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Perinatal infection :tiger: (:star: Gonococcal infection (:green_heart: Rx…

- - - - Single one-time dose of Ceftriaxone 25-50 mg/kg IV or IM (Max 125 mg)
      - NSS eye irritations immediately & frequently until D/C is eliminated
      - :cry:Topical ATB alone — inadequate & not necessary; tho it’s not harmful & it’s routine practice
      - In practice ➯ Continue ATB 48-72 hrs to ensure Negative C/S of sterile site
    - - Ceftriaxone 25-50 mg/kg/day IV or IM OD x 7 days or
        Cefotaxime 25 mg/kg q 12 hrs if Hyperbilirubinemia
      - If it’s meningitis ➯ Continued Rx for total 10-14 days
    - - 0.5% Erythromycin ophthalmic or
        1% Tetracycline ophthalmic ointment or
        1% silver nitrate
      - :warning: not prevent chlamydial ophthalmia & nasopharyngeal colonization
- - - - Begins a few days - wks after birth
        
        Ocular congestion
        
        Edema
        
        D/C
      - Scars & Pannus are rare
    - - Afebrile, insidious onset 2-19 wks after birth
      - Repetitive staccato cough, Tachypnea & rales (but not always present)
      - May found nasal stiffness & otitis media
      - Severe pneumonia:
        infants & immunocompromised adults
        
        Wheezing - uncommon
        
        CXR: Hyperinflation, infiltration
  - - - Erythromycin base or Ethylsuccinate 50 mg/kg/day in 4 divided doses x 14 days (efficacy 80%, 2nd course mayb required) or
        
        Azithromycin 20 mg/kg OD x 3 days
    - - Prophylactic antimicrobial Rx — not I/C (unknown efficacy)
      - Monitor clinical symptoms to ensure appropriate Rx if infection deve
      - If cannot ensure adequate F/U ➯ consider preemtive therapy
- - - - Trimus (กรามค้าง)
      - Severe muscular spasms (risus sardonicus)
      - :timer_clock: Timings
        
        Gradual onset, 1-7 days
        
        Progress to
        
        Severe painful generalized muscle spasms (aggravated by External stimulus)
        
        Autonomic dysfunction (Diaphoresis, Tachycardia, Labile BP, arrhythmias)
        
        For Severe spasms: Persist for ≥ 1 wk & subside over several wks
    - - Muscle spasms in areas contiguous to wound (รอบๆแผล)
      - Mild form
    - - Generalized tetanus occurs in Newborn lacking passive immunity cuz moms are not immune
      - Common in Developing countries — preg women aren’t receive tetanus vaccine & nonsterile umbilical cord care
      - :timer_clock: Timings
        
        Symptoms usu appear fr 4-14 days after birth (average = 7 days)
      - Dx by Clinical
        after excluding
        other causes of Tetanic spasms
        
        Hypocalcemic tetany
        
        Phenothiazine reaction
        
        Strychnine poisoning
        
        Conversion disorder
      - :green_apple: Rx
        
        :star2: Tetany Ig (TIG) 3000-6000 U single dose IM
        (some experts rec 500 U)
        
        No TIG available considers
        
        Equine tetanus antitoxin (TAT) 1500-3000 (after testing for sensitivity & desensitization if necessary) Or
        
        IVIG containing tetanus Ab 200-400 mg/kg can be considered
        
        No indication of wide excision of umbilical stump
        (other forms of tetanus: wound should be cleaned & debrided)
        
        Supportive care & Pharmacotherapy to control tetanic spasms
        
        :pill:Drugs
        
        :star2: Drug of choice: Metronidazole 30 mg/kg per day q 6 hr (max 4 g/day) for 7-10 days
        
        Alternative drug: Parenteral penicillin G 100,000 U/kg per day q 4-6 hr (max 12 million U/day) for 7-10 days
        
        Active immunization during convalescence fr tetanus (ds may not result in immunity)
        eg หลังโดนตะปูตำ กลัวติด tetanus ➯ ให้ Ig + Vaccine
      - :green_book: Prevention
        
        Prenatal immunization of Previously unimmunized women AND those for whom 10 yrs hv passed since their previous tetanus vaccine
        
        Infant born outside hospital and umbilical cord is likely contaminated (cut with nonsterile equipment)
        
        :star2:Unknown mother’s tetanus immunization status ➯ TIG should be administered to NB unless tetanus serostatus can be confirmed quickly
        
        TIG for prophylaxis 250 U IM (regardless of age or weight)
        
        Infant DTP vaccine: give on standard schedule
        
        Vaccine
        
        dT at
        
        0 wks
        
        4 wks
        
        6-12 mo
        
        Insufficient time: 2 doses of Td
        
        each dose ≥ 4 wks apart
        
        2nd dose should be given ≥ 2 wks before delivery
        
        :star2: Tdap should replace 1 dose of Td at between GA 27-36 wks
    - - Dysfunc of Cranial nerves asso. with infected wounds on head & neck
  - - - Tetanospasmin binds to Gangliosides at Myoneural junction of skeletal ms & on neuronal mb in spinal cord ➯ Blocks inhibitory impulses to motor neuron
      - Tetanolysin: hemolytic & cytolytic properties
      - Found in soil & animal & human intestines
      - Greater risk :!: In Contaminated wounds (wounds with devitalized tissue & puncture trauma)
      - Not transmit fr person to person
- - - - :sunflower: Early-onset sepsis (EOS)
        
        Happen at age < 72 hrs of birth or < 7 days
        
        Results fr Vertical exposure to high bacterial load during birth
        
        :thunder_cloud_and_rain: RFs
        
        Preterm
        
        :red_flag: PROM > 18 hrs (น้ำเดินมาเกิน)
        
        Maternal fever in labor ( > 38°C)
        
        :red_flag: Chorioamnionitis
        
        Maternal colonization with Group B streptococcus (GBS)
        
        Previous infant with invasive GBS ds
      - :sunflower: Late-onset sepsis (LOS)
        
        Happen at age > 72 hrs of birth or ≥ 7 days
        
        Results fr Community Acquired organisms or Within the hospital (mostly fr organism acquired by nosocomial transmission fr person to person)
        
        :thunder_cloud_and_rain: RFs of late onset nosocomial infection
        
        Preterm
        
        Indwelling venous or arterial catheters or tracheal tube
        
        Prolonged ATBs, parenteral nutrition, gastric acid suppression therapy
        
        Damage to skin fr tape, skin probes, etc
    - - Usu nonspecific deterioration
      - Apnea, Bradycardia
      - Respiratory distress/ :arrow_up: ventilatory requirements
      - Slow feeding/Vomiting/Abdominal distention
      - Temperature instability/Fever/Hypothermia
      - Tachycardia/Collapse/Shock
      - Purpura or Bruising fr DIC
      - Irritability/Lethargy/Seizures
      - Jaundice
      - :arrow_down: limb movement in bone or joint
      - Tense or bulging fontanelle — found in late stage of meningitis
      - On monitoring :mortar_board:
        
        DTX— hypo/hyperglycemia
        
        CBC— Neutropenia, neutrophilia, left shift or Thrombocytopenia,
        
        Coagulopathy
        
        Acute phase reactants — raised CRP or procalcitonin
    - - CBC, differential, plts
      - :yellow_heart: :yellow_heart: Blood culture (gold standard)
      - C-reactive protein/procalcitonin
      - Urine—microscopy & culture for LOS
      - CSF if I/C
      - CXR if I/C
      - Tracheal aspirate if I/C
      - Coagulation screen, Blood gas (consider)
    - - Supportive care: Airway, Breathing, Circulation, Checking Blood glucose
      - Sepsis suspected ➯ start ATBs immediately after taking cultures
      - :sunflower: early-onset sepsis: should cover G+ & G— organisms
        ➯ Penicillin/Ampicillin + Aminoglycoside (Gentamicin/Tobramycin)
        AG uses to strengthen G—
      - :sunflower: late-onset sepsis: cover Coagulase-neg Staphyloccus & Enterococcus
        ➯ Nafcillin/Flucloxacillin + Gentamicin
        or
        ➯ Cephalosporin (eg Ceftazidime/Gentamicin + Vancomycin(only if found MRSA) )