Transcript Neonatal Infections

Neonatal Infections
May 2005
Dr Patricia Fenton
Sheffield Children’s Hospital
Neonatal Infections
Hazard analysis at critical control point
A baby production line
Uterus to push chair
The Bad News Is…..
No
Pictures
The Good News Is….
994 out of every 1000
infants born in the
UK survive
Some Definitions
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Infant - <1 year
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Neonate - < I month
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“early onset” - < 7 days
Infant Deaths 93-97 (Number)
8000
7000
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6000
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5000
4000
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3000
2000
1000
0
Congen
Infection
E and W figures
Neonates account
for 67% of deaths
Infection is NOT a
major cause of
neonatal death.
A Hazardous Journey
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The uterus: Listeria monocytogenes
The birth canal: group B streptococcus
The unit: Acinetobacter baumanii
Devices: CNS
The attendants: Staph aureus
Three Barriers to Infection
NORMAL
FLORA
SKIN AND
MUCOUS
MEMBRANES
IMMUNITY
Impaired Barriers
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Thin skin
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Raw umbilicus
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Invasive devices
Small/premature =
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Poor antibody response
Poor neutrophil response
Poor complement activation
Impaired macrophage activity
Poor T cell function
Reduced placental IgG
Clinical Presentations
Not breathing well
 Not feeding well
 Not looking well
lethargic irritable mottled
 Fever and tachycardia
 Seizures
AND NOT A BLOOD TEST OR XRAY!
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Listeria monocytogenes
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1-3 cases per million per year E&W
17 pregnancy associated cases 2001
>300 pregnancy assoc. 87-89
Soft cheese, paté and chilled meals
All animals
5% humans in bowel
Listeria - an interesting organism
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G + rod
Flagellae-RT not BT
Tumbling motility
Haemolytic BA
Invasin (IC)
Actin tails
Listerioloysin O
Log10 bacteria per ml
9
8
7
6
5
4 degrees
minus 20
4
3
2
1
0
1 week
2 weeks
3 weeks
4 weeks
Disease Spectrum
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Influenza like illness (maternal)
Sepsis with stillbirth
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Neonatal sepsis/meningitis
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Sepsis/meningitis in impaired immunity
(at any age)
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Treatment, Outcome and Control
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Ampicillin or amoxycillin
Plus gentamicin
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One third fatal
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Avoidance, food quality measures, high
level of suspicion, early treatment
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Early Onset GBS Disease
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376 cases in 2001
39 died
Important because:
 Identified risk factors
 Preventable
Risk Factors
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Previous baby affected by GBS
GBS in urine at any time this pregnancy
Preterm labour
Prolonged ROM
Fever in labour
(RCOG guidelines 2003)
Screening Based Strategy
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27% carry it (rectal plus vaginal swabs)
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Antibiotic prophylaxis 86% reduction
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Treat 1000, prevent 1.4
Risk Factor Strategy
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25% women have one or more risk
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Antibiotic prophylaxis 69% reduction
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Treat 1000, prevent 2
The Disease
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Early onset
Low apgar
Sepsis
Pneumonia
GBS causes 70% early onset sepsis
Low birth weight
Prevention
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Choose your mother carefully (IgG)
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Be big (mortality 6% vs. 18%)
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Penicillin AT ONSET OF LABOUR
Christmas Day HH
Premature 35/40
 No ANC
 Septic, ventilated
 Extubated day 11
 Home “to die”
BUT….
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The Unit
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24 cots (2x6 bedded 1x12 bedded)
Zero to two cases per year for 5 years
4 month period 11 cases clinical sepsis
All cases in one 6 bedded ward area
The Bug
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Acinetobacter baumannii
Gram negative cocco-bacillus
Water-dwelling saprophyte
Long survival on dry surfaces
Mattresses, air con, ventilators
Up to 25% normal human skin flora
Dissemination via hands?
What Happened Next?
Cultured everything.
Results?
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Nothing
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Followed each baby
and everything that
happened to them
And they found
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Hydrocolloid dressings-large sheets
Cut and stored
Used on skin
CULTURE POSITIVE OUTBREAK
STRAIN
What happened next?
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Practice stopped
Outbreak ended
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3 babies died
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Lessons Learnt
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A knowledge of background infection
rates useful (none to 11)
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Susceptible patients are just that
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Plastic wallets make good incubators
Devices
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Initial response
Getting worse
Central line in situ
?CNS
Coagulase negative staphylococci
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Gram positive cocci
Normal skin flora
Low grade pathogen in normal host
Hydrophobic cell surface (adheres)
Polysaccharide production - biofilm
Neonatal infections
Neonatal Unit B/C
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CNS
Stau
E.coli
GNB’s
GBS
234
17
19
32
18
Attendants
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6 week period
4 blistered babies
Early discharge
14 more identified
Staph aureus
Phage type 3A/3C
Exfoliative toxin A
Outbreak Control
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Swabs of all staff handling newborns
Check all hands
One individual handled 17/18 affected
Epidemic strain from nose, axilla, peri
All other staff negative
Treatment of carrier ended outbreak
Staphylococcus aureus
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Looks like CNS and..
Normal flora (30% adults) but..
Highly pathogenic
Exfoliative toxin A - SSSS
Potential for cross infection
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Treated with flucloxacillin
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Control Measures
Wash hands
and
check hands
Conclusions
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Infection: significant hazard to neonate
Journey womb to push chair
Bacteria for every occasion
Smaller is frailer
Never give up on a neonate
Our Aim at SCH
Family focused service
Putting the needs and welfare
of children first