Sepsis of newborns
Sepsis of newborns is a serious infectious process of children of the first four weeks of life, which is caused by the introduction into the body of conditionally pathogenic microbes and the development of severe acyclic infection of the whole organism. The basis for the development of sepsis of newborns is dysfunction of immunity, mainly phagocytic part of it.
The starting impetus to the development of neonatal sepsis is a purulent focus, from which microorganisms enter the bloodstream of the patient due to untenable anti-infection protection, this is called bacteremia. Bacteria are carried with blood to other organs. In connection with the development of a systemic inflammatory response, multi-organ failure is manifested, expressed by disturbances of the hemostasis system, damage to the microcirculatory bed. In 30-40% of cases, the sepsis of newborns leads to death.
Causes of neonatal sepsis
Which particular pathogen causes sepsis in newborns will depend on the time of infection, as well as the site of infection. If this happened in childbirth, it is likely that the cause was the conditionally pathogenic flora of the intestine and the genital organs of the mother. The disease in this case starts in the first two - three days after birth.
Late sepsis of newborns is often due to Group B streptococci in the birth canal. Klebsiella, enterobacteria, staphylococci, serrations, Pseudomonas aeruginosa, E. coli are frequent causative agents of sepsis. Pseudomonas spp., Klebsiella spp., Enterobacter spp. And other gram-negative flora, can cause sepsis in children already in the intensive care unit. Infection occurs through medical equipment, hands of medical workers, venous lines. Among the viruses that can cause sepsis of newborns should be noted cytomegalovirus and enteroviruses. In addition, there is a sepsis of fungal etiology. Often there is a change in the prevailing pathogen during the period of the child's illness or even confusion of the flora. If the entrance gate for microbes is the umbilical wound, sepsis is more often than staphylococcal etiology. Less often, its cause is E. coli. Cutaneous sepsis of newborns is more likely to cause staphylococci and streptococci. Hospital flora penetrates the child's body through venous catheters, drains, intubation tubes, catheters for sanitation.
After birth, a newborn is faced with an abundance of microorganisms around. His skin, mucous membranes, intestines begin to be populated with microbes. But not everyone is sick with sepsis. Children who were born before 37 weeks of gestation and small children are usually affected. Boys get sick more often. Low scores on the Apagr scale in the fifth minute are also a predisposing factor of infection. The untreated maternal urinary tract infections, as well as the carriage of Group B Streptococcus, increase the risk of sepsis in their children. If the mother has a fever, the water has been swallowed ahead of time( especially with preterm labor), and the anhydrous interval is more than 18 hours, the chance of sepsis in their children is increased.
Symptoms and signs of neonatal sepsis
Regardless of the form of neonatal sepsis, the severity of the child's condition is characteristic. Do termless children are more likely to have a fever. Sepsis of premature babies, as well as minor ones, is often accompanied by hypothermia. The skin of children is pale, marbled, with a dirty-gray color. The features of the child's face are pointed. Rapidly progressive jaundice can start early. The child's behavior changes. He can be both listless and oppressed, and irritated, restless. Sometimes there are cramps, some children fall into a coma. Spontaneous bleeding of mucous membranes, bleeding from places of blood sampling is characteristic. Rapid or rare breathing, weakening of breathing and wheezing speak about the progression of respiratory failure.
An increase or decrease below normal heart rate, a drop in blood pressure, edema and hepatomegaly indicate an increase in heart failure. Renal failure manifests itself as a marked decrease in diuresis. When sepsis, children do not eat well, their stomach is swollen, food is eaten in the stomach, there may be frequent regurgitation, vomiting and anorexia. Also characteristic for sepsis is a pronounced venous network on the abdomen, an enlarged spleen. Sometimes sepsis leads to intestinal paresis. In the stool, you can detect various impurities, such as mucus or greens.
Among secondary( metastatic) foci of sepsis of newborns, most often there is purulent meningitis, pneumonia, osteomyelitis, enterocolitis. Less common are kidney and liver abscesses, arthritis, mediastinitis, carditis, pyelonephritis and others.
Diagnosis of neonatal sepsis
At the first stage of diagnosis of sepsis of newborn infants, it is necessary to identify foci of infection. It also happens that the primary focus of infection is absent in the mother's body or in the placenta. Especially it concerns early sepsis of newborns. Careful collection of anamnesis from the mother, studying the details of the course of labor, detailed examination of the child, assessment of the dynamics of the symptoms are the necessary stages of diagnosis.
X-ray examination of the chest and abdominal organs will help to identify pneumonia, carditis, enterocolitis, peritonitis. Spinal puncture is indispensable in the diagnosis of meningitis. To reveal arthritis or osteomyelitis will also help X-ray study.
At the second stage of the diagnosis, it is necessary to evaluate the adequacy of the operation of all body systems. It is necessary not only to determine the severity of organ failure, but also to monitor vital indicators in time for timely treatment.
One of the first laboratory studies is an expanded blood test. Anemia, a decrease or increase in the number of leukocytes and neutrophils, a decrease in platelets - are important criteria in the diagnosis of neonatal sepsis.
Gases of blood are necessarily investigated. Sepsis is characterized by a decrease in oxygen saturation, respiratory or mixed acidosis.
Electrocardiographic examination of the heart will show electrolyte disturbances. Ultrasound of the heart is characterized by a decrease in cardiac output with the development of heart failure.
To assess the work of the kidneys, you can by the results of blood tests for urea and creatinine( with renal insufficiency, they increase).It is necessary to carefully evaluate the amount of excreted urine during the day.
Hepatic insufficiency can be diagnosed by results of tests for bilirubin and transaminases.
To investigate the disorders of functions from the nervous system, neurosonography is most often used. It provides an opportunity to see signs of brain edema, hydrocephalic syndrome, intraventricular hemorrhage.
You can not do without coagulogram research in order to detect violations of the hemostatic system in time, which threaten the life of a sick child.
Assessment of the systemic inflammatory response( SVO) is the third stage of diagnosis. Its criteria include temperature in the armpit( above 37.5 ° C or below 36.2 ° C), changes in the general blood test, an increase in the C-reactive protein in the blood of the child above 6 mg / l, an increase in the procalcitonin greater than 2 ng /Ml and an increase in the blood level of interleukin-8 is greater than 100 pg / ml.
If the child of the first three days of life has 3 or more signs of CBO, then it is possible to suspect sepsis and immediately begin treatment. In children older than four days of life, the diagnosis of "sepsis" is made when there are not only three signs of NWS.It is necessary to identify the primary infectious focus, as well as violations of the functions of at least two systems of the body.
A very important stage in the diagnosis of the disease is a microbiological study of various body environments. This is done by sowing blood, spinal cord fluid, separated from the foci, aspirate from the stomach and trachea. It must be remembered that sowing blood can give false positive and false negative results. It is necessary to take the material for research, observing all the rules, so that there are fewer mistakes.
Treatment of neonatal sepsis
All forms of sepsis in newborns are treated in the intensive care unit or in the department of neonatal pathology.
It is recommended to breastfeed a child with sepsis for breast milk. If his condition allows, then you can put the baby to the chest. If sucking from the breast requires a lot of effort from the baby, then it is worth feeding the expressed breast milk from a bottle or a beaker. When a child can not suck because of his condition or too small gestational age, the expressed breast milk is injected into the stomach through the probe. If there is no maternal milk, then the baby should be fed with milk formulas. They can be sour-milk, low-lactose, lactose-free, enriched with prebiotics and other components. The mixture is selected depending on how the child absorbs nutrition, whether there is a bloating, whether the stool is broken. Premature babies should be fed with special milk formulas that contain split protein for better digestion.
In the midst of a child's illness, it is better to put it into a kuvez. Humidity in the kuveze is not lower than 60%, and temperatures of at least 30 ° C are important components of proper care for a sick child.
Directly treating neonatal septicemia occurs simultaneously in two ways. The first is the effect directly on the pathogen that caused the disease. And the second is the correction of violations of the functions of all organs involved in the process.
As soon as possible, antibiotic therapy is prescribed. Depending on the form of neonatal sepsis, a choice is made in favor of one or another drug. Until the agent is isolated, the antibiotic or a combination thereof that will be most effective against the suspected microorganisms is prescribed. When the pathogen is known, the antibiotic is given a narrower spectrum of action. The choice is made in favor of drugs that easily penetrate into the cerebrospinal fluid, into the brain substance, as well as into the bone and lung tissue. In the priority are the drugs that are the least toxic for children. Preferably, antibiotics are administered intravenously.
Most often, treatment begins with antibiotics belonging to the class of penicillins( Oxacillin, Ampicillin, Amoxiclav).Usually they are combined with aminoglycosides, which include Gentamicin, Netromycin, Amikacin. Cephalosporins are also used. In case of ineffectiveness of starting antibiotics, Vancomycin, Meronem, Linezolid are appointed. You can be sure about the effectiveness of ongoing activities, if after two days from the beginning of treatment the child is better. If the symptoms of SVO and organ failure persist or increase, it is necessary to change the antibiotic.
In addition to antibiotics for sepsis of newborn children, therapy aimed at correcting immunity, intravenous fluids( glucose, salts, vitamins), anti-shock therapy and restoration of impaired functions of internal organs are carried out. For the correction of immunity, human immunoglobulins( Pentaglobin) are used. The mortality of children receiving this treatment is significantly reduced. This is especially important when sepsis of premature babies, because the immune system is initially weakened. Intravenous infusions of glucose-salt solutions help to fill a lack of fluid, improve blood properties. If the food is not absorbed through the mouth, it is necessary intravenously to inject the child with proteins, fats and carbohydrates, which is called parenteral nutrition.
Anti-shock treatment of neonatal sepsis includes therapy with drugs that maintain blood pressure at a normal level( Dopamine, Dobutamine, Adrenaline).Sometimes it is necessary to supplement the treatment with hormonal drugs( Hydrocortisone).This increases the survival rate of sick children. To correct the disorders of the blood coagulation system, children are poured fresh frozen plasma. It helps to make up for the lack of clotting factors that is observed in sepsis.
In addition to the therapy of life-threatening conditions, antifungal agents( Dufleukan), vitamin therapy, interferon therapy( Viferon) are simultaneously administered.
Prevention of neonatal sepsis
Prevention of neonatal sepsis is a series of activities aimed at preventing the infection of a child, beginning with pregnancy. Preparing for pregnancy, preventing abortion, examining a woman before conception of a child - all this will help to ensure that this pregnancy is without complications.
Thorough monitoring of the condition of a pregnant woman, detection of bacteria in urinalysis and urinary tract infection, carriage of group B Streptococcus, timely sanitation of foci of infection in the mother's body can reduce the risk of infection of a newborn child. There are recommendations for the introduction of antibacterial drugs to women who are carriers of Group B Streptococcus. Considering that a significant proportion of affected children were born prematurely, it is necessary to prevent the birth of children before the deadline with all their efforts.
One of the most difficult tasks in the intensive care units of newborns is the fight against nosocomial infections. To prevent infection of children must strictly comply with sanitary and hygienic measures in the hospital. Training of medical personnel, the proper technique of washing hands, the use of skin antiseptics and disposable gloves will reduce the risk of transferring dangerous microorganisms to the child. It is necessary to encourage the child's stay with his mother, putting it on the mother's abdomen after childbirth so that it is seeded by the maternal flora from birth, and not from the hospital. In intensive care, the mother should be involved in taking care of the baby, feeding him, using the "kangaroo" method for nursing preterm infants. Encouraging breastfeeding, assisting and educating mothers in breastfeeding skills from the first days after giving birth contribute to the normal development of anti-infection protection.
