Infections in the Newborn Flashcards
What are the common organisms causing septicaemia?
Gram negatives: klebsiella, e.coli. Group B hemolytic streptococci (S. Agalactiae)
When does septicaemia arise?
Before or after birth
Nocosomial after 72 hours
What are the clinical signs of septicaemia?
Nonspecific: Lethargy, Abdominal distention, Poor feeding, Apnea, Poor weight gain, Jaundice, Hypothermia, Pallor
How is septicaemia diagnosed?
Leucopaenia- total white cell count
Confirmed on blood culture
CRP may be normal at first, and increase above 10mg/l
What are the complications of septicaemia?
Meningitis Pneumonia Metabolic disturbances including acidosis Hypoglycaemia DIC
How is sepsis treated?
Suitable antibiotics given to cover both gram +&- organisms
E.g. Penicillin 100000u/kg 12hrly and gentamicin 5mg/kg daily.
Review blood culture and CRP after 48 hours rx
Treat for 7-10/7 if B/C + or CRP raised (>10), rx usually continued until CRP
How do you manage an infant in which septicaemia is clinically suspected?
Start Abx and review after 48 hours
Full course of rx not given unless investigations performed as to avoid drug resistance
What is the risk of a fetus contracting HIV in utero?
5%
What is the risk of the infant contracting HIV intrapartum (NVD)?
15%
What is the added risk of contracting HIV if mixed feeds are given?
15%
What is the effect on transmission if the mother has AIDS or contracts HIV during pregnancy and why?
Transmission is even higher because she will have a higher viral load.
What are other factors that can increase the risk of HIV infection? (8)
Amniocentesis Chorioamnionitis PROM Preterm delivery Fetal scalp sampling or fetal scalp electrode Assisted delivery with episiotomy and vacuum Mastitis or breast abscess Oral thrush
When do perinatally infected infants present clinically and how?
Between 3/12 and 3 years
Stop thriving and develop severe infections due to damaged immune system
What indicators are used to determine management plan in HIV positive mothers? What are the cut offs?
WHO stage or CD4 count
WHO stage 3 or 4 OR CD4 350 cells/ml
How is a woman with stage 3 HIV managed antepartum?
Started on lifelong HAART using triple drug therapy
How is a woman with a CD4 count of 550 cells/ml managed antepartum?
She is started on oral AZT 300mg bd at 14/40
How is a woman with stage 2 HIV and a CD4 count of 400 cells/ml managed during labour?
Given AZT 3 hourly during labour
Single dose nevirapine 200mg at onset of labour
Truvada (TDF and FTC) given during labour
Given to reduce viral resistance
What criteria must be met for formula feeding to be safe?
Affordable Feasible Acceptable Safe Sustainable
In poor communities, what feeding is recommended, for how long and why?
Breast feeding until at least 6/12 Reduces risk of malnutrition and gastroenteritis
What is the immediate management of an HIV exposed neonate?
Single dose oral nevirapine within 6 hours of birth
Dose is 15mg for infants >2.5kg, 10mg if 2-2.5kg, and 2mg/kg if
How long is an HIV exposed infant given nevirapine?
Until 6 weeks
How does nevirapine protect the exposed neonate?
It reduces HIV transmission during breastfeeding in mothers with CD4 count >350 cells/ml
When is the first HIV test for the HIV exposed infant?
PCR done at 6 weeks
What is the management plan after 6 weeks if the HIV exposed infant tests positive?
The infant is HIV infected he must be fast-tracked onto lifelong HAART
What is the management plan after 6 weeks if the HIV exposed infant tests negative?
If negative, the nevirapine should be continued until 2/52 after breastfeeding stopped. The PCR should be repeated 4/52 later.
If he mother is on HAART, when should infant’s nevirapine be stopped?
6 weeks
When can Elisa/Rapid screening be used in the infant and why?
After 18/12
Before then, the test could be a false positive due to the presence of maternal antibodies which have crossed the placenta
What prophylaxis should HIV exposed infants get and for how long
Prophylactic cotrimoxazole from 6 weeks while waiting for PCR result
Should HIV exposed infants receive normal immunizations?
Yes
Which immunization should not be given to infants known to be HIV infected?
BCG
How do you treat an unbooked mother in labour?
Truvada at start of labour
Stat dose NVP
AZT 3hourly during labour
How do you treat an HIV positive mother on HAART who comes in in labour with a high viral load?
Additional 3 hourly AZT
What is Option A (PMTCT strategy)?
.
What is PMTCT strategy B?
.
What is PMTCT strategy B+?
.
What 5 parameters are integrated in PMTCT?
Antenatal care Postnatal care Child health Reproductive health (FP, Pap smear) TB screening (- give INH prophylaxis if HIV +)
Why is a CD4 count done if option B followed?
Informs decision to provide prophylaxis (bactrim if CLAT serum screen)
What are the 3 classes of ARVs?
Nucleoside reverse transcriptase inhibitorsNon-NRTIsProtease inhibitors
What is first line ARVs?
Single dose- efavirenz (EFV), emtricitabine (3TC), tenofevir (TDF)
Trade names- atripla, atroiza, odimune
How often is viral load monitored?
Every 4/12
At what point is a viral load concerning?
> 400
When can you not give AZT?
Anaemic patients with an Hb
When can you not give EFV?
History of severe psychiatric illness
When can you not give TDF?
Severe/chronic kidney disease
How to manage raised VL?
Check adherence
Recheck in 1/12
Change to SLR
What is the management for the infant if the mother had a VL >1000 during pregnancy?
PCR at birth, and if positive, refer to urgent HAART for infant
Add AZT for 1/12 with NVP
Stop AZT if mothers viral load suppresses and she is breast feeding
How does congenital syphilis present?
Rash. HSM. Heavy placenta. Pallor. Jaundice. Purpura. Resp distress. Metaphysitis. LBW.
Maternal syphilis can result in what obstetric outcomes?
Miscarriage. Stillbirth. Neonatal death. Live birth and survival
How is a symptomatic infant treated for syphilis?
Procaine penicillin 50 000 units per kg daily for 10 days
How is an asymptomatic infant treated for syphilis?
Benzathine penicillin stat dose.
What are the typical features of the rash present with congenital syphilis?
Blistering rash most common. Blisters burst to leave raw areas. Typically on hands and feet. Rash heals without scarring. Rash clears with penicillin therapy.
Peeling of hands and feet is common in congenital syphilis, how does it arise?
Blisters burst. Release blister fluid, which is highly infectious because full of spirochaetes. Burst blisters soon start to peel, resulting in characteristic peeling of hands and feet.
What are the characteristics of the rash occurring on the body in congenital syphilis?
Less common than blistering peripheral rash
Can be blistering, but also can be macular or papular
Pink to brown in colour
Not tender, painful or itchy
Purpura is common due to low platelets
What is the cause of hepatomegaly in congenital syphilis and what are the consequences?
Liver enlarges due to sites of extra medullary erythropoesis
Hypoglycaemia and low levels of clotting factors are common
Liver is hard and non tender, and does not progress to cirrhosis
What are the characteristics of the placenta in congenital syphilis?
Typically large, heavy and pale. It is soft and tears easily. It is heavy relative to the infant’s body mass (+/- 1/3). On histology, it shows chronic inflammation with many spirochaetes.
What are the bony features of an infant with congenital syphilis?
Osteitis common. Metaphysitis is typical - seen in 8% infants with untreated syphilis. In severe cases, the metaphyses appear fragmented. The epiphyses are normal. Metaphysitis caused by local inflammatory process due to deposition of immune complexes.
In what area is syphilitic metaphysitis most marked and what is the appearance? What is the cause of this appearance?
Most marked on the inner tibia and ‘rat bite’ sign is seen. Rat bite sign caused by decalcification.
