common immunoglobulin found in the gastrointestinal tract. Levels not detected until the infant is 2-3 weeks old.
A. Immunoglobulin A B. Immunoglobulin G C. Immunoglobulin M
Crosses the placenta and enters into fetal circulation around 30 weeks of gestation.
Match the correct pathogen with its description 16.
This pathogen is a major source of infection from hospital personnel with improper hand washing.
17.
Most common cause of gram negative infections.
18.
Infection can be either early or late in its onset and is one of the most serious causes of mortality in the newborn.
A. Escherichia Coli B. Group B Strep C. Staphylococcus
Match the correct pathogen with its common treatment 19.
Escherichia Coli
A. Ampicillin
20.
Group B Strep
B. Gentamicin
21.
Staphylococcus
C. Vancomycin
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Neonatal Sepsis
References Bellig, L. (2004, June 23). Neonatal sepsis. Emedicine. Retrieved July 12, 2004 from http://www.emedicine.com/ped.topic2630.htm CDC. Group B Strep. Retrieved July 23, 2004, from http://www.cdc.gov/ncidod/dbmd/gbs/ Deacon, J. & O’Neill, P. (1999). Core Curriculum for Neonatal Intensive Care Nursing (2nd ed.). Philadelphia, PA: W.B. Saunders Company. Gardner, S. & Merenstein, G. (2002). Handbook of Neonatal Intensive Care (5th ed.). St. Louis, MI: Mosby. Haw, P. (2003). Care of the Sick Neonate: A Quick Reference for Health Care Providers. New York, NY: Lippincott Williams & Wilkins. Huether, E. S. & McCance, L. K. (2000) Understanding Pathophysiology (2nd ed.). St. Louis, MI: Mosby. Ladewig, P., London, M., Moberly, S., & Olds, S. (2001). Contemporary Maternal-Newborn Nursing Care (5th ed.). New York, NY: Prentice Hall. Lowdermilk, L. D., Perry, E. S., & Bobak, M. (2000). Maternity & Women’s Health Care (7th ed.). St. Louis, MI: Mosby. McKenney, W. M. (2001, December). Neonatal nursing. Understanding the neonatal immune system: high risk for infection. Critical Care Nurse, 21(6), 35-47. Mullaney. D. (2001). Group B streptococcal infections in newborns. JOGNN, 30(6), 649-658. Neonatology on the Web. Neonatal Infections. Retrieved July 14, 2004, from http://www.neonatology.org/syllabus/sepsis/index.htm Oddie, S. & Emblrton, N. (2002). Risk factors for early onset neonatal group B streptococcal sepsis: case control study. British Medical Journal, 325(7539), 308-311. Polinski, C. (1996, October). The value of the white blood cell count and differential in the prediction of neonatal sepsis. Neonatal Network, 15 (7), 13-22. Sater, J. K. (1998, September / October). Treatment of sepsis in the neonate. The Journal of Intravenous Nursing, 21 (5), 275-281. Sinha, A, Yokoe, D. & Platt R. (2003). Intrapartum antibiotics and neonatal invasive infections caused by organisms other than group B streptococcus. The Journal of Pediatrics, 145 (5), 492-497. Wong, J. D. (2003). Whaley & Wong’s Nursing Care of Infants and Children (7th ed.). St. Louis, MI: Mosby.
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Neonatal Sepsis
Self-Learning Packet Evaluation Name of Packet: Employee
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