NEONATAL SEPSIS AND
MENINGITIS
Dr. Muse Mohamed Ahmed
Hospital Administrator at SOS Children’s
Village and MD for Pediatrics
Introduction
• Neonatal sepsis is a clinical syndrome of systemic illness
accompanied by bacteremia occurring in the first month of
life
• Systemic and local infections (lung, cutaneous, ocular,
umbilical, kidney, bone-joint, and meningeal) are common in
the newborn period.
• Infection may be acquired in utero through the
transplacental or transcervical routes and during or after
birth.
Introduction
• Ascending infection through the cervix,
with or without rupture of the amniotic
fluid membranes, may result in
amnionitis, funisitis (infection of the
umbilical cord), congenital pneumonia,
and sepsis.
Introduction
• The bacteria responsible for ascending
infection of the fetus are common
bacterial organisms of the maternal
genitourinary tract, such as group B
streptococci, Escherichia coli,
Haemophilus influenzae, and Klebsiella
Introduction
• The sixfold-higher rate of sepsis in preterm infants relates to
the more immature immunologic systems of preterm infants
and to their prolonged periods of hospitalization, which
increase risk of nosocomially acquired infectious diseases.
• Severely premature infants are at even greater risk secondary
to less effective defense mechanisms and deficient transfer
of antibodies from the mother to the fetus.
Introduction
• Neonates in the neonatal intensive care
unit live in a hostile environment, with
exposure to endotracheal tubes, central
arterial and venous catheters, and blood
draws, all predisposing to bacteremia and
meningitis
Introduction
• Bacterial sepsis and meningitis often are linked closely
in neonates.
• Despite this association, the incidence of meningitis
relative to neonatal sepsis has been on a steady
decline.
• The incidence of meningitis is approximately 1 in 20
cases of sepsis.
• The causative organisms isolated most frequently are
the same as for neonatal sepsis:
Definitions
• Neonatal meningitis is a serious medical condition in infants
that is rapidly fatal if untreated.
• Meningitis is an inflammation of the meninges, the
protective membranes of the central nervous system, is more
common in the neonatal period.
• Symptoms seen with neonatal meningitis are often
unspecific and may point to several conditions, such
as sepsis .
• These can include fever, irritability, and dyspnea.
Definitions
• Neonatal sepsis is a clinical syndrome of bacteraemia
characterized by systemic signs and symptoms of infection in
the first four weeks of life.
• Pathogens invade neonatal blood circulation (bacteremia),
growth, reproduce and make toxin so that patients appear
severely infected toxicosis symptoms.
• It is a total body inflammatory reaction.
• It can cause death if not recognized and treated properly
Definitions
• SIRS
– hyperthermia >38◦C or hypothermia < 36◦C
– Tachycardia
– Tachypnea
–Abnormal WBC(>12,000/mm3 or <4,000/
mm3 or >10% bands)
Mechanism of neonatal sepsis
• Neonatal sepsis presents during two periods.
1. Early-onset sepsis (birth to 7 days) often begins in
utero and usually is a result of infection caused by the
bacteria in the mother’s genitourinary tract.
– Organisms related to this sepsis include group B
streptococci, E. coli, Klebsiella, L. monocytogenes.
– Develops Meningitis in 30% of cases
Mechanism of neonatal sepsis
2. Late-onset sepsis (8 to 28 days) usually occurs in a healthy
full-term infant who was discharged in good health from the
normal newborn nursery.
– Hematogenous seeding may result in focal infections, such as
meningitis (in 75% of cases).
– Osteomyelitis (group B streptococci, Staphylococcus aureus)
– Arthritis (gonococcus, S. aureus, Candida albicans, gramnegative bacteria)
– And urinary tract infection (gram-negative bacteria).
Pathway of infection
Antepartum infection
Intrapartum infection
Gravida bacteremia
Premature rupture
of membranes
Placenta
Elongation of labor
Infect fetus
Birth canal bacteria ascending
dirty amniotic fluid
Postpartum infection
Umbilicus
Skin
Mucosa
Nail bed
Respiratory
tract
Digestive tract
Urinary tract
Bacteria invade blood
Sputum aspirator
Nebulizer
Incubator
Unsuitable
disinfection
CLINICAL FEATURES
1. Early-onset sepsis (birth to 7 days) is an
overpowering multi-organ system disease.
– Early manifestations—grunting, poor feeding, pallor,
apnea, lethargy, hypothermia, or an abnormal cry—
may be nonspecific.
–Profound neutropenia, hypoxia, and hypotension may
be present
CLINICAL FEATURES
Late-onset sepsis (8 to 28 days) usually occurs in a
healthy
–full-term infant who was discharged in good health
from the normal new-born nursery.
– Clinical manifestations may include lethargy, poor
feeding, hypotonia, seizures, bulging fontanelle,
fever, and direct-reacting hyperbilirubinemia
CLINICAL FEATURES
• Suspect meningitis if signs of serious bacterial infection are
present, particularly if any one of the following is present:
• The infant is:
– Drowsy, lethargic or unconscious
– Convulsing
– Has a bulging fontanelle
– Irritable
– Has a high-pitched cry
Diagnosis
• The child’s history helps determine the
likely source of sepsis.
• Always fully undress the child and
examine carefully for signs of local
infection before deciding that there is no
other cause.
Diagnosis
• On examination, look for:
– fever with no obvious focus of infection .
– negative blood film for malaria
– no stiff neck or other specific sign of meningitis, or negative
lumbar puncture for meningitis
– confusion or lethargy, signs of systemic upset (e.g. inability to
drink or breastfeed, convulsions lethargy or vomiting everything,
tachypnoea)
– Purpura may be present.
Diagnosis
• In some severe cases, a child may present
with signs of septic shock:
–cold hands with poor peripheral perfusion
and increased capillary refill time (> 3 s),
fast, weak pulse volume, hypotension and
decreased mental status.
Investigations
• The investigations will depend on presentation
but may include:
–full blood count
–urinalysis (including urine culture)
–blood culture
–chest X-rays.
–ESR and CRP
–CSF analysis
Treatment
• Start the child immediately on antibiotics.
– Give IV Ampicillin at 50 mg/kg every 6 h for 7–10 days.
plus
– IV Gentamicin 7.5 mg/kg once a day for 7–10 days
– Alternatively, give ceftriaxone at 80–100 mg/kg IV once
daily over 30–60 min for 7–10 days.
– When staphylococcal infection is strongly suspected, give
flucloxacillin at 50 mg/kg every 6 h IV plus IV gentamicin at
7.5 mg/kg once a day.
Treatment
– Give oxygen if the child is in respiratory distress or
shock.
–Treat septic shock with rapid IV infusion of 20 ml/kg
of normal saline or Ringer’s lactate.
–Reassess. If the child is still in shock, repeat 20 ml/kg
of fluid up to 60 ml/kg.
– If the child is still in shock (fluid-refractory shock),
start adrenaline or dopamine if available.
Supportive care
• If the child has a high fever (≥ 39 °C) that is
causing distress or discomfort, give
paracetamol or ibuprofen.
• Monitor Hb and, when indicated, give a blood
transfusion of 20 ml/kg fresh whole blood or
10 ml/kg of packed cells, the rate of infusion
depending on the circulatory status.
Monitoring
• The child should be checked by a nurse at least
every 3 hrs and by a doctor at least twice a day.
• Check for the presence of new complications,
such as shock, cyanosis, reduced urine output,
signs of bleeding (petaechiae, purpura, bleeding
from venepuncture sites) or skin ulceration.
Prevention
• Exclusive breastfeeding
• Keep cord dry
• Hand washing by care givers
• Hygiene of baby
• No unnecessary intervention
• Better management of IV lines
• Disinfection of equipment's
References
• Nelson Pediatric Book
• Hospital Care For Children book
• Neonatology Management, Procedures,
On-Call Problems, Diseases, and Drugs
Book