Septicaemia in the neonate/child

Question 1

Define bacteraemia.

Answer 1

Proliferation of bacteria in the circulation.

Question 2

Define septicaemia.

Answer 2

Systemic response to infection; tachypnoea, tachycardia and fever or hypothermia.

Question 3

Define sepsis syndrome/systemic inflammatory response syndrome (SIRS).

Answer 3

Evidence of reduced end-organ perfusion (oliguria/altered) with elevated lactate levels.

Question 4

Define septic shock.

Answer 4

Sepsis syndrome plus hypotension that doesn’t respond to fluid therapy.

Question 5

What are causes of early onset neonatal sepsis?

Answer 5

Usually multiorgan system disease with respiratory failure, meningitis, circulatory shock and ATN due to BBS or E.coli.

Question 6

What are causes of late-onset neonatal sepsis?

Answer 6

Usually occurs due to Neisseria meningitides, streptococcus pneumonia, Hib, HSV, CMV or enterovirus.

Question 7

What are causes of hospital acquired septicaemia?

Answer 7

Occurs predominantly among preterm infants in NICU dude to staphylococcus aureus, staph epidermidids or gram-negative organisms.

Question 8

What are causes of septicaemia in immunocompromised children?

Answer 8

Infected by broader spectrum of pathogens including fungi

Question 9

What are causes of septicaemia in older children?

Answer 9

Usually caused by Neisseria meningitides or Strep. pneumonia.

Question 10

What are associations of early onset neonatal septicaemia?

Answer 10

Vaginal colonisation with GBS

PROM (> 24hr term, > 18hr preterm infants)

Preterm delivery.

Question 11

What are associations between septicaemia and medical instrumentalisation?

Answer 11

In-dwelling central venous lines and ET tubes

Peritoneal dialysis

Surgery and prosthetic heart valves

Question 12

What is the pathophysiology of septicaemia?

Answer 12

Gram-positive bacteria peptidoglycans

Gram-negative bacteria lipopolysaccharides

Host response: Release of inflammatory cytokines, coagulation cascade, prostaglandins and NO which leads to vasodilation, increase capillary permeability and shift in intravascular compartment, resulting in hypotension.

Question 13

What are causes of toxic shock syndrome?

Answer 13

Staph. aureus and strep pyogenes may act as ‘superantigens’ that activate entire classes of T cells and initiate a particularly severe form of SIRS.

Question 14

Summarise the epidemiology of septicaemia?

Answer 14

Most common cause of bacteraemia is pneumococcus.

Most common cause of septic shock is meningococcal septicaemia.

Question 15

What are signs and symptoms of septicaemia?

Answer 15

Determine immunisation status. Presentation depends on the primary system affected:

• CNS:
  
  • ​Infant: Bulging fontanelle (neonates), lethargy, irritability, poor feeding.
  • Child: Headache, photophobia, neck stiffness, seizures, decreased GCS.
• Respiratory: Tachypneoa, apnoea, grunting, cyanosis.
• Cardiovascular: Tachycardia, hypotension.
• GI: Poor feeding, abdominal pain, vomiting, diarrhea.
• General: Lethargy, fever, hypothermia, purpuric rash.

Question 16

What are investigations associated with septicaemia?

Answer 16

Bloods: Increase/Decrease WCC (neutropenia/neutrophilia), increase CRP, U&E, blood glucose, clotting, ABG (hypoxia, metabolic acidosis).

Radiology: CXT, USS abdomen if intra-abdominal sepsis is suspected.

MC&S: MSU, blood culture CSF (LP if vital signs are stable enough to tolerate procedure). LP is contraindicated if there are signs of raised ICP, purpura or deranged clotting (DIC).

Question 17

What is the general management of septicaemia?

Answer 17

Transfer to NICU/PICU

Supportive: Fluid resuscitation +/- inotropes to maintain BP and perfusion, adequate oxygenation by non-invasive or ventilatory means.

Empirical antimicrobial therapy: Follow local hospital guidelines.

Question 18

What is the management for neonatal septicaemia?

Answer 18

<48 hours: Benzylpenicillin + gentamicin.
If meningitis, cefotaxime + amoxicillin.

>48 hours: Third-generation cephalosporin (cefotaxime).

Question 19

What is the management for hospital-acquired infections?

Answer 19

Vancomycin + gentamicin

Question 20

What is the management for immunocompromised patients?

Answer 20

Wider cover usually required.

Question 21

How is septicaemia prevented?

Answer 21

Immunisation (includes pneumoccous).

Intrapartum IV penicillin mothers colonised with GBS or PROM, previous GBS infant.

Question 22

What are complications associated with septicaemia?

Answer 22

Multiorgan failure

DIC

Residual neurological deficit

Question 23

What is the prognosis of septicaemia?

Answer 23

Mortality: Septic shock 40-70%

Multiorgan failure 90-100%