NEONATAL INFECTIONS

NEONATAL INFECTIONS

Infections occur frequently in the

neonate, causing illness and possibly death.

There are several reasons for the neonate to

get infections like the variety of organisms

usually present in the uterus during

gestation, in the cervix and vagina during

delivery, and in the environment of hospital

and community; and immature host defense

that causes the neonate to be overcome by

these organisms.

Pathophysiology

fetus can acquire microorganisms transplacentally

or during delivery

nosocomial infections

Mode of infection

Antenatal:

Transplacental

Amnionitis

Intranatal:

early rupture of membranes

Contamination while passing through the vagina

Ophthalmia neonatorum (gonococcal infection)

Oral thrush (candida albicans)

Cord sepsis from improper asepsis while cutting cord

Postnatal:

Transmission from infected mother, relatives or

hospital staff

Cross infection from another infected baby

Infected articles used for feeding, bathing, clothing

etc.

Clinical manifestations of

infections in the neonate

General:

Fever, hypothermia

“Not doing well”

Poor feeding

Lethargy

Scleroderma

Gastrointestinal system:

Abdominal distention

Anorexia, vomiting

Diarrhoea

Hepatomegaly

Respiratory system:

Apnea, dyspnea

Tachypnea, retraction

Flaring, grunting

Cyanosis

Cardiovascular system:

Pallor, cyanosis

Mottling

Cold, clammy skin

Hypotension

Central nervous system:

Irritability

Tremors, seizures

Hyporeflexia

Abnormal Moro reflex

Irregular respirations

Full fontanel

Hematologic system:

Jaundice

Splenomagaly

Pallor

Petechiae, purpura

Bleeding

TOXOPLASMOSIS

The host of this parasite is the cat and the

organism is acquired in humans either by direct

faeco- oral ingestion of undercooked meat

containing toxoplasma cysts.

Features

hydrocephalus or microcephalus,

intracranial calcification, chorioretinitis,

jaundice, hepatosplenomagaly, petechiae,

bleeding manifestations and intrauterine

growth retardation.

Diagnosis is by isolating the organism in

body fluids by culture or polymerase chain

reaction and serological tests.

Treatment consists of pyrimethamine and

sulphadiazine.

RUBELLA

The gestational age at the time of transmission of

maternal infection determines the virulence of fetal

infection. Most florid fetal illness is seen in the first

8 to 10 weeks of gestation.

Diagnosis is by serology and culture.

Congenital defects include sensorineural deafness,

cardiovascular malformations like patent ductus

arteriosus, microcephaly and mental retardation,

IUGR, cataract, glaucoma and retinopathy and

thrombocytopenic purpura.

There is no effective treatment for congenital

rubella

CYTOMEGALOVIRUS

common features are microcephalus, intracranial

calcification, hepatosplenomegaly, petechiae and

jaundice.

Diagnosis is made by culture of the organism &

specific IgM antibodies in the blood.

There is no specific treatment.

In those who present with the above signs, the

mortality rate is 20 to 30%

HERPES SIMPLEX

The newborn is usually infected during delivery by

the presence of maternal vaginal herpes simplex

type 2.

The infection presents at the end of the first week

with or without herpetic rash.

Diagnosis is by culture of the virus from

cerebrospinal fluid.

Treatment is with acyclovir

VARICELLA ZOSTER

caused by a DNA virus belonging to the herpes

group. It spreads by droplet infection or by direct

contact.

Following the incubation period of 12- 16days, a

prodrome characterized by fever, malaise and

myalgia is usual. A rash then appears in crops of

pruritic clusters of vesicles progressing to pustules

seen on the skin and mucous membrane in a

centripetal distribution. It is common to see all

stages of rash on the trunk.

complications like pneumonia, aseptic meningitis,

encephalitis, myocarditis, glomerulonephritis and

thrombocytopenia may occur.

Diagnosis is based on clinical manifestations,

examination of Giemsa- stained smears and the 4

fold rise in the serum antibody titre.

treatment includes acyclovir, Varicella zoster

immunoglobulin

HEPATITIS B

The neonate infection rate from the carrier mothers

ranges from 10 to 40%. If the newborn is affected,

85 to 90% will become chronic carriers (HBsAg

positive) and many will experience progressive

hepatic damage, with the likelihood of

hepatocellular carcinoma

an incubation period of 35 to 50 years.

The infant rarely demonstrates the classical

symptoms; the great majority has subclinical

infection and enters the carrier state.

In infants born to high risk mothers, hepatitis B

immunoglobulin 200 IU IM is given soon after

birth together with hepatitis B vaccine IM in a

different limb and followed by similar dosage of

vaccine at 1 and 2 months of age. Universal

immunization (1st dose after birth, then at 1 and 6

months of age) of all infants is recommended

ACQUIRED IMMUNO

DEFICIENCY SYNDROME

retrovius that primarily infects cells of immune

system, including helper T lymphocytes (CD4 T

lymphocytes), monocytes and macrophages.

Incidence

Without intervention, 15 to 30% of infants born to

HIV infected women will be affected.

Transmission

HIV is transmitted by sexual contact, percutaneous

exposure to contaminated blood and mother to child

transmission. Vertical transmission may occur in

utero, at the time of delivery, or via breast feeding.

Risk factors

High maternal plasma HIV RNA

Advanced maternal disease stage

Low CD4 lymphocyte count

Premature delivery

Increased exposure to maternal blood or cervical

secretions at the time of delivery

Clinical manifestations

Primary acute infection

Non specific symptoms

Infections related to immunodeficiency:

Organ system disease

Malignancy

Diagnosis

HIV antibody is measured by ELISA

Confirmatory test is by Western blot

HIV nucleic acid, RNA or DNA can be detected by

PCR, branched DNA chain assay and nucleic acid

sequence- based amplification

Prevention

Limit the vaginal examinations to a minimum.

Avoid using scalp electrodes or intrauterine

monitoring catheters.

All linen should be collected in a vessel containing

hypochlorite solution.

All cotton swabs, dressing pads, mops must be

discarded in a container with hypochlorite

solution.

All needles, syringes and sharp blades must be

collected and disposed off with due precautions.

After delivery, the flooring must be cleaned with

antiseptic solution by an attendant who observes

all precautions as detailed above.

Fumigate the labor room or theatre.

Autoclave all instruments after proper washing and

cleaning.

The patient should be explained the need for

protection of the staff.

Intrapartum therapy

Zidovudine 2mg/kg IV during the first hour of labor,

there after 1mg/kg/hour throughout the rest of labor.

Zidovudine the same dosage 4 hours before cesarean

section.

Avoid artificial rupture of membranes

Cap, mask, gown, double gloves, goggles should be

worn.

Caesarean section decreases 50% risk of vertical

transmission.

Sterilize the instruments and linens.

Health care workers should protect themselves

Post exposure prophylaxis

Use disposable syringes and discard properly.

Postpartum care

After delivery, all the newborns are administered zidovudine

oral syrup in the dose of 2mg/kg body weight 4 times daily

for 6 weeks postpartum.

Babies born to HIV infected mothers are HIV positive

because of passive transfer of maternal antibodies to the

newborn. Levels of these antibodies gradually decline and by

the end of 6 months most non infected babies will become

seronegative.

Majority of the babies born to HIV infected mothers have no

physical signs of infection. Rarely, they may exhibit the so-

called HIV embryopathy characterized by growth retardation,

microcephaly and craniofacial abnormalities.

Breast feeding

Contraception

Counseling

Management

Decrease fetal viral exposure by preventing

chorioamnionitis, shortening the duration of labour,

delay rupture of membranes.

The practice of elective caesarean section at term/

onset of labour to prevent exposure of the fetus

Zidovudine is the only drug proven to be of value in

reducing perinatal transmission risk of HIV from 25%

to about 7%.

The practice of advocating elective caesarean section

close to term to reduce the risk of vertical

transmission of the disease is still debatable.

SYPHILIS

Congenital syphilis is a severe, disabling, and often

life-threatening infection seen in infants. A pregnant

mother who has syphilis can spread the disease

through the placenta to the unborn infant.

Causative agent

Treponema pallidum

Classification

Early

Newborns may be asymptomatic and are only

identified on routine prenatal screening. If not

identified and treated, these newborns develop poor

feeding and rhinorrhea.

After, they can develop late congenital syphilis.

Symptomatic newborns, if not stillborn, are born,

with hepatosplenomegaly, skeletal abnormalities,

pneumonia and a bullous skin disease known as

pemphigus syphiliticus.

Late

Late congenital syphilis is a subset of cases of

congenital syphilis.

Symptoms:-

blunted upper incisor teeth known as Hutchinson's

teeth

inflammation of the cornea known as interstitial

keratitis

Deafness from auditory nerve disease

frontal bossing (prominence of the brow ridge)

saddle nose (collapse of the bony part of nose)

hard palate defect

swollen knees

Clinical manifestations

Failure to gain weight or failure to thrive

Fever

Irritability

No bridge to nose (saddle nose)

Rash of the mouth, genitals, and anus

Rash: Starting as small blisters on the

palms and soles, and later changing

to copper-colored, flat or bumpy rash on

the face, palms, and soles

Watery fluid released from the nose

Mulberry molars (permanent first molars

with multiple poorly developed cusps).

Frontal bossing

Poorly developed maxillae

Enlarged liver and spleen

Petechiae

Diagnosis

physical examination of the infant may show signs

of liver and spleen swelling and bone inflammation.

A routine blood test for syphilis is done during

pregnancy.

The mother may receive the following blood tests:

Fluorescent treponemal antibody absorbed test

(FTA-ABS)

Venereal disease research laboratory test (VDRL)

An infant or child may have the following tests:

Bone x-ray

Dark-field examination to detect syphilis bacteria

under a microscope

Eye examination

Lumbar puncture

Treatment

Penicillin is used to treat all forms of

syphilis. IM procaine Penicillin G

50,000units per Kg Per each day for 10 days.

Complications

Blindness

Deafness

Deformity of the face

Nervous system problems

Death from pulmonary hemorrhage

Prevention

Safer sexual practices may help prevent syphilis.

Prenatal care is very important. A routine blood

test for syphilis is done during pregnancy.

ACQUIRED NEONATAL

INFECTIONS Adequate hand washing with an antibacterial

solution before examination or contact with the

neonate

Avoidance of overcrowding

Individual equipment is required for each cot

Communal areas should be kept clean. Scales should

be covered with disposable paper for each weighing.

Sterilization or disposal of equipment such as

oxygen and suction tubing

Cleanliness in preparation and storage of feeds

THRUSH

It is caused by Candida albicans.

The most common sites of infections are the

mouth and napkin areas. In the mouth, the lesions

are small, white, raised plaques with some

surrounding erythema. In the napkin area the rash

is erythematous with a clearly demarcated border.

The rash often involves the groin.

It is treated with nystatin mixture orally 1,00,000

units in 1ml 4 times a day after feeds or by oral

application of 1% aqueous solution of gentian

violet or clotrimazole mouth paint. Clotrimzole 1%

or nystatin ointment 2% or miconazole ointment

2% is used for 2 weeks in the nappy and the groin.

Oral administration of nystatin or flucanazole

recommeded for 2 weeks

CONJUNCTIVITIS ( OPHTHALMIA NEONATORUM

Causative agents

Unilateral conjunctivitis after 5 days of life is often

due to Chlamydia trachomatis. Purulent

contunctivitis which may affect one or both eyes

within 48 hours of age. Other microorganisms

causing neonatal conjunctivitis are streptococcus,

Staphylococcus, Pneumococcus, E.coli, Herpes

simplex virus. Chemical conjunctivitis is due to

irritation of silver nitrate, soap and local antibiotic

drops.

Mode of infection

Infected hands of caregivers, infected birth canal

and cross infection from other infected infants

Infection can occur directly from other sites of

infections like skin and umbilicus

Clinical features

Varies with mode of infection and causative

organism

Neonate may present with sticky eyes with or

without discharge from watery or mucopurulent

discharge

Eyelids may be swollen

Closed eyelids due to spasm of orbicularis oculi

muscle

Diagnosis

Diagnosis is made by examination of smear of

the eye discharge and by culture in Thayer- Martin

medium

Management

Antibiotic therapy after detecting causative

organism

Sulfacetamide or framycetin or chloramphenicol

drops or erythromycin ointment are used

Pencillin therapy for gonococcal disease

Clean the eyes with sterile cotton swabs soaked in

saline should be done after hand washing

Prevention

Treatment of maternal infection, aseptic

technique during delivery, special care and

attention in face and breech presentation,

isolation of infected baby and maintenance

of general cleanliness

Complications

Orbital cellulitis

Dacrocystitis with obstruction of nasolacrimal duct

Corneal ulceration

Blindness

OMPHALITIS

Infection of the necrotic umbilical stump,

Purulent discharge, red and inflamed periumbilical

area and foul smell are indicative of umbilical

sepsis.

In mild cases frequent cleaning with spirit or

alcohol and application of antibiotic powder (

containing neomycin, bacitactin and polymyxin O

are enough)

Systemic antibiotics are started after taking a skin

swab, and application of antibiotic creams locally.

SKIN INFECTIONS

Skin pustules or paronychia (infection of the bed

of the nails) are usually caused by Staphylococcus

aureus. Treatment with topical antibiotic

SYSTEMIC INFECTIONS

early’ in the first 3 days, or ‘late’ after usually 7 to

10 days.

The commonly implicated organisms are group B

beta- hemolytic streptococcus, E-coli, Klebsiella,

Psedomonas, Staphylococcus aureus, and in the

very preterm infant, Staphylococcus epidermidis.

Risk factors for systemic infections:

Prolonged rupture of membranes (24 hours)

Known vaginal colonization with group B

streptococcus

Prematurity

Maternal fever

Any breach of the skin such as skin trauma

Indwelling catheters

Presentation

respiratory distress, lethargy, poor temperature

regulation, poor feeding, vomiting, apnea, pallor

and abdominal distention.

Diagnosis

Complete blood count and smears

Blood culture

Urine culture

Lumbar puncture

Chest radiography

Radiograph of abdomen

Radiograph of bone joint

Treatment:

Systemic antibiotics

Transfer the newborn to a special care unit

Provide appropriate supportive

SPECIFIC INFECTIONS

PNEUMONIA

etiology may be congenital or acquired

Transmission of congenital infections may be

either transplacental or via the birth canal.

Clinical features: respiratory distress preceded by

lethargy, apnea, refusal of feeds, vomiting and

temperature instability.

Diagnosis is by chest radiograph and culture of

blood and tracheal aspirate.

Treatment is by appropriate antibiotics and

supportive therapy for respiratory distress.

MENINGITIS

Meningitis is the inflammation of the meninges

Features: The onset usually in the first week, is

gradual with temperature instability, fever, bulging

anterior fontanelle, high pitched cry or excessive

crying, poor feeding, vomiting and convulsions.

diagnosed by lumbar puncture.

It requires 21 days of treatment with

intravenous antibiotics. Broad spectrum

antibiotics like ceftazidime and cefepime

are given.

OSTEOMYELITIS/ SEPTIC

ARTHRITIS

common organisms are S. aureus, Neisseria,

group B streptococci.

involved bones are femur, humerus, tibia, radius

and the maxilla.

Presentation is with fever, bone or joint

tenderness. Radiograph of the appropriate area is

taken to confirm the diagnosis.

Treatment: Septic arthritis may require aspiration

of joint and surgical drainage. Antibiotic treatment

should be for 6 weeks. The prognosis is usually

good.

URINARY TRACT INFECTION

Bacteria may signal generalized sepsis with

hematogenous spread to the kidney

Features: Occasionally kidneys may be enlarged

and palpabe. In all neonate with poor weight gain

inspite of adequate intake of feeds, urine analysis

and culture must be done.

Common organisms are E.coli, Klebsiella and

enterococci.

Diagnosis is by urine culture.

Treatment: cephalosporin and aminoglycoside

until antibiotic sensitivities are obtained. A repeat

culture should have no growth after 48 to 72 hours

of therapy. Until the diagnosis is treated, oral

antibiotic prophylaxis with trimethoprim can be

given in the initial 10 to 14 days.

TETANUS NEONATARUM

Etiology:

Caused by infection by clostridium tetani

Contamination and infection of the umbilical

stump at the time of cutting the cord is an

important cause.

Lack of active immunization with TT contributes

high incidence

Clinical features:

Common onset of symptoms is 5-15 days

It does not manifest during first two days of life

and is rare after two weeks of life.

The infant keeps mouth slightly open due to pull

as a spasm of the muscles of the neck but reflex

spasm of massesters is invoked on trying to

open mouth during feeds.

Reflex spasm of pharyngeal muscles leads to

dysphasia and choking during feeding.

During handling and touching, lock jaw or

trismus is followed by spasm of the limbs.

The usual flexed posture of the baby is replaced

by generalized rigidty and opisthotonous in

extension

The spasm of larynx and respiratory muscles is

associated with apnoea and cyanosis

The spasm is characteristically induced by

stimuli of touch, noise and bright light.

Frequent muscular spasms leads to fever,

tachycardia and tachypnoea

NEONATAL SEPSIS

Neonatal sepsis is the infection in blood that occurs

in an infant younger than 90 days old. Early-onset

sepsis is seen in the first week of life. Late-onset

sepsis occurs between days 8 and 89.

Neonatal sepsis is the clinical syndrome of

bacterimia characterized by systemic signs and

symptoms of infection in the first month of life.

Classification

Early- onset neonatal sepsis

Late- onset neonatal sepsis

Etiology and risk factors

Early-onset neonatal sepsis most often appears

within 24 hours of birth. The baby gets the infection

from the mother before or during delivery.

Babies with late-onset neonatal sepsis get infected

after delivery. The following increase an infant's risk

of sepsis after delivery:

Having a catheter in a blood vessel for a long time

Staying in the hospital for an extended period of time

Clinical manifestations

Body temperature changes

Breathing problems

Diarrhea

Low blood sugar

Reduced movements

Reduced sucking

Seizures

Slow heart rate

Swollen belly area

Vomiting

Yellow skin and whites of the eyes (jaundice)

Diagnosis Blood culture

C-reactive protein:.

Complete blood count (CBC)

Micro ESR: 13-15 mm is abnormal

A lumbar puncture (spinal tap

If the baby has a cough or problems breathing, a chest x-ray will be taken.

Urine culture tests

serum procalcitonin polypeptide

immunologic studies

Treatment

Babies in the hospital and those younger than 4 weeks

old are started on antibiotics before lab results are back.

(Lab results may take 24-72 hours.)

Older babies may not be given antibiotics if all lab

results are within normal limits. Instead, the child may

be followed closely on an outpatient basis.

Babies who do require treatment will be admitted to the

hospital for monitoring.

Antibiotics according to the culture sensitivity reports.

Complications

Disability

Death

Prevention

Preventive antibiotics may be given to pregnant

women who have chorioamnionitis, Group B

streptococcus, or who have previously given birth

to an infant with sepsis due to the bacteria.

Preventing and treating infections in mothers,

providing a clean birth environment, and

delivering the baby within 24 hours of rupture of

membranes, where possible, can all help lower the

chance of neonatal sepsis.

NURSING MANAGEMENT Policy guidelines:

Handwashing:

Housekeeping routines:

Disinfection of equipments:

Procedures:

Surveillance of bacterial flora:

Fumigation

Isolation policies

Prevention of injuries

NURSING DIAGNOSES

Infection related to presence of microorganism in the body

Hyperthermia or hypothermia related to infectious process

Impaired skin integrity related to presence of lesions

Delayed growth and development related to inadequate feeding and presence of infection.

Impaired parenting related to separation secondary to admission in the NICU.

Parental anxiety related to disease condition of the newborn

Impaired gas exchange related to immaturity of the lungs and presence of respiratory infections

Impaired tissue perfusion related to lack of oxygenation secondary to accumulated secretions incase of respiratory infections.

Ineffective airway clearance related to accumulation of secretions due to respiratory infections.

Risk for fluid and electrolyte imbalance related to poor feeding

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