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Warning Signs and How to Treat Late Onset Sepsis in the Neonate
Many of us have heard stories about sepsis in newborn children less than 4 weeks old. Dr. Jenny Camacho discusses the warning signs of sepsis and how The Women's Hospital treats late onset sepsis in the neonate.
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Learn more about Jenny Camacho, MD
Jenny Camacho, MD
Jenny Camacho, MD is a board-certified pediatrician and neonatologist at The Women's Hospital.Learn more about Jenny Camacho, MD
Transcription:
Deborah Howell (Host): Many of us had heard stories about sepsis in newborn children less than four weeks old. Today, we'll ask what are the warning signs and how do we treat late onset sepsis in the neonate? I'm Deborah Howell. And our guest today is Dr. Jenny Camacho, a Neonatologist at Deaconess, The Women's Hospital. And together we'll take on the topic of late onset sepsis in the neonate.
Welcome Dr. Camacho.
Jenny Camacho, MD (Guest): Hi, thank you so much for having me.
Host: Wonderful. Let's jump right in with a definition if we can. What is sepsis?
Dr. Camacho: Sepsis is basically the body's extreme response to any kind of infection. So when we're looking at the neonatal population and in particular, the NICU, we kind of base it on how old the baby is. So early onset sepsis occurs within about the first 72 hours of life. And it's typically related to some kind of bacteria that's acquired around the time of birth. Then we think about late onset sepsis anytime after about 72 hours of life until about 90 days of life. And this is due to any sort of microorganism that's in the postnatal environment. But it can sometimes be related to an infection acquired from the mother where the baby gets colonized during the birthing process. And then that bacteria later develops into an infection.
But today I would like to focus specifically on late onset sepsis in preterm neonates in the NICU.
Host: Okay, fair enough. So how do I know my baby in the NICU has late onset sepsis?
Dr. Camacho: So we have to remember that our tiny babies in the NICU can't talk to us and they can't tell us how they are feeling. So this is where we need to focus on their overall clinical picture. And the difficult part is that the clinical picture can range from really subtle signs, like mild increases in apnea to really specific fulminant septic shock. So clinical signs and symptoms can range from increased heart rate to low blood pressure, poor perfusion, difficulty breathing, lethargy, decreased tone, difficulty with managing their temperatures, fever, more commonly a hypothermia is what we see. The hard part about temperature instability is that it can be difficult to gauge this in the NICU since most of our preterm babies are going to be in incubators that control the temperature for them. So if the, but if the incubator needs to work harder to keep the infant warmer, that's something that we, that nursing needs to pay attention to. And then if the temperature doesn't normalize after troubleshooting environmental causes, that's where we really start to focus on sepsis and that we need to rule it out.
But other signs and symptoms can be things like feeding intolerance, vomiting, diarrhea, abdominal discussion, low or high glucose, even seizures can be signs that some sort of infectious processes is. But really the biggest clue is that there's some sort of deviation from how the baby is typically acting.
So this is where myself, as the neonatologist really relies on the staff, taking care of the baby to tell me that something's going on. If you think about it, nursing and respiratory therapists spend so much more at the bedside than I'm able to do. They're really my eyes and my ears for every single one of my patients since I can't be at the bedside of 15 babies all at once. So their input is so valuable and important, and I can't stress that enough. So the more severe the clinical presentation the infant has the faster we have to act to make sure we get labs done and the antibiotics started.
Host: Dr. Camacho, what are some risk factors for late onset sepsis?
Dr. Camacho: Neonatal risk factors that we think about include prematurity and low birth weight. And when I say low birth weight, I mean, any baby that is born less than 1500 grams or about three pounds, five ounces. Premature infants are at increased risk compared to term infants for a couple of different reasons.
First, premature infants have an even weaker immune system since they miss out on the third trimester of pregnancy where immune globulins that are transferred across the placenta, go into the baby. Second, they have immature skin that's really thin and delicate. So they're at risk for breakdown and pathogens can enter their bodies this way.
And then thirdly, invasive devices that can provide care like nutrition and respiratory support and kind of further compromise these typical barriers that we think of. So bacteria can also cling to these devices and cause infection that way. Babies that have central venous lines, umbilical lines, peripheraly inserted central catheters or even breathing tubes. Those babies are also at increased.
Host: What tests need to be done?
Dr. Camacho: So we have to evaluate for all possible sources and causes that could be related to sepsis. So we have to evaluate for urinary tract infections, meningitis, pneumonia, necrotizing enterocolitis, bloodstream infection, cellulitis, those kinds of things. So we'll typically start with blood tests, like a complete blood count, a C-reactive protein, glucose, blood gas, gram stain, and culture of the blood.
Then we also look at urine tests like doing a urinanalysis and a urine culture. And we also look at the cerebral spinal fluid, but in some cases if the baby is really clinically ill. It can be difficult to get these cultures. And so sometimes we have to wait to do those and we start antibiotics right away.
Some of the other tests that we need to do include a chest x-ray if the baby's having some, you know, respiratory distress, or if there's a change in their breathing status, we'll sometimes do an abdominal x-ray if there are signs of feeding intolerance.
Host: You know, I'm wondering what organisms cause late onset sepsis?
Dr. Camacho: So let's start with bacteria since these are the usual culprits. Bacteria differ by region and even by hospital, but in general, coagulase negative staph aureus is the most frequent cause. Other bacteria, like methicillin sensitive staph aureus, but we also think of methicillin-resistant staph aureus too.
And finally we think of gram negative bacteria, like pseudomonas, E coli, Klebsiella. Those are some typical examples. We also think of group B streptococcus and listeria. Outside of bacteria, we think of things like fungus, such as candida or other viruses, like enterovirus, cytomegalovirus, respiratory syncytial virus, influenza, herpes simplex virus. These are all things that we typically think about.
Host: Sure now let's talk about the treatments.
Dr. Camacho: So since bacteria is the number one cause we have to start antibiotics as soon as possible. And I can't stress the importance of starting antibiotics as soon as possible, especially if the baby is really clinically ill, it's important to get those antibiotics on within an hour of noticing that there's something going on.
And so at women's hospital for late onset sepsis, we typically will start nafcillin and gentamycin is our initial antibiotics, unless they've had an indwelling central catheter in the last three days. And in that instance, we'll start vancomycin in addition to gentamycin to help cover for methicillin-resistant staph aureus.
Once we have the result of any blood cultures back or urine cultures or cerebral spinal fluid cultures back then we tailor the antibiotics based on the bacteria. If we suspect that there's, you know, a fungal cause we might start some sort of antifungals. And if we suspect that there's any sort of virus like cytomegalovirus or herpes simplex virus we can start antivirals against those.
In some instances there's viruses like, you know, respiratory syncytial virus, we're all we need to do is just provide supportive treatment. So we will typically optimize the baby's respiratory support. So this might mean that, you know, if the baby's not on any sort of breathing support that we start, that. We add extra oxygen if they need it. We place them on a ventilator if they're really that clinically ill. They also might need some help maintain their blood pressures. So we'll give them extra fluids. We sometimes need to give them medications that will also help increase their blood pressure, if fluids alone don't work. Now in some centers, depending upon the age and the size of the baby can be placed on something called extra corporeal membrane oxygenation, which is basically machines that will take over the function of the heart and the lungs.
But this is super, super rare. And it's not done very commonly. And finally, we have to make sure that we keep the baby's temperature within a normal range. And if we suspect that the infection might be due to some sort of indwelling catheter, like a central line, we take the catheter out.
Host: Sure such delicate work. So this is the sensitive, but burning question that, you know, for all parents, will my baby die?
Dr. Camacho: You know, unfortunately neonatal sepsis does remain a major cause of mortality in premature and very low birth weight infants. And in fact, worldwide, sepsis in general causes about over 400,000 neonatal deaths each year. In the US mortality ranges from about 10 to 20% and it can be higher if the bacteria is a gram negative bacteria like e-coli or pseudomonas.
There was a single center study that was done of 424 infants by Lovett and Colleagues where they found that there were several factors that were independently associated with an increased risk of mortality from sepsis. These included gram negative or fungal infections. The need for the baby to be intubated, the need for a blood pressure medications to help keep their blood pressure higher, lower blood glucose, lower platelets, and the presence of necrotizing enterocolitis.
And so, think that the difficult aspect for myself and for anyone that works in the NICU, is that sometimes despite our best efforts, they don't always make it. And so, we work extremely hard in the newborn intensive care unit to really focus on what we can do to prevent infection.
Host: Yeah, I hear the passion in your voice on every baby to make it.
Dr. Camacho: Yes. I'm trying not to get choked up because I love do and I love my patients.
Host: Yeah. Yeah. Well, they're very lucky to have such a caring leader of the team. What can be done to prevent late onset sepsis?
Dr. Camacho: Since the stakes are high we're really very diligent in the NICU about infection prevention. So one of the major things that we do is hand hygiene. That remains one of the most effective methods for reducing healthcare associated infections. So we come into the NICU and we wash our hands with a CHG based a handwash at the beginning of our shift. Before and after touching the babies, we focus on putting alcohol-based hand sanitizer on.
So those are, you know, hand hygiene is huge. The next thing we think about too is proper care of any sort of central lines in place. Using a sterile technique when we insert those catheters is really important as far as reducing the risk of introducing infection into the baby.
But at the same time, we also have to make sure that we can remove those catheters as soon as possible. Once we realize we don't need them anymore, we need to take the line out because the longer that it's there you put the baby any sort of increased risk for infection. Also one thing that we do is starting you know, feeding the baby with breast milk early on that really can help decrease infection.
One thing that the medical community really has been focusing on lately is something called antibiotic stewardship. And this basically refers to where we have judicious use of antibiotics therapy with a goal of reducing the risk of antibiotic resistance and fungal infections. So that's something that we focus on and we have, you know, infection protocols and things in place.
And finally implementing and adhering to protocols regarding infection is really another major factor that can help with prevention of late onset sepsis.
Host: Sure of course. What would you say is the best part of your day?
Dr. Camacho: The best part of my day is when I get to go home, and I know that the babies in the NICU are doing well, that's the best part of my day.
Host: Ah, it is really been wonderful to talk to you today. Thank you for all the great information. Thank you for being with us. Thank you for all you do for our tiniest humans that are so beloved. Dr. Comacho, thank you for talking about late onset sepsis in the neonates. We really approved.
Dr. Camacho: You're welcome. I'm happy to do it anytime.
Host: This is The Women's Hospital, a place for all your life. To schedule an appointment or to learn more call 812-842-4530. Or visit deaconess.com/twh to get connected to one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Deaconess Women's Hospital podcasts. For more health tips and updates follow us on your social channels. I'm Deborah Howell. Thank you for listening and have yourself a great day.
Deborah Howell (Host): Many of us had heard stories about sepsis in newborn children less than four weeks old. Today, we'll ask what are the warning signs and how do we treat late onset sepsis in the neonate? I'm Deborah Howell. And our guest today is Dr. Jenny Camacho, a Neonatologist at Deaconess, The Women's Hospital. And together we'll take on the topic of late onset sepsis in the neonate.
Welcome Dr. Camacho.
Jenny Camacho, MD (Guest): Hi, thank you so much for having me.
Host: Wonderful. Let's jump right in with a definition if we can. What is sepsis?
Dr. Camacho: Sepsis is basically the body's extreme response to any kind of infection. So when we're looking at the neonatal population and in particular, the NICU, we kind of base it on how old the baby is. So early onset sepsis occurs within about the first 72 hours of life. And it's typically related to some kind of bacteria that's acquired around the time of birth. Then we think about late onset sepsis anytime after about 72 hours of life until about 90 days of life. And this is due to any sort of microorganism that's in the postnatal environment. But it can sometimes be related to an infection acquired from the mother where the baby gets colonized during the birthing process. And then that bacteria later develops into an infection.
But today I would like to focus specifically on late onset sepsis in preterm neonates in the NICU.
Host: Okay, fair enough. So how do I know my baby in the NICU has late onset sepsis?
Dr. Camacho: So we have to remember that our tiny babies in the NICU can't talk to us and they can't tell us how they are feeling. So this is where we need to focus on their overall clinical picture. And the difficult part is that the clinical picture can range from really subtle signs, like mild increases in apnea to really specific fulminant septic shock. So clinical signs and symptoms can range from increased heart rate to low blood pressure, poor perfusion, difficulty breathing, lethargy, decreased tone, difficulty with managing their temperatures, fever, more commonly a hypothermia is what we see. The hard part about temperature instability is that it can be difficult to gauge this in the NICU since most of our preterm babies are going to be in incubators that control the temperature for them. So if the, but if the incubator needs to work harder to keep the infant warmer, that's something that we, that nursing needs to pay attention to. And then if the temperature doesn't normalize after troubleshooting environmental causes, that's where we really start to focus on sepsis and that we need to rule it out.
But other signs and symptoms can be things like feeding intolerance, vomiting, diarrhea, abdominal discussion, low or high glucose, even seizures can be signs that some sort of infectious processes is. But really the biggest clue is that there's some sort of deviation from how the baby is typically acting.
So this is where myself, as the neonatologist really relies on the staff, taking care of the baby to tell me that something's going on. If you think about it, nursing and respiratory therapists spend so much more at the bedside than I'm able to do. They're really my eyes and my ears for every single one of my patients since I can't be at the bedside of 15 babies all at once. So their input is so valuable and important, and I can't stress that enough. So the more severe the clinical presentation the infant has the faster we have to act to make sure we get labs done and the antibiotics started.
Host: Dr. Camacho, what are some risk factors for late onset sepsis?
Dr. Camacho: Neonatal risk factors that we think about include prematurity and low birth weight. And when I say low birth weight, I mean, any baby that is born less than 1500 grams or about three pounds, five ounces. Premature infants are at increased risk compared to term infants for a couple of different reasons.
First, premature infants have an even weaker immune system since they miss out on the third trimester of pregnancy where immune globulins that are transferred across the placenta, go into the baby. Second, they have immature skin that's really thin and delicate. So they're at risk for breakdown and pathogens can enter their bodies this way.
And then thirdly, invasive devices that can provide care like nutrition and respiratory support and kind of further compromise these typical barriers that we think of. So bacteria can also cling to these devices and cause infection that way. Babies that have central venous lines, umbilical lines, peripheraly inserted central catheters or even breathing tubes. Those babies are also at increased.
Host: What tests need to be done?
Dr. Camacho: So we have to evaluate for all possible sources and causes that could be related to sepsis. So we have to evaluate for urinary tract infections, meningitis, pneumonia, necrotizing enterocolitis, bloodstream infection, cellulitis, those kinds of things. So we'll typically start with blood tests, like a complete blood count, a C-reactive protein, glucose, blood gas, gram stain, and culture of the blood.
Then we also look at urine tests like doing a urinanalysis and a urine culture. And we also look at the cerebral spinal fluid, but in some cases if the baby is really clinically ill. It can be difficult to get these cultures. And so sometimes we have to wait to do those and we start antibiotics right away.
Some of the other tests that we need to do include a chest x-ray if the baby's having some, you know, respiratory distress, or if there's a change in their breathing status, we'll sometimes do an abdominal x-ray if there are signs of feeding intolerance.
Host: You know, I'm wondering what organisms cause late onset sepsis?
Dr. Camacho: So let's start with bacteria since these are the usual culprits. Bacteria differ by region and even by hospital, but in general, coagulase negative staph aureus is the most frequent cause. Other bacteria, like methicillin sensitive staph aureus, but we also think of methicillin-resistant staph aureus too.
And finally we think of gram negative bacteria, like pseudomonas, E coli, Klebsiella. Those are some typical examples. We also think of group B streptococcus and listeria. Outside of bacteria, we think of things like fungus, such as candida or other viruses, like enterovirus, cytomegalovirus, respiratory syncytial virus, influenza, herpes simplex virus. These are all things that we typically think about.
Host: Sure now let's talk about the treatments.
Dr. Camacho: So since bacteria is the number one cause we have to start antibiotics as soon as possible. And I can't stress the importance of starting antibiotics as soon as possible, especially if the baby is really clinically ill, it's important to get those antibiotics on within an hour of noticing that there's something going on.
And so at women's hospital for late onset sepsis, we typically will start nafcillin and gentamycin is our initial antibiotics, unless they've had an indwelling central catheter in the last three days. And in that instance, we'll start vancomycin in addition to gentamycin to help cover for methicillin-resistant staph aureus.
Once we have the result of any blood cultures back or urine cultures or cerebral spinal fluid cultures back then we tailor the antibiotics based on the bacteria. If we suspect that there's, you know, a fungal cause we might start some sort of antifungals. And if we suspect that there's any sort of virus like cytomegalovirus or herpes simplex virus we can start antivirals against those.
In some instances there's viruses like, you know, respiratory syncytial virus, we're all we need to do is just provide supportive treatment. So we will typically optimize the baby's respiratory support. So this might mean that, you know, if the baby's not on any sort of breathing support that we start, that. We add extra oxygen if they need it. We place them on a ventilator if they're really that clinically ill. They also might need some help maintain their blood pressures. So we'll give them extra fluids. We sometimes need to give them medications that will also help increase their blood pressure, if fluids alone don't work. Now in some centers, depending upon the age and the size of the baby can be placed on something called extra corporeal membrane oxygenation, which is basically machines that will take over the function of the heart and the lungs.
But this is super, super rare. And it's not done very commonly. And finally, we have to make sure that we keep the baby's temperature within a normal range. And if we suspect that the infection might be due to some sort of indwelling catheter, like a central line, we take the catheter out.
Host: Sure such delicate work. So this is the sensitive, but burning question that, you know, for all parents, will my baby die?
Dr. Camacho: You know, unfortunately neonatal sepsis does remain a major cause of mortality in premature and very low birth weight infants. And in fact, worldwide, sepsis in general causes about over 400,000 neonatal deaths each year. In the US mortality ranges from about 10 to 20% and it can be higher if the bacteria is a gram negative bacteria like e-coli or pseudomonas.
There was a single center study that was done of 424 infants by Lovett and Colleagues where they found that there were several factors that were independently associated with an increased risk of mortality from sepsis. These included gram negative or fungal infections. The need for the baby to be intubated, the need for a blood pressure medications to help keep their blood pressure higher, lower blood glucose, lower platelets, and the presence of necrotizing enterocolitis.
And so, think that the difficult aspect for myself and for anyone that works in the NICU, is that sometimes despite our best efforts, they don't always make it. And so, we work extremely hard in the newborn intensive care unit to really focus on what we can do to prevent infection.
Host: Yeah, I hear the passion in your voice on every baby to make it.
Dr. Camacho: Yes. I'm trying not to get choked up because I love do and I love my patients.
Host: Yeah. Yeah. Well, they're very lucky to have such a caring leader of the team. What can be done to prevent late onset sepsis?
Dr. Camacho: Since the stakes are high we're really very diligent in the NICU about infection prevention. So one of the major things that we do is hand hygiene. That remains one of the most effective methods for reducing healthcare associated infections. So we come into the NICU and we wash our hands with a CHG based a handwash at the beginning of our shift. Before and after touching the babies, we focus on putting alcohol-based hand sanitizer on.
So those are, you know, hand hygiene is huge. The next thing we think about too is proper care of any sort of central lines in place. Using a sterile technique when we insert those catheters is really important as far as reducing the risk of introducing infection into the baby.
But at the same time, we also have to make sure that we can remove those catheters as soon as possible. Once we realize we don't need them anymore, we need to take the line out because the longer that it's there you put the baby any sort of increased risk for infection. Also one thing that we do is starting you know, feeding the baby with breast milk early on that really can help decrease infection.
One thing that the medical community really has been focusing on lately is something called antibiotic stewardship. And this basically refers to where we have judicious use of antibiotics therapy with a goal of reducing the risk of antibiotic resistance and fungal infections. So that's something that we focus on and we have, you know, infection protocols and things in place.
And finally implementing and adhering to protocols regarding infection is really another major factor that can help with prevention of late onset sepsis.
Host: Sure of course. What would you say is the best part of your day?
Dr. Camacho: The best part of my day is when I get to go home, and I know that the babies in the NICU are doing well, that's the best part of my day.
Host: Ah, it is really been wonderful to talk to you today. Thank you for all the great information. Thank you for being with us. Thank you for all you do for our tiniest humans that are so beloved. Dr. Comacho, thank you for talking about late onset sepsis in the neonates. We really approved.
Dr. Camacho: You're welcome. I'm happy to do it anytime.
Host: This is The Women's Hospital, a place for all your life. To schedule an appointment or to learn more call 812-842-4530. Or visit deaconess.com/twh to get connected to one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Deaconess Women's Hospital podcasts. For more health tips and updates follow us on your social channels. I'm Deborah Howell. Thank you for listening and have yourself a great day.