Perinatal infection 🐯

⭐ Gonococcal infection

🖼 Clinical

NB got 👁s involvement — Gonococcal ophthalmia neonatorum

Possible scalp abscess (scalp monitoring)

Disseminated ds with bacteremia

Arthritis

Meningitis

Vaginitis

Urethritis

👤 Agent: Neisseria gonorrhoeae (G— , oxidase positive diplococcus) ➯ G— neg diplococci

⏲ Onset: Delivery - 5 days post birth (early)

🍀 Dx test

Gram’s stain & culture

Nucleic acid amplification tests (NAATs) — usu for genital specimen

💚 Rx of Ophthalmia neonatorum,
Scalp abscess,
or Disseminated infections

  1. Hospitalized to evaluate for Disseminated infection
  1. H/C, Eye discharge, Other potential sites of infection; CSF
  1. Tests for C. Trachomatis, Congenital syphilis, HIV
  1. Confirm maternal HBsAg
  1. Appropriate exam for Mother + Partner(s) and Rx for N. gonorrhoeae

For Ophthalmia neonatorum

  1. Single one-time dose of Ceftriaxone 25-50 mg/kg IV or IM (Max 125 mg)
  1. NSS eye irritations immediately & frequently until D/C is eliminated

😢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

For Disseminated Neonatal Infections &
Scalp abscesses & Arthritis, Septicemia

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

🖊 Control infants immediately after birth (< 1 hr)

0.5% Erythromycin ophthalmic or
1% Tetracycline ophthalmic ointment or
1% silver nitrate

⚠ not prevent chlamydial ophthalmia & nasopharyngeal colonization

⭐ Chlamydial infection
(Chlamydia trachomatis)

🍍Effects

🚩Neonatal chlamydial conjunctivitis


Begins a few days - wks after birth

  • Ocular congestion
  • Edema
  • D/C

Scars & Pannus are rare

🚩Pneumonia

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

Genitourinary tract

LGV

Trachoma

🐖Etiology: C. trachomatis (obligate intracellular bacteria)

🍃 Dx tests

Urogenital infection - NAATs (Nucleic acid amplification tests)

  • usu use in Ureterogenital D/C
  • Not been approved by FDA for testing of conjunctival or respiratory specimen

Pneumonia: Acute microimmunofluorescent serum titer IgM of ≥ 1:32 = Diagnostic

💚 Rx

Infants c chlamydial conjunctivitis or pneumonia

  • 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

Prompt Rx of mother & sexual partner(s)

Inform parents abt signs & potential risks of IHPS (Erythromycin)

Infants born to Mothers with untreated Chlamydial infection

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

⭐ Tetanus neonatorum

🐍 Neurotoxin of Clostridium tetani in contaminated wound

  1. Generalized (lockjaw)

Trimus (กรามค้าง)

Severe muscular spasms (risus sardonicus)

⏲ 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

  1. Local

Muscle spasms in areas contiguous to wound (รอบๆแผล)

Mild form

  1. Tetanus neonatorum 👶

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

⏲ 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

🍏 Rx

🌟 Tetany Ig (TIG) 3000-6000 U single dose IM
(some experts rec 500 U)

No TIG available considers

  1. Equine tetanus antitoxin (TAT) 1500-3000 (after testing for sensitivity & desensitization if necessary) Or
  1. 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

💊Drugs

🌟 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

📗 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)

🌟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

🌟 Tdap should replace 1 dose of Td at between GA 27-36 wks

  1. Cephalic

Dysfunc of Cranial nerves asso. with infected wounds on head & neck

🍐Etiologic agents: Clostridium tetani

Spore forming, Obligate Anaerobic, Gram ➕ bacilli

Toxins 🐍

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

⭐ Neonatal sepsis

Common & serious problems in Neonatal period

🌍 Incidence & RF

1-5 / 1000 live births

Highest incidence in VLBW infants (BW < 1,500 g)

🌠 Bacterial sepsis

Classification
based on onset

🌻 Early-onset sepsis (EOS)

Happen at age < 72 hrs of birth or < 7 days

Results fr Vertical exposure to high bacterial load during birth

⛈ RFs

Preterm

🚩 PROM > 18 hrs (น้ำเดินมาเกิน)

Maternal fever in labor ( > 38°C)

🚩 Chorioamnionitis

Maternal colonization with Group B streptococcus (GBS)

Previous infant with invasive GBS ds

🌻 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)

⛈ 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

🖼 Clinical presentation

Usu nonspecific deterioration

Apnea, Bradycardia

Respiratory distress/ ⬆ ventilatory requirements

Slow feeding/Vomiting/Abdominal distention

Temperature instability/Fever/Hypothermia

Tachycardia/Collapse/Shock

Purpura or Bruising fr DIC

Irritability/Lethargy/Seizures

Jaundice

⬇ limb movement in bone or joint

Tense or bulging fontanelle — found in late stage of meningitis

On monitoring 🎓

DTX— hypo/hyperglycemia

CBC— Neutropenia, neutrophilia, left shift or Thrombocytopenia,

Coagulopathy

Acute phase reactants — raised CRP or procalcitonin

👨🏾‍🔬 Inx

CBC, differential, plts

💛 💛 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)

💚 Mx

Supportive care: Airway, Breathing, Circulation, Checking Blood glucose

Sepsis suspected ➯ start ATBs immediately after taking cultures

🌻 early-onset sepsis: should cover G+ & G— organisms
➯ Penicillin/Ampicillin + Aminoglycoside (Gentamicin/Tobramycin)
AG uses to strengthen G—

🌻 late-onset sepsis: cover Coagulase-neg Staphyloccus & Enterococcus
➯ Nafcillin/Flucloxacillin + Gentamicin
or
➯ Cephalosporin (eg Ceftazidime/Gentamicin + Vancomycin(only if found MRSA) )

✴ Group B Streptococcal (GBS) infection 🍇

Leading cause of bacterial sepsis in Term infants (both onset of sepsis)

Early onset — usu present with respiratory distress & septicemia
(>90% present in First 24 hrs)

Late onset — Higher proportion with Meningitis

CDC 2010 recommends Active prevention by culturing ALL Mom at GA 35-37 wks & offering Intrapartum prophylactic ATBs to those who are positive for GBS

⭐ HIV infection (To be continued)