Neonatal Sepsis and observation Guideline GL 380

Transcription

1 Neonatal Sepsis and observation Guideline GL 380 Approval and Authorisation Approved by Job Title Date Paediatric Clinical Governance Chair, Paediatric Clinical 19/1/18 Governance Committee Change History Version Date Author Reason 2.0 Aug 2009 N Pritchard Update of expired Guideline 2.1 Aug 2011 G Boden Update of expired Guideline 2.2 July 2013 P de Halpert Revised in line with NICE 2.3 March 2016 P de Halpert Reauthorized 2.4 Jan 2018 P de Halpert Revised in line with RCOG 1

2 The approach to assessing and treating Early onset neonatal sepsis uses a scoring system that identifies risk factors and clinical indicators. There are red-flag and non-red flag indicators for both and are listed below. RED FLAG INDICATORS Risk Factors tick Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis] Suspected or confirmed infection in another baby in the case of a multiple pregnancy Clinical Indicators Respiratory distress starting more than 4 hours after birth Seizures Need for mechanical ventilation in a term baby Signs of shock IF ANY RED FLAG FEATURES THEN PERFORM INVESTIGATIONS AND START ANTIBIOTIC TREATMENT WITHIN 1 HOUR 2

3 Risk Factors tick Invasive group B streptococcal infection in a previous baby Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy Term Prelabour rupture of membranes ( >24 hours before established (4cm dilated) labour) Preterm birth following spontaneous labour (before 37 weeks' gestation) Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth Intrapartum fever higher than 38.0 C, or confirmed or suspected chorioamnionitis Clinical Indicators Altered behaviour or responsiveness Altered muscle tone (for example, floppiness) Feeding difficulties (for example, feed refusal) Feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension Abnormal heart rate (bradycardia or tachycardia) Signs of respiratory distress Hypoxia (for example, central cyanosis or reduced oxygen saturation level) Jaundice within 24 hours of birth Apnoea Signs of neonatal encephalopathy Need for cardio pulmonary resuscitation Need for mechanical ventilation in a preterm baby Persistent fetal circulation (persistent pulmonary hypertension) Temperature abnormality (lower than 36 C or higher than 38 C) unexplained by environmental factors Unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation (INR >2.0) Oliguria persisting beyond 24 hours after birth Altered glucose homeostasis (hypoglycaemia or hyperglycaemia) Metabolic acidosis (base deficit of 10 mmol/litre or greater) in neonate (not cord) Local signs of infection (for example, affecting the skin or eye) TOTAL NUMBER OF INDICATORS 3

4 NON-RED FLAG INDICATORS IF 2 OR MORE NON RED FLAG RISK FACTORS OR CLINICAL INDICATORS THEN PERFORM INVESTIGATION AND START ANTIBIOTIC TREATMENT WITHIN 1 HOUR In babies without red flags and only one risk factor or one clinical indicator, using clinical judgment, consider: whether it is safe to withhold antibiotics, and whether it is necessary to monitor the baby's vital signs and clinical condition if monitoring is required continue it for at least 12 hours (at 0, 1 and 2 hours and then 2-hourly for 10 hours) using the Baby Observation Chart - any abnormal values must be acted upon. INVESTIGATIONS Before starting antibiotics: CRP Blood cultures Lumbar puncture if it is thought safe to do so AND: o there is a strong clinical suspicion of infection, or o there are clinical symptoms or signs suggesting meningitis. o NB: If performing the lumbar puncture would unduly delay starting antibiotics, perform it as soon as possible after starting antibiotics. Do not routinely perform (if not clinically indicated): Urine MC&S Skin swab Specific infections: Purulent eye discharge eye swabs, including for Chlamydia, gonococcus. Start systemic antibiotic treatment for possible gonococcal infection while awaiting the swab microbiology results Any clinical signs of umbilical infection - purulent discharge or signs of periumbilical cellulitis (e.g., redness, increased skin warmth or swelling). Perform a blood culture, take a swab sample for microscopy and culture, and start antibiotic treatment with IV Flucloxacillin and Cefotaxime. During antibiotics: Repeat CRP hours after presentation Consider performing a lumbar puncture in a baby who did not have a lumbar puncture at presentation who is receiving antibiotics, if it is thought safe to do so and if the baby: o Has a CRP >25 mg/l o has a positive blood culture, or o does not respond satisfactorily to antibiotic treatment 4

5 Normal CSF values RBC/mm 3 WBC/mm 3 Protein g/l Glucose mmol/l Preterm < 7 days 30 (0-333) 9 (0-30) 1 ( ) 3 Preterm >7 days (2-70) 0.9 ( ) 3 Term <7 days 9 (0-50) 5 (0-30) 0.6 ( ) 3 Term > 7 days <10 3 (0-10) 0.5 ( ) 3 Bloody Tap Calculate the ratio WBC to RBC allow 1:500 if unsure treat for meningitis ANTIBIOTIC TREATMENT First choice antibiotics for empirical treatment for suspected infection are benzylpenicillin and Cefotaxime Benzylpenicillin 50mg/kg every 12 hours o Consider shortening the dose interval to 8-hourly based on clinical judgement (e.g., if the baby appears very ill) Cefotaxime 50 mg/kg every 12 hours o For further information on dosing and reconstitution please refer to the neonatal formulary DURATION OF TREATMENT In babies given antibiotics because of risk factors for infection or clinical indicators of possible infection consider stopping the antibiotics at 36 hours if: the blood culture is negative, and the initial clinical suspicion of infection was not strong, and the baby's clinical condition is reassuring with no clinical indicators of possible infection, and the levels and trends of C-reactive protein concentration are reassuring. The usual duration of antibiotic treatment should be 7 days for babies with: positive blood culture, and those with a negative blood culture but in whom there has been strong suspicion of sepsis Consider continuing antibiotic treatment for more than 7 days if: the baby has not yet fully recovered, or this is advisable, based on the pathogen identified on blood culture (seek expert microbiological advice if necessary). If continuing antibiotics for longer than 36 hours despite negative blood cultures, review the baby at least once every 24 hours. On each occasion, consider whether it is appropriate to stop antibiotic treatment, taking account of: the level of initial clinical suspicion of infection the baby's clinical progress and current condition, and the levels and trends of CRP concentration 5

6 AFTERCARE If there have been any concerns about early-onset neonatal infection before a baby is discharged, advise the parents and carers verbally and in writing that they should seek medical advice (for example, from NHS Direct, their general practice, or an accident and emergency department) if they are concerned that the baby is showing any of the following signs (this is contained in the standard obstetric discharge information) abnormal behaviour (for example, inconsolable crying or listlessness) unusually floppy has developed difficulties with feeding or with tolerating feeds has an abnormal temperature unexplained by environmental factors (lower than 36 C or higher than 38 C) has rapid breathing has a change in skin colour. If a baby has been treated for suspected or confirmed early-onset neonatal infection: inform the parents and carers about potential long-term effects of the baby's illness and likely patterns of recovery, and reassure them if no problems are anticipated take account of parents' and carers' concerns when providing information and planning follow-up. When a baby who has had a group B streptococcal infection is discharged from hospital: advise the woman that if she becomes pregnant again: o there will be an increased risk of early-onset neonatal infection o she should inform her maternity care team that a previous baby has had a group B streptococcal infection o antibiotics in labour will be recommended inform the woman's GP in writing that there is a risk of: o recurrence of group B streptococcal infection in the baby, and o group B streptococcal infection in babies in future pregnancies. If the woman has had group B streptococcal colonisation in the pregnancy but without infection in the baby, inform her that if she becomes pregnant again, this will not affect the management of the birth in the next pregnancy. INTRAPARTUM ANTIBIOTICS Maternal antibiotics should be provided as per the RCOG Green Top Guideline (No.36) and according to the Maternity unit guideline at the Royal Berkshire Hospital. Any baby born to a mother who has received intrapartum antibiotics should have vital signs and clinical condition monitored for at least 12 hours (at 0, 1 and 2 hours and then 2- hourly for 10 hours) using the Baby Observation Chart. Any abnormal observations should be acted upon. The baby should be treated using the red-flag/non-red flag indicators as above. 6

7 Late onset sepsis These are often infants who are on Buscot but consider altering treatment for infants presenting after hours on the postnatal ward. The main consideration should be the higher risk of meningitis in these infants which often does not present with the classic symptoms seen in older children or adults. Also antibiotic choice should reflect the potential causative organisms. Management Late Onset Sepsis in Neonates SYMPTOMS MANAGEMENT FIRST LINE ANTIBIOTICS Respiratory Distress (Grunting is always abnormal at this stage) Increased Ventilatory requirements Paediatric Review If sepsis suspected clinically Partial Screen Low threshold for LP particularly if neurological symptoms or signs Commence IV Antibiotics If on postnatal ward admit to Buscot for observation Flucloxacillin and Cefotaxime Increased CPAP time Unwell neonate, signs or symptoms suggestive of sepsis Paediatric Review urgently Partial Screen including CXR and urine LP when clinically stable Supportive care Flucloxacillin and Cefotaxime Commence IV Antibiotics Signs or symptoms suggestive of NEC or intra-abdominal sepsis Paediatric Review Partial screen Abdominal X-ray NBM with ng tube Cefotaxime, Flucloxacillin and Metronidazole (Cefotaxime and Flucloxacillin if umbilical flare only) Commence iv antibiotics Signs or symptoms suggestive of sepsis with a percutaneously inserted central catheter ( Long-line) or umbilical line insitu Paediatric Review early Examination of catheter insertion site Partial Screen including CXR and urine Consideration of LP if clinically stable Commence IV Antibiotics Supportive care Consider line removal ( see below) Cefotaxime and Vancomycin When using Vancomycin, check renal function prior to commencement and ensure that levels are taken (pre the 3rd dose) and acted upon Deterioration or failure to improve on first line antibiotics Clinical Review Repeat blood cultures LP if not previously done Consider viral/fungal infections Consider Hidden infection e.g. endocarditis or osteomyelitis or line infection Options to be discussed with consultant - Ceftazidime - Meropenem - Gentamicin - Vancomycin 7

8 When to consider the removal of a Long-line We are often faced with a preterm infant who is clinically septic with a long-line in situ. This long-line may be providing vital nutrition or delivering important medication (e.g. Inotropes) and vascular access may have proved extremely difficult previously. The table below gives guidance as to how to manage this problem, most importantly ensure alternative venous access is secured before removing any long line and discuss with senior staff. In some cases it may be appropriate to remove the long line before culture results are known Culture Result Management Positive Blood Culture Coagulase Negative Staphylococci (CONS) If clinically stable and the long-line cannot be removed Antibiotic treatment for minimum 7 days Re-culture at 5 days and if BC negative continue antibiotic treatment for 7 days in total Any suggestion of deterioration or failing to achieve negative cultures then remove the long-line If long-line removed Treat until negative cultures and for at least 48 hours after long line removal All cases should be re-cultured after completing course of antibiotics Consider monitoring CRP Positive Blood culture Remove the long-line after the successful placement of peripheral line Staphylococcus Aureus, Gram negative organisms or Fungus Treat according to organism type Negative culture clinically stable Leave line in situ Consider stopping antibiotics after cultures negative (at 36hrs) or treat as suspected CONS sepsis Careful on going assessment if antibiotics stopped after only 48 hours Low threshold for restarting antibiotics Negative culture not improving or clinical deterioration Remove the long-line after the successful placement of peripheral line Treat with antibiotics for at least 48 hours after line removal Re-culture Consider broadening antibiotic therapy and antifungals if not improving 8

9 Investigation of Invasive Fungal Disease in Neonates Fungal infection should be considered if the following risk factors are present. Urine and blood cultures should be sent however more extensive investigations and treatment should not be commenced without prior discussion with the on call neonatal consultant. Risk factors Late onset sepsis Infants < 1500g or < 25 weeks Unexplained thrombocytopenia Unexplained hyperglycaemia Infants receiving prolonged/multiple courses of antibiotics Infants with central line and TPN administration Use of ranitidine/omeprazole Post abdominal surgery Poor skin integrity Infants not improving on first line antibiotics Oral or perineal Candidal rash Investigations Candida can be difficult to detect and treatment may need to start based on clinical suspicion before infection confirmed Prolonged blood culture (need to add comment on blood culture request) Repeat blood cultures (samples can be intermittently positive) CSF culture ( high risk of meningitis in systemic infection) SPA/catheter urine for hyphae and fungal culture CXR CSF After discussion with senior medical staff the following can also be considered Ophthalmology assessment for chorioretinitis Liver and renal ultrasound Echocardiography Treatment Liposomal Amphotericin B intravenously for 3 weeks (2 weeks post last positive culture) o Test dose required with monitoring of renal and liver function during usage (see cbnf) Removal of central line once peripheral access obtained NB Localised skin or oral infection can be treated with simultaneous administration of topical and oral preparations in term well infants but investigation, monitoring and treatment of invasive fungal disease should be considered for high risk infants. 9

10 Patient Details Date Baby Observation Chart Time o C o o o o o o o Resp Intermittent Grunting Continuous grunting Mild Recession Significant recession Colour: pink/blue/pale BM Fed Vomited On heater On phototherapy Signature Observations should be recorded 2-4 hourly for hours and daily if on IV antibiotics unless Paediatrician advises additional checks Values falling outside of the shaded areas should be discussed with the midwife in charge and the Paediatrician informed. Please also notify the Paediatrician if any other concerns. Date Time Reason for observations BMs required Drug withdrawal scoring required SIGNED Title 10

11 Well infants All infants require a set of observations at birth prior to transfer to the postnatal wards and a second set at 4 hours of age. If first observations are abnormal take corrective action (e.g. for low temperature) consider Paediatric review and repeat observations 1-2 hours later with Paediatric review if observations not improving. At risk infants in the following groups require further observations at 1hr and 2hrs of life and thereafter 2hrly for 12hours. 1. Sepsis Risk 2. Significant Meconium (defined as dark green/black liquor that is thick and tenacious or meconium stained liquor with visible lumps of meconium) 3. Group B Strep i. If GBS positive swab in this pregnancy or invasive GBS in previous neonate irrespective of whether mother has received intrapartum antibiotics ii. If GBS swab positive in previous pregnancy (but not invasive disease in previous baby) and not screened in this pregnancy irrespective of whether mother has received intrapartum antibiotics Other situations: If any abnormal observations in previous 12 hours: Continue 4 hrly for further 12 hours after clinical review Infants on iv antibiotics: once daily after first 24hours whilst still on iv therapy A baby born to a mother who was GBS swab +ve in a previous pregnancy (with no invasive GBS in that baby), and swab negative in this pregnancy does not additional observations. Any concerns or abnormal observations should be discussed with the Paediatrician Any infant requiring more than 2 reviews by the ST1-3/FY Neonatal doctor/annp for the same problem should be discussed with the Neonatal Registrar. 11