Neonatal sepsis

CONTENT
UNIT 15.2 MAJOR PROBLEMS OF NEWBORN
NEONATAL SEPSIS
Definition:
When pathogenic organisms gain access into the blood stream, they may cause an overwhelming
infection without much localization (septicemia), or may get predominantly localized to the lung
(pneumonia) or the meninges (meningitis). Systemic bacterial infections are known by the
generic term neonatal sepsis (NNS), which incorporates septicemia, pneumonia and meningitis
in the newborn baby.
Prevalence :Worldwide neonatal sepsis accounts for 15% of neonatal death. (UNICEF 2015).
According to the survey conducted by Health Policy and Planning Department of Government of
Nepal in 2014 neonatal sepsis accounts for 47.7% of the neonatal death in Nepal.
Types of Neonatal Sepsis
On the basis of onset of symptoms , neonatal sepsis is divided into:
1. Early onset neonatal sepsis : Symptoms develop within 72 hours of life due to intrauterine
infections, maternal conditions like prolonged rupture of membrane, foul smelling liquor
,maternal genital tract infections,multiple per vaginal examination and maternal fever. It
manifests frequently as pneumonia and less commonly as septicaemia and meningitis.
2. Late onset neonatal sepsis: It develops after 72 hours( may be at the end of first week or in
second week). It is acquired as nosocomial infections from the baby care area or due to in
appropriate neonatal care, low birth weight, lack of breast feeding and superficial infections.
Causes / Risk factors
Escherichia coli, Staphylococcus aureus and Klebsiella sp. are the predominant organisms.
Organisms like Acinetobacter, Pseudomonas and coagulase negative staphylococci are also
important pathogens in hospital acquired infections.
The risk factors associated with development of neonatal sepsis are:
1.Maternal risk factors
 Maternal history of uterine infection i.e. chorioamnionitis
 Premature rupture of membranes and prolonged rupture of membranes for more than 24
hours
 Maternal infection or fever including STIs.
 Unclean delivery
 Prolonged, complicated or difficult labor/birth
2. Newborn risk factors

 Low birth weight, prematurity
 Fetal distress
 Birth asphyxia and resusucitation
 Congenital anomalies i.e. trachea-esophageal atresia
 Lack of breast feeding and immunocompromised baby
 Performance of invasive procedure without aseptic technique
 Sex : male
Pathophysiology
Micro-organisms invade the body tissue
Newborn exhibits immune response and immune response activates the biochemical
cytokines and inflammatory mediators
Increased capillary permeability and vasodilation endothelial damage
Fluid seeps from capillaries activation of
coagulation system which begins to form
clots whether or not bleeding present
filling of fluid into lungs
In meningitis, fluid accumulates
collapsed alveoli inability for O2 and CO2 exchange in subarachnoid space
lung failure tissue becomes less perfused increased intracranial pressure
and acidotic
infarction and necrosis of brain tissue
multiple organ failure
different neurological manifestation
Clinical Features
1. Cardiovascular symptoms: Pallor, hypotension and abnormal heart beat.
2. Respiratory symptoms: Apnea, tachypnea, cyanosis, grunting, retractions.
3. Nervous system: Diminished activity, lethargy, hyporeflexia, poor cry, coma, irritability,
seizures , bulging fontanel.

4. Gastrointestinal symptoms: poor feeding , diarrhoea, vomiting, abdominal distention,
hepatomegaly and poor weight gain.
5. Hematopoeitic system: Jaundice, pallor, purpura, petechiae, ecchymosis, splenomegaly and
bleeding.
Diagnostic Measures
 History of maternal condition at antenatal,intranatal and postnatal period,feeding to child
,delivery history , newborn condition at birth, practice of newborn care and congenital
anomalies..
 Newborn examination for clinical features.
 Blood test: total count, differential count, culture, haemoglobin and peripheral smear
 Sepsis screen should be performed in equivocal cases. A panel of tests (sepsis screen)
consisting of total leukocyte count (TLC; <5000/mm3), absolute neutrophil count (ANC;
<1800/mm3), immature to total neutrophil ratio (I/T ratio; more than 20%), CRP (more than
1 mg/ dl) and micro ESR (15 mm or more in the first hour) constitutes a useful sepsis screen
for clinically doubtful cases. Sepsis screen is considered positive if two of these parameters
are positive. Value of sepsis screen is more for exclusion of diagnosis of neonatal sepsis.
 Chest X-Ray : This is a routine component of neonatal septic screen, and is mandatory in all
infants with respiratory distress, apnoea or continuing oxygen requirement.
 Lumbar puncture and CSF culture should be performed in all babies suspected with neonatal
sepsis.
CSF indices in meningitis
Condition Physical
Characteristic
Cytology
cell/Cumm
Protein (gm/L) Glucose
(mmol/L)
Normal Clear and
colourless
Lymphocytes 0
to 32
0.1 to 0.4 2.5 to 4.2
Bacterial Yellowish and
turbid
Lymphocytes 5
to 50
0.5 to 2.0 <2.0
Tuberculos Colourless spider
web
Lymphocytes
100 to 300
>0.5 <2.0
Viral Clear Lymphocytes 10
to 100 after 36
hour
0.1 to 0.6 Normal
Fungal Clear Lymphocytes 50
to 500
Increased Decreased

Management
A. Management at home or community
 Advice the mother to keep the baby warm. Kangaroo mother care is a useful modality to
maintain temperature of small and sick neonates.
 Encourage for feeding if possible.
 Give first dose of antibiotics
 Counsel the mother on baby's condition and refer immediately to higher center.
B. Management at hospital
Institution of prompt treatment is essential for ensuring optimum outcome of neonates with
sepsis. Supportive care and antibiotics are the two equally important components of treatment.
1. Supportive care:
Good supportive care requires meticulous attention to various aspects:
 Provide warmth to ensure normal temperature (36.5°-37.5°C). Baby should be nursed in a
warm environment. Heat sources can be used to keep the baby warm. Body temperature
should be monitored frequently.
 Start oxygen by hood or mask, if the baby is cyanosed or grunting. Provide bag and mask
ventilation if baby is apneic or breathing is inadequate. Instilling normal saline drops in
nostrils may help clear the nasal block.
 Establish IV line and give fluid at maintainance volume according to the baby's age for the
first 12 hours. Infuse 10% of glucose at dose of 2 ml/kg stat. The amount of IV fluid for a
1 day old baby with birth weight less then 1500gm is 60 ml per kg of 10% dextrose.
Similarly, if the baby is 7 days old with birth weight less than 1500gm, then 150 ml per kg
of 10% dextrose is given.
 Assess capillary refill time by pressing at sternum (normally <2-3 seconds) and also assess
the skin color. If refill time is delayed then infuse normal saline or Ringer lactate 10 ml/kg
over 5-10 minutes. Repeat the same dose if perfusion continues to be poor. Dopamine and
dobutamine may be required to maintain normal perfusion.
 If capillary refill time is normal, start on maintainance fluid.
 Enteral feeding is to be avoided if baby is very sick or has abdominal distention.
Maintainance of fluid should be done by IV infusion.
 Vitamin K 1 mg IM should be given to prevent bleeding disorders.
 Measure haemoglobin every 3 days during hospitalization and again at discharge.Transfuse
blood, if baby has a low hematocrit (less than 35-40%) and haemoglobin less than 10
mg/dl.
 Provide gentle physical stimulation if apnea is present.
 Correction of hypoglycaemia with glucose infusion: 2 ml/kg of 10% glucose, through an
intravenous line is given over 2–3 minutes. Glucose infusion is continued at a rate of 4-6

mg/kg/min or 60 ml/kg/day. Blood glucose should be maintained at 70–100 mg/dl. The
infusion may be stopped after hypoglycaemia is corrected.
 For convulsions :
 Intravenous administration of phenobarbitone 20 mg/kg body weight slowly over a
period of 10–15 minutes is effective. After 1 hour, if seizures still persist, another
20mg/kg body weight IV of phenobarbitone is given. If seizures still persist, another 10
mg/kg IV of phenobarbitone can be given . A maintenance dose of 2.5–4 mg/kg body
weight per day administered orally or intramuscularly for at least a period of 2 weeks or
even longer.
 In resistant cases when convulsion reoccur within 6 hrs then IV phenytoin (Dilantin), 20
mg/kg. Mix phenytoin in 15 ml of normal saline and infuse at the rate of 0.5 ml per
minute over 30 minute. Do not use other fluid to infuse phenytoin as it causes phenytoin
to crystallize.
 If baby has any 3 of the following conditions, presume early sepsis and start the treatment :
 Prematurity or low birth weight (1800gm).
 Maternal fever or UTI prior to delivery for greater than 2 weeks.
 Foul smelling liquor
 Prolonged rupture of membrane
 APGAR score 3 or less than 3 at 5 minutes after birth.
 History of repeated vaginal examination before delivery.
2. Antibiotic therapy:
Antibiotic therapy should cover common causative organisms like E.coli, Staphylococcus
aureus and Klebsella pneumonia. A combination of Ampicillin and Gentamycin is
recommended for treatment of sepsis and pneumonia. In case of suspected meningitis,
Cefotaxime should be used along with aminoglycosides .The antibiotic choice depends upon
the causative organisms detected on the culture.
Antibiotic Each dose Frequency
Less
than 7
days
of age
More
than 7
days of
age
Route Duration Remarks
1. Septicemia or pneumonia
a. Injection
Ampicill
in
50
mg/kg/dose
12hourly 8hourly IV, IM 7-10 days May switch over to
oral Amoxicillin (15
mg/kg/dose,
8hourly) after 3-4
days of parenteral
ampicillin provided
if infant is

improving.
AND
b. Injection
Gentami
cin
2.5
mg/kg/dose
12hourly 12hourl
y
IV,IM 7-10 days May give
5mg/kg/dose as a
single IM dose every
24hrs for neonates
of all ages
2. Meningitis
a. Injection
Ampicill
in
100mg/kg/
dose
12hourly 8hourly IV/IM 3 weeks
AND
b. Injection
Gentami
cin
2.5
mg/kg/dose
12
hourly
8 hourly IV/IM 3 weeks
AND
c. Injection
Cefotaxi
me
25
mg/kg/dose
12hourly 8hourly IV/IM 3 weeks
Source : Antibiotic Use for Sepsis in Neonates and Children : 2016 Evidence Update, Division of
Clinical Pharmacology, Children's National Health System, Washington.DC.USA.
 If the condition is improved after 3 days of treatment with antibiotics , continue treatment
until the dose gets completed.
 Observe the baby for 24 hours after discontinuing the antibiotics. If baby is well and no
other problems then discharge the baby.
 If signs of sepsis reoccur then repeat the culture and treat with additional antibiotics.
C. Nursing management
1. Assessment
-Assess the child condition ,vital signs, capillary refill.
-Asses for signs and symptoms of sepsis and shock.
-Review of lab investigations.
-Assess for presumed sepsis conditions that may require treatment.
2. Nursing diagnosis
-Increased body tempeature related to infectious procress.
-Impaired gas exchange related to decreased ventilation secondary to inflammation and
infection of air spaces
-Ineffective breastfeeding related to respiratory distress secondary to disease condition.
-Inadequate nutrition: less than body requirement related to ill status of child.
- Risk for injury related to convulsion.
-Anxiety related to disease condition

3. Nursing Interventions
 Maintain body temperature
 Monitor body temperature regularly and administer the prescribed antipyretics.
 Provide tepid sponging, cross ventilation, remove extra clothes, administer IV fluid as
prescribed.
 Facilitate respiratory efforts:
 Maintenance of warm, humid and well- ventilated environment.
 Position of child should be changed frequently to prevent pooling of secretions in lungs.
 Oxygen administration as per need and suction secretions.
 Provide adequate nutrition:
 Provide feeding through NG tube until tolerated according to the demand of the baby.
 Enteral feeding has to be discontinued if abdominal distention is present and nutrition of
the baby can be maintained through IV fluids.
 Breastfeeding can be encouraged when the baby's condition begins to improve.
 Prevention of possible injury.
 Keep close observation of the child.
 Maintain safe environment by keeping the side rails up.
 Administer anticonvulsants drugs as prescribed.
 Avoid restraining the baby and interfering during convulsions.
 Parent education:
 Enforce to complete entire course of antibiotics.
 Assess improving status of child.
 Teach about danger signs of newborn and to have prompt visit to health facility if present
any.
 Advice to keep child warm.
 Teach about infection prevention measures , hand hygiene, wearing masks and gown
while handling baby.
 Encourage vaccination of the baby according to EPI schedule.
Prevention of Neonatal Sepsis:
 Treatment of mother's infection during pregnancy.
 Exclusive breastfeeding and no prelacteal feeding.
 Six clean practice for the delivery: clean hand, clean perineum, clean delivery surface, clean
cord cutting, clean cord tie and clean cord care.

 Hand washing before handling the babies.
 Hygiene of the baby (Sponging, clean clothing).
 Avoid unnecessary invasive procedure. Aseptic technique in invasive procedure.
 Clean environment of neonatal unit and use of sterile gowns before entering the unit and
while handling the baby. Cots and incubators should be washed with soap and water and
sterilized with cetrimide solution.
 Isolation of infected babies.
 Prophylactic antibiotics for high risk babies. i.e. preterm babies or birth weight less than 2
kg, maternal fever in preceding 2 weeks, foul smelling liquor, prolonged rupture of
membrane for more than 24 hrs,
 Limitation of visitors and handling of the baby.
 Immunization
 Parental education about danger signs of newborn and importance of hospital visit.
Prognosis: The outcome depends upon weight and maturity of the infant, type of etiologic agent,
its antibiotic sensitivity pattern and adequacy of specific and supportive therapy. The early-onset
septicemia carries risk of adverse outcomes. The institution of sepsis screen for early detection of
infection, judicious and early antimicrobial therapy, close monitoring of vital signs and intensive
supportive care are the most crucial factors responsible for a better outcome.
Summary
When pathogenic organisms gain access into the blood stream, they may cause an overwhelming
infection without much localization (septicemia), or may get predominantly localized to the lung
(pneumonia) or the meninges (meningitis) is called neonatal sepsis. Escherichia coli,
Staphylococcus aureus and Klebsiella sp. are the predominant organisms for causing neonatal
sepsis. It is characterised by pallor, apnea, tachypnea, bulging fontanel, poor feeding and
multiple organ failure. it can be diagnosed through sepsis screen and CSF analysis. Appropriate
antibiotics according to etiological factors can be given and necessary supportive care are to be
provided for its management. Prognosis depends upon weight , maturity of the infant and the
etiological agent.

References
 Subedi, D.,& Gautam ,S.(2017) .Midwifery nursing part III ( 3rd ed.). Medhavi Publication
,Baneshwor, Kathmandu,Nepal (pp:194-198).
 Shrestha,T.(2016). Essential child health nursing(2nd
ed.).MedhaviPublication, Jamal,
Kathmandu, Nepal (pp: 89-92).
 Datta,P.(2014).Pediatric nursing(3rd
ed.). Jaypee Brothers MedicalPublishers,New
Delhi,India(pp: 101-102).
 Koner,H.(Eds.).(2013).DC Dutta's textbook of obstetrics(7th
ed.).Jaypee Brothers Medical
Publishers,New Delhi,India(pp: 487-488).
 Paul,V.K & Bagga.A.(2013).Ghai essential paediatrics(8th
ed.).CBS Publishers and Distributors,
New Delhi, India(pp: 552-554).
 Sharma,R. (2013). Essential Paediatrics for Nurses( 2nd ed.). Jyapee Brothers Medical Publisher
, New Delhi,India( pp:223-230).
 Thakur, L .(2012).Advanced child health nursing (3rd ed.).Ultimate Marketing ,Lazimpat
,Kathmandu,Nepal (pp: 66-69).
 Managing newborn problems.(2003).Geneva:Department of reproductive health and
research,WHO.

SAMPLE QUESTION
Subject : Midwifery II Total Hour :30 min
Course no : BSN19 Total Mark :10
Pass Mark : 4
Candidates are required to give answers in their own words as far as practicable.
The figures in the margin indicates full marks.
Attempt all questions.
Objective Type of Question
1.Write 'T' for true and 'F' for false for the following statements in the box. 1X2=2
a. The most common causative agent for neonatal sepsis is E.coli.
b. ANC greater than 5000/mm3
indicates positive sepsis screen.
2.Fill in the blanks with suitable answer. 1X2=2
a. Capillary refill in newborn is assessed by pressing…………….
b. Late onset neonatal sepsis appears………………..
Subjective Type of Question
Long Answer Type Question
Answer the following question.
a. What isneonatal sepsis?Discussthe preventive measuresof neonatalsepsis? 2+4=6

Neonatal sepsis

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