Yeah.
Mhm.
Mhm.
Mhm.
Good day.
Today we're gonna talk about neonatal bacterial
sepsis.
This is a really crucial subject for
everyone who cares for babies to really be very
knowledgeable about.
Uh It is one of the most common causes of
death in both premature and full term infants.
So it's really a crucial subject that we
all know a lot about.
Now.
We're today we're just gonna talk about bacterial sepsis.
We're not gonna talk about acute viral infections
in the newborn.
Uh For one main reason we don't know too much about him and
very few places have the facilities to do viral cultures.
However,
viral infections,
acute viral infections are probably quite common.
Maybe just as or more common than bacterial
infections in the newborn.
But we really don't know too much about them again because we
really,
most places don't have facilities for culturing viruses.
So today we're just gonna talk about neonatal
bacterial sepsis.
And I'm gonna divide the the discussion or talk up
into two parts.
The first half is going to be on general bacterial
sepsis,
And the second half is going to be specifically on
group B.
Streptococcal Septicemia,
which is an extremely common
problem occurring especially over the past five or
10 years.
First let's go and talk about
the pathogenesis of neonatal bacterial
sepsis.
That is how uh the bugs get into the
kid.
And we'll look at the first slide where we
have the three main routes of
infection.
The first one is the trans placental route
and this is pretty uncommon as far as the cause of
bacterial sepsis in the newborn.
Uh And in fact it's quite rare if it occurs much at
all.
Uh The second uh
source of infection in the newborn is the a
sending route now that we mean where
the bacteria comes usually
from the maternal vagina and a sends up through the
birth canal uh and into the
amniotic cavity and infects the
fetus.
This of course,
is probably quite common,
especially when there's evidence of an munitis
or prolonged rupture membranes.
The third type of
of pathogenesis is the postpartum
uh postpartum acquired infections.
And uh in this case as with the a sending
infection,
the bacteria probably comes across the
the gastric
gastrointestinal or the respiratory
mucosa.
It may be acquired during delivery again from
the germs in the bacteria in the maternal vagina.
Uh And it's frequent uh with asphyxia and a
lot of other problems which we're going to discuss in just a minute.
And that's the next slide.
The perinatal events which
make one suspect that a baby,
a fetus or newborn might be
susceptible to infection.
And all these things should make one think
gee this kid might be infected.
I'd better worry about it.
That includes maternal fever,
maternal urinary tract infection,
prolonged rupture of membranes and by prolonged rupture of
membranes.
Uh Most of the time we mean greater than 18 to
24 hours of of of rupture of
membranes.
And of course if there if the amniotic fluid is foul
smelling or there's evidence of Ambien itis doesn't really matter
whether the membranes eruption long time or not.
It's still very suspicious for neonatal
sepsis,
prolonged labor,
low birth weight premature infants.
If there's meconium staining,
if resuscitation is required,
that is the baby had a low app guard if there are congenital
anomalies,
uh if surgical procedures like umbilical
catheterizations,
uh chest tube placement or any
major surgery is required.
And as I said before,
low apgar scores,
all of these things should make us
think gee this kid might be
susceptible to neonatal sepsis.
Uh Now you have to think about it in
order to pick it up and neonatal sepsis.
You don't get too many second chances uh
if you don't make the diagnosis uh and the
baby is not treated,
the chances are the baby will go on and die.
So anytime the history
gives us one of these events
which suggests in neonatal sepsis,
we ought to really think very seriously about it.
Now one other thing that I didn't mention there
is hand washing,
and the next slide shows our
beloved dr smith,
he's a radiologist.
And this is I think the second time in five years that he has ever been in the newborn
nursery.
But it shows that even though he's only been up in the nursery twice in
his life,
he does know that he's got to wash his hands
before touching a baby and I don't know what a radiologist
would do touching a baby.
But sometimes they do uh
washing the hands before examining the baby's
is absolutely crucial.
As far as infections that are required within the nursery.
The most common source of infections are
dirty hands from personnel caring for the
babies.
So it's absolutely mandatory that
anyone who touches a baby in the newborn nursery
must wash their hands before hand.
Things like gowns and gloves and masks
may or may not be used depending on the circumstances.
But washing the hands is absolutely the
most important thing.
And anyone who is caught touching a baby without
washing their hands ought to get their hands slapped.
Okay,
Now,
what about the bacteria that cause neonatal
sepsis?
What type of germs caused sepsis?
Well,
there are a lot different than the types of bacteria that cause
septicemia saying you or I or in a three month old or a
six month old.
And the next slide lips lists The
most common causes of neonatal sepsis over
the past 30 or 40 years.
And as we can see back in the forties,
Group A beta strep was the most common
cause of infection in the newborn,
One of the more common causes.
Now this is the same strep that causes strep
throat and rheumatic fever and and things like that.
Uh Now in the fifties,
staph aureus became a very common cause of neonatal
sepsis.
And in the sixties uh e coli and other
gram negative organisms were the most common
cause Today.
The 1970s,
it's by far,
group B streptococcal infections.
Now,
these are fairly unique to the pregnant
woman in the newborn.
Uh and that's why we're gonna spend an awful lot of
time in the last half of this.
Talk on group B strep infections in the
newborn.
Uh the next slide shows us
the lists of organisms
uh that can cause sepsis
bacterial sepsis in the newborn.
And these include Group B beta streptococcal
infection.
And from now on throughout this talk,
I'm going to use this abbreviation G B B S for
Group B beta hemolytic streptococcal infections,
and E.
Coli is by far the second most common
cause.
These first two causes Group B strep and E.
Coli constitute by far the greatest majority,
the great majority of uh causes of
neonatal bacterial sepsis.
Some other things that can cause sepsis,
other germs are Klebsiella and arab actor
Proteus pseudomonas,
staff,
enterococcus and Listeria.
Now we know what germs,
We know the history that that should make us think of neonatal
sepsis.
We know what bugs cause it.
What about the clinical symptoms?
Pathology.
Well,
and you or I we know what the clinical symptoms are,
high fever,
shaking chills.
Uh,
and same with the six month old baby or,
you know,
two or three year old child.
Those are pretty much the same symptoms
altogether different in the newborn.
The symptoms I have seen on the next slide.
I didn't put much down there all.
I said,
we're symptoms and signs non specific.
And what does that mean?
Well,
that means probably the most common symptom is
the baby is not doing well.
The mother or the nurse says,
chief,
this,
this baby is just not acting properly.
Uh,
maybe the baby is not feeding well.
Maybe the baby spitting up.
Maybe the baby is having a little bit of loose
stools.
Maybe the baby is a little jaundice.
Maybe he's got a high temperature just as likely
though,
that he has a low temperature or a normal temperature.
So,
a normal temperature in a newborn does not
ever rule out the possibility of infection.
As I said,
it's just as likely that the temperature will be normal as it is,
that the baby will have a high temperature or low temperature.
However,
if the temperature is high or low and that
absolutely means the baby has neonatal sepsis
until proven otherwise and a high temperature or a
low temperature.
And a baby is an absolute indication for
doing cultures and beginning therapy for
neonatal sepsis.
Just the other day,
one of our nurses delivered a baby up
here on our nursery and the labor was
totally unremarkable.
The pregnancy was unremarkable.
Full term baby.
The app guards were good membranes were ruptured very
long.
And the only thing in the observation
nursery,
the baby's temperature just wasn't quite normal.
He had to be bundled up in order to keep his temperature normal.
And I asked the nurse,
I said now how often does that occur in a full term
baby?
And the internal resident were with me and she said it's very
unusual.
She said this this almost never happens in the observation nursery.
That we have problems keeping the full term babies temperature up and have
to bundle the baby in order to keep the temperature up.
So the intern and resident immediately uh did
culture started therapy.
And sure enough the next day the blood culture grew up,
Group B strep had they waited on that baby
another 24 hours or so until the baby was really
sick.
The chances are the baby wouldn't be around today.
So when it comes to symptoms and signs of
sepsis in the newborn,
you've got to have a high index of suspicion.
And in general any time a newborn
baby is not acting properly,
you have to consider sepsis.
And usually I like to teach people that anytime a
kid is anything but normal.
A newborn,
there are two things you always have to consider
hypoglycemia and sepsis.
And those are two things that you don't wanna miss because the
longer you miss them,
the more likely the baby is either going to die
or develop long term
uh,
residual central nervous system abnormalities because you
didn't pick up the problem and start
treatment immediately.
Okay,
so symptoms and signs are tough.
But in general,
if a baby is not normal,
think of sepsis.
Okay,
now let's say we've got a baby that,
that we're thinking about sepsis.
Uh,
what does that mean?
You do?
Well,
in an older person,
uh,
you do a culture,
maybe a few cultures and you watch the baby.
Well,
it's a whole different ball game.
Uh,
in the newborn,
Also in an older person,
you look at the white cot If it's normal,
you think,
well that's pretty unlikely whole different ballgame in the
newborn.
There are a few things that must be done in
every newborn that you consider sepsis.
And let's look at these the most important thing.
Our cultures.
Okay.
Blood culture,
preferably two cultures.
CSF spinal fluid,
LP urine culture,
which we're gonna talk about in a minute and a chest x ray
and no evaluation of a baby
for sepsis is adequate without these things
here,
with maybe one or two exceptions.
And now let's talk just a little bit about those,
these different things here.
The blood culture.
Okay.
Where do you do a blood culture?
Well,
if a baby's got an umbilical line in,
its been in for a few hours,
so you can't do the blood culture from the umbilical line,
you've got to do the blood culture sterile e from
peripheral veins,
like the anti cubicle vein or possibly scalp
veins.
Uh preferably you should do to blood
cultures and all of us who have dealing
with newborns know how anemic some of these
blood cultures can be.
You know,
you see someone scored two or three or four red cells in the blood culture
bottle,
that's not adequate.
You should get preferably one cc but
certainly a half a cc of blood when doing a blood
culture.
Now,
what about the blood culture is by far the most
important test that must be done.
Now.
What about the spinal tap?
I think again,
when you're dealing with meningitis in the newborn there,
you can't go by the symptoms and signs that you do with older
Children and adults.
Uh If the baby has a possibility of
being stepped,
have sepsis,
you gotta think of meningitis.
That means you have to do a spinal tap.
There ain't no other way of evaluating a
baby for meningitis without doing a spinal tap.
Now there may be a couple instances where a spinal
tap is not absolutely indicated.
And I think that for example and
the extremely sick
Baby with respiratory distress who comes in
at a few hours of age and is extremely precarious,
you know is intubated on 100 oxygen.
And all you do is touch the baby and he turns black on you.
Uh and he really is precarious.
I think in those babies uh maybe it's
probably all right to do a blood culture and a urine culture
and not do the L.
P.
At that time.
Go ahead and start antibiotics.
But I think that's about the only
situation where and an L.
P.
Is not absolutely necessary for an evaluation of
sepsis in a newborn.
Any baby over a day I think where you're
considering sepsis has to have an L.
P.
And preferably all babies should have an L.
P.
Okay.
What about super pubic uh What about
urine cultures?
Well super pubic urine cultures are the best.
Now let's look at this next slide shows you a picture how to do that.
Uh You feel the baby's
pubis in the midline of course
and the bladder is right
below that.
In a little bit superior.
After one feels the pubis about a half a
centimetre or centimetres above that.
One goes through the abdomen after sterile
prep of course and hopefully enters
the bladder and aspirated the bladder of ignorance.
Now,
obviously one should do this procedure
only when the bladder is full.
Obviously you can't ask the baby if he's got a void.
So preferably what you want to do is make sure the baby has
not avoided for an hour or two,
so that the bladder is full.
Uh Super pubic taps are not
totally benign,
they are dangerous.
Uh uh One has to be
careful of doing super pubic taps and I don't think one should do
them if if you've never seen it done and never
never have the opportunity to observe the procedure.
But you should,
if one is taking care of sick newborns,
they should learn how to do super pubic because it's the only
really good way of getting
urine for culture.
Clean voided catches so called clean voided catches in
the newborn are usually pretty worthless.
Uh They almost always have contaminants,
catheterization certainly can be done.
But again,
I think super pubic taps,
if done by competent people
are safe and
probably the method of choice for doing getting urine for
culture.
Remember I said it done by competent people.
All the most of the complications reported with super pubic taps,
or because they have not been done properly.
Okay.
And then the last of those four tests that were required,
I said was chest X ray.
Again,
that ought to be done in any baby where you're considering sepsis.
Because the possibility of pneumonia,
you can't rule out pneumonia and a baby by listening to his lungs.
A newborn baby.
Okay,
now,
what other tests are done for sepsis?
Let's look at a few other tests on the next slide.
I like to use a platelet count and kind of a screening
tool for sepsis.
It's low in some cases.
In most cases though it's normal.
What about a white count?
Well,
in the first few days of life,
of course the white count can be 2030 40,000.
And it's not really very helpful.
Uh And we're gonna talk about that in just a minute.
What about a said count?
Well in some cases uh it can be
elevated uh babies with
sepsis,
or it can be very low and the band count,
if it's extremely high,
can suggest sepsis.
But we have to worry about these tests for
one main reason they're all too
often normal in the face of florid
sepsis.
In the newborn.
For example,
the white count,
as I said,
in the first few days of life,
it maybe 20 30,000 to be normal.
Uh Now,
if the white count is very low,
Like less than 780 in the first few days of
life,
that is very worrisome,
saying with the sec counter,
that's very low,
like less than 2000 or so in the first day or two,
first first week of life,
that's uh somewhat or less than
1500 say.
Uh That's somewhat worrisome.
Uh But they're too
often cases where the
white count and the said count,
the band count are totally normal and the baby has
floored sepsis.
So if you're gonna use those tests for screening
tool,
that is,
you're going to use these tests to to routine
and look at a whole group of babies and say,
gee that kid has an abnormal white counter.
Platelet counter said Count.
I wasn't thinking about sepsis in him,
but gee,
since this is abnormal,
I better think about it.
I think that's okay.
You must never never,
never use those tests to
say this,
you must never use them to say,
well,
this kid's kind of sick and I had to think about
steps,
but the white count's normal or the said counts normal.
I won't worry about it if you ever do that,
that's when you're gonna get into trouble.
So if you use them as a screening tool,
fine and dandy.
But if you use them to rule out sepsis in a suspicious
infant absolutely wrong.
The same thing goes with other tests like
gastric aspirate for Polly's and cultures.
Uh Said rates.
Nbt tests all the other tests that have been
evaluated as for for sepsis in the
newborn there.
Okay to use the screening tools,
but never,
never,
never find yourself caught in the trap
where you're ruling out sepsis in a
suspicious infant.
Because those tests are normal.
The only way to properly
evaluate a baby for sepsis must
include a blood culture,
a spinal tap,
a urine culture and a chest X ray.
And without those tests,
it's an inadequate evaluation of a baby for
sepsis.
Okay,
let's go on to therapy.
What about therapy?
Well,
what about antibiotics?
First of all?
Uh the antibiotics usually recommended are
ampicillin,
100 to 200 mg per kilogram per day
ivy or penicillin.
100,000 to 200,000 units per kilo per day
ivy.
That's one of those two.
Plus.
The next slide.
Can a Mason 15 mg per kilogram per
day.
I am.
Or Jenna mice in 5 to
7.5 mg per kilo per day.
I am.
Okay.
Now,
there,
those are just kind of rough guidelines
ideally.
The drugs of course should be
decided upon depending what organism grows.
That's what you do in adults frequently.
But you can't do that in the newborn once you suspect
sepsis,
you have to do the cultures and start the antibiotics.
Okay,
you can't wait until the cultures come back because by that time if the
kid truly is septic you'll die,
you'll be dead by that time probably.
So as soon as you suspect sepsis you do the cultures
and you start the antibiotics.
Now.
What about ivy versus I am.
Well certainly any baby that has meningitis must have
I.
V.
Antibiotics.
Any baby who has hypotensive or not
doesn't have good peripheral profusion of the skin
must have I.
V.
Antibiotics.
Now,
any baby problem that is a small small
premature a little teeny weeny
kid,
you can't give shots.
I am too.
He doesn't have enough m muscle to give I am shots too.
So every small premature baby should get I.
V.
Antibiotics also.
Now I don't think that I.
V.
Antibiotics are absolutely necessary in every newborn
baby.
You evaluate for sepsis.
I think that if the baby is tolerating
feedings well which is not very often in kids who are
really concerned about sepsis.
But if that's the case or if the kid is improving
uh and you've already had him on I.
V.
Antibiotics for three or four days and the cultures uh
come back negative but you're gonna continue for a few more days.
And and the kids a big kid he's got good blood pressure,
he's acting fine.
I think that I am antibiotics are okay in that
group.
I don't think that every single newborn has to have I.
V.
Antibiotics but don't extrapolate that
please and don't say.
But I heard Rich Shriners say that you could use I am
antibiotics and all newborns with sepsis.
That's not the case.
Most sick babies
especially premature babies,
babies with meningitis,
babies who have poor profusion meaning their
hypotensive or they're they're not refusing their
skin,
peripheral tissues well must have I.
V.
Antibiotics.
Okay.
What about the drugs?
Well again ampicillin,
penicillin.
Uh generally to cover the grand positive
caucus like Group B.
Strep and Jeremies and contamination to
cover the gram negative organisms like E.
Coli.
Obviously if you're cultures come back positive
and you may want to change your antibiotics
according to the cultures or you may want to discontinue one
antibiotic.
There are some circumstances where you may think of some other
organism like you may think of back to Reuters because the kid
has a perforated gut.
And in which case you might want to use a different drug like
Clarkson or chloramphenicol.
But in general we start out with either with
ampicillin or penicillin and canonizing
Arjuna.
Missing ideally the doses should be
regulated according to the disease.
For example,
meningitis versus pneumonia.
Uh whether the baby's full term or term
and whether the baby's uh less than a
week old or more than a week old.
And your standard textbooks,
the recent ones and recent articles on
evaluate the drug treatment and drug doses.
You can look up these uh specific doses
for each of those circumstances in there if I told you now,
you wouldn't remember him anyway because I can't remember him either.
Okay,
now I just want to reemphasize about treatment.
You've got to start the antibiotics as soon as you do the
cultures after you thought of acceptance and the kid,
you can't wait till the cultures are negative.
Now one other aspect,
there's more than just antibiotics in the treatment of babies with
sepsis and that's the next slide shows the complications of
sepsis.
And essentially what that means is we need to watch for these
complications and we need to treat these complications as they
occur,
disseminated intravascular coagulation and that's why
if the kid is using the acceptance,
we do clotting studies.
And of course we look for platelets because low platelets are
common with sepsis.
Hypertension must be watched for and treated
acidosis,
metabolic acidosis must be watched for and
treated.
Hypoxia must be must be watched for
it.
And of course prevented.
And that's why you want to always provide adequate oxygen to these kids.
Hyponatremia is common again,
must be watched more closely.
These babies frequently have an alias and can't be fed.
Meningitis may develop and that's why of course we always do
lPS.
You may see osteo myelitis,
you may see arthritis.
Otitis hypoglycemia is a common
problem with sepsis and again,
you have to look for it in order to find it.
If you wait till the kid is seizing,
it's too late john this is also common
and you have to watch for secondary abscesses.
So all of these things should be watched
for and hopefully prevented when you're treating a baby
with sepsis.
Now,
one other thing I want to mention about about working a baby
up for sepsis,
neonatal,
bacterial sepsis and your culture,
as far as how often you do it remember that most of the
time your culture is gonna be negative if most of the babies
that you evaluate for sepsis really our septic,
you're not doing a good job.
Uh At least Eight or nine out of
10 babies where you culture and look for sepsis really.
The culture should be negative because if
you're every single baby,
you evaluate perceptions really has sepsis.
You must be missing babies.
There is no one in the world who is good enough to look at a
baby and uh just examine the baby and say
for sure whether he has sepsis or not.
So,
a good physician usually will find that
most of the cultures that he does,
as far as blood cultures,
yearning spinal taps are negative uh and only a
small percentage will be positive.
But when you're talking about a disease as bad as sepsis with
such a high mortality,
that's the way you've got to obviously play the game.
You gotta treat pick up,
you got a suspect and treat more kids than actually have
it.
Now,
when do you discontinue antibiotics?
Well,
if the cultures are negative and the kid is doing fine and
you're convinced it's not sepsis,
I usually stop after 34 or five days.
Uh Of course if the baby has
Septicemia,
then you continue for at least 10 and
possibly 14 days.
And if it's meningitis,
that's a whole different ball game.
And we're not gonna talk about that right now.
Okay now let's the second half of this uh
session let's talk about group B strep
infections and uh that's the reason
I'm doing that is because it's such a common problem.
Now it's by far the most common cause of neonatal
sepsis.
Uh And let's look at the first slide as far as the
classification of of actually this should be just
classification of strep in general.
Uh The strips are classified as far as group A group
being groups et cetera.
As to the policy Sacha ride which is common to
all strep and uh at least all beta
strep.
And so group B.
Has all the group B beta strap have a particular group B.
Policy Sakurai which is common to all of them.
Now.
In addition the group B strep are divided up
into types one A.
B.
C.
Type two and Type three.
And that's cyril logic
classification is determined by the specific
type specific policy.
Sacco ride on the capsule
of the bacteria.
Uh Okay now what about how
common is is group B
strep and how what's the
magnitude of the problem in relation to society in
general?
Well I think the next slide will give you a little bit of idea
as as far as what kind of problem we're talking about.
Mhm.
Roughly 3 to 40% of all
pregnant females have group B.
Strep in their vagina in the third trimester.
Now that's a wide variation of number.
And we'll talk about why that varies so much a little bit later.
It depends upon what study what city you look at.
1 to 20% of all newborns will have Group B
strep on their skin and their mouth throat around the
umbilical cord.
That's a lot of babies.
If it's if it's 20% and even 12 or
3% is a lot of babies.
When you talk about the whole country in the whole world,
neonatal,
Group B strep sepsis and meningitis.
That is positive blood cultures and CSF cultures
occur in 2 to 3 per 1000 live births.
Again,
that's a pretty common problem,
especially when you when you appreciate the
magnitude of the mortality
etcetera.
The fatality of Group B strep
sepsis and meningitis is somewhere between 3 30
80%.
Depending on what series you look at,
that shows you how serious of a disease we're talking about.
And the other very important thing that's just been
that's just come up the past few years is that a very high
percentage of hospital personnel have Group B
strep their colonized with Group B strep in their
nose,
throat,
on their skin or in the vagina and in some series as high as
45% of Obi and nursery
personnel have Group B strep.
Okay.
Group B strep infections in the newborn
have generally been divided into early
onset infections and late onset.
And by early onset infections,
we usually mean infections in the first week of life,
usually in the first day or two of life.
And on late onset,
we usually mean after the first week of life and anywhere
up to about a month or a month and a half of age,
sometimes two months of age.
Okay,
now we're going to the symptoms and signs and
problems with early onset are somewhat
different than late onset infection.
So first let's look at those babies who
present with Group B strep in the first week of life.
Okay.
And this is the next slide.
first of all there frequently,
although not always low birth weight premature babies.
They also frequently present with respiratory
distress.
And uh this is respiratory distress that
clinically can't be differentiated from any other cause of
respiratory distress.
They may have apnea.
And I think that any baby premature or
full term who has apnea in the first day or
day and a half or two days of life must
seriously be considered to have possibility sepsis.
And especially Group B strep sepsis,
they may present with hypotension or shock.
And in general,
the organisms that your culture are the
same as the organisms in the
mother's vagina.
And that's why it's thought that early onset
Group B strep usually uh
comes from uh infection during the birth
process and the baby occurs,
it acquires it from the mother's vagina.
Now,
other things uh as far as early onset Group
B strep include that frequently.
There are obstetrical complications
such as prolonged rupture memories,
but not always.
And as I said before,
the respiratory distress is identical
clinically to respiratory distress syndrome or highland
membrane disease,
or transient to keep near the newborn or wet lung or
RDS type to whatever terminology you like
to use.
And that's why I think that any baby with
serious respiratory distress in the
first day or two of life should have cultures
done and be started on antibiotics until the cultures are negative
because there is no one who can rule
out Group B strep as the cause of that respiratory
distress.
Now,
as we said before,
there's a very high mortality,
especially with early onset strep
When meningitis is present,
which is not very common in the early onset,
it's usually type three.
Okay,
what about the chest x rays?
With early onset?
Group B strep?
The next slide will show you what the chest x
rays can look like.
We already said that clinically the kids can have respiratory
distress quite similar to any other cause of
respiratory distress.
Well frequently the chest X rays are normal and
again that doesn't mean anything as far as ruling out infection.
They also may have a typical pattern of highland membrane
disease and I don't know whether the baby,
the baby probably has both highland memory disease and Group B
strep in those situations,
they also may show a typical pattern of transient ticket
nia or wet long or RDS,
type two.
And many of these babies,
although again,
not all,
but many of them will have pleural effusions.
The last two kids,
In fact,
we had the nursery that came in with respiratory distress.
They had a clinical picture of transient ticket.
I mean a radiographic picture of transient apnea with
good sized pleural effusions and both of them had Group B.
Strep infections.
Okay,
let's look at a couple X rays.
Okay,
now this X ray here looks fairly typical for
transit to keep near wet lung.
There's a patchy kind
of uh interstitial infiltrate
radiating from the highlands.
And as you can see here,
there's some fluid in the fishers.
And this is a baby who won quite likelihoods they
had transit to keep near wet lung.
But this baby had group B.
Strep sepsis.
And that's why you have to think about it anytime.
You have a baby that has an X ray picture like this,
about the next slide shows a baby with an X ray
that looks like severe highland membrane disease.
You can see the endotracheal tube in there's air bronco
grams,
there's a diffused granular appearance.
It's so severe,
you can't even see the hard border hardly.
Uh And the baby has hypo ventilation with the
diaphragms way up in a small chest.
Well,
this these are X rays that are typical
for transit to kidney and highland membrane disease or respiratory
distress syndrome.
But both babies had Group B strep
septicemia.
And again,
that's why I emphasize that.
I think any baby with moderate or
severe respiratory distress should have cultures
done and should be placed on antibiotics as
if he has Group B strep until the cultures are negative.
Again,
if you miss it,
well,
it's too late.
You know,
the baby's gonna die.
Whereas the other supportive treatment like oxygen
and fluids and temperature control and blood pressure
control is the same.
No matter whether the kid has Group B strep or just
highland membrane disease,
or just transient to Kipnis.
Okay.
Uh what about late onset Group B strep?
That is that occurs after the first week of age?
Uh Well,
first of all the types,
that is whether it's type one abc,
type two or type three are usually not the
same as in the vagina,
which makes us uh lead to think,
leads us to think that that the baby does not
acquire this infection from the mother's vagina
during delivery,
but probably acquires it somewhere else.
Meningitis is very frequent and when
meningitis is present,
it's usually Group B A,
Group B strep,
type three.
Okay,
some other characteristics of late onset strip
include that because probably because there's meningitis,
but there's a higher incidence of long term neurologic sequelae.
However,
there's a much lower mortality with the late onset Group B strep
than there is with the early onset.
And again,
you can see other infections like otitis
arthritis,
osteomyelitis,
cellulitis,
conjunctivitis can all present
uh in babies with a Group B strep
uh Meningitis uh in the late
onset type Group B strep.
Okay.
What about the treatment of Group
B strep meningitis?
That is late onset.
Uh Well obviously the same thing
goes as I mentioned in the first part of this talk on
sepsis.
Uh But there's been some problems in the past few years with
Group B strep,
there have been more cases of relapse and apparent
recurrence.
So the doses of antibiotics have been
uh brought upwards a little bit and as far as the
duration of antibiotics,
they've gone upward a little bit over the past few years.
And the next slide shows what we presently recommend
for Group B strep meningitis.
And it must be ivy penicillin,
I.
V 150 to 250,000
units per kilogram per day or ampicillin.
Ivy 100 to 200 mg per kilo per day.
And I prefer the higher doses
rather than the lower doses now.
Also probably one ought to continue Jenna missing or
Kanneh mason,
there is some evidence that
can a missing and Jenna missin.
Maybe synergistic uh with
penicillin or ampicillin for the treatment of group B strep.
Okay.
Number three uh the I.
V.
Antibiotics should be continued for at least 10 to
14 days after the spinal fluid is
sterile And number four after the
antibiotics are discontinued,
72 hours,
repeat culture should be done and the baby watch for another
24-48 hours before being
discharged.
Okay,
there are a few other things as far as Group B strep that I
just want to kind of throw in here in the next few
slides to explain one the variation and
colonization rate,
If we can explain it,
and also to explain some of the problems that we're having
as far as Group B strep and how to approach it.
The next slide uh is an explanation,
possible explanations for various variations and
colonization rates.
Remember I said that in some cities,
three or 4% of the women have Group B strep in the vagina and other
cities,
30 or 40% of the women have group B strep.
Well,
of course it could be geography,
but that's pretty unlikely,
but it's possible
socioeconomic status.
We know that that uh pregnant women
uh in lower socioeconomic groups have a higher incidence of Group
B strep.
But probably the most important
reasons to explain this discrepancy in this
variation and colonization rates are 34 and
five.
A number of cultures.
The more cultures you do want a pregnant woman from
her peri anal area,
her vaginal area,
her cervical area,
the more likely you are to find Group B strep.
Also the sites of cultures,
if you only do this,
the vaginal area,
you're less likely to find it than if you do the cervical area
and especially the peri anal area,
the culture technique.
It's been well shown that
certain types of culture media
are better for culture and group B strep.
And if all you do is culture and the routine sheep blood agar
plate,
you're much less likely to find Group B strep.
Then if your culture on a special culture medium
geared specifically for uh
growing strep.
Okay,
now how do we identify Group B strep?
The next slide shows this uh
and most of us,
none of us,
I guess our microbiologists are bacteriologist and
we have to trust our laboratory,
but there are few things we need to know.
Many hospitals in the past have just screened for
Group B strep by looking for beta hemodialysis that
is not adequate.
A significant percentage of groupie straps
will not be beta hemolytic,
there'll be non hemolytic or gamma hemolytic.
Even if you do subsurface cultures,
even if you culture and aerobically a lot a
significant percentage,
it's small but significant will be gamma or non
hemolytic.
So you have to do
biochemical and immunological methods or
serological methods to rule out Group B
strep.
Okay,
now,
what does that mean for the practicing
physician?
Well if you get a result back
that says strep gamma
strep and if it's from the blood urine,
are spinal fluid in a newborn,
baby or an infant.
You better worry that that still is Group B
strep.
And you ought to make sure the laboratory totally
evaluates it biochemically immunologically or
psychologically for whether
it's Groupie or non groupie,
uh whether it's uh gamma hemolytic
or beta hemolytic.
So no matter whether you're result comes back,
beta hemolytic strep or gamma he gamma
strap,
make sure the laboratory in every
strep that's grown uh from a
baby who has from his blood,
urine or spinal fluid.
Make sure whether it's gamma or beta.
That they totally evaluated for whether it's Group A group B
etcetera.
Okay,
now what kind of problems do we still
have?
We got some real critical answers as far as Group B strep that
we need to get questions that we need to get the answer
to.
And this is what a lot of the research is going around the
country uh is concerned with right now.
And the next slide shows some of these uh
shows some of these questions.
Number one,
what about antibiotic treatment in pregnant females?
Uh And it would seem that gee why
not take every woman who has Group
B.
Strep and culture and treated with penicillin?
Well,
there a number of problems there.
Number one,
as I just mentioned before,
if you just do one culture or two cultures are three culture
and you just culture the cervical or the vaginal
or the peri anal area,
you're quite likely not to find group B strep.
And then if you do a whole bunch of cultures,
a whole bunch of sites.
In addition,
if you just use a regular sheep blood agar that most
laboratories use,
you're not nearly as likely to find a group B strep.
And if you use special culture medium.
In addition,
there is no evidence whatsoever that if you treat the
mother for a week or 10 days that you'll get rid
of the strip.
And in fact,
in newborn babies with Group B
strep sepsis or meningitis,
who received 10 14,
21 days of parental penicillin or
ampicillin.
Many if not most of those babies,
we'll still be colonized on the skin,
nose or throat or pharynx with Group B
strep when they're done with antibiotics.
So there's a real question whether even treating the woman will get
rid of the get rid of the Group B
strep.
Now,
remember also the number of women that you're talking about if
in fact 10,
20 or 30% of women have Group B strep in their
vagina.
You're talking about treating hundreds of thousands and
millions of women uh in
the world with large doses of penicillin.
And what effect is that going to have on those women as far
as uh causing
penicillin,
allergy and anaphylaxis?
While we might be killing more women from penicillin
anaphylaxis than saving babies.
Because remember that only about one out of
100 of those mothers and probably not even quite that
many will have a baby who gets sick with the
Group B strep.
So just saying,
we're gonna culture every pregnant woman with group B strep in the vagina is
not the answer.
Only research is going to tell us.
Now.
The next question there is.
What about venereal transmission?
And then what about treatment of the infants?
And we'll talk about both of those now.
Well,
there's good evidence now that the male can have Group B strep
too.
And if you treat the mother,
of course,
you've got to treat the mail and of course that just doubles the number of
patients you're gonna treat.
Uh if you're talking about treating pregnant women with Group B
strep.
And so we don't know enough about the venereal
transmission of it yet to to make that decision.
What about treating the infant?
Well,
as I said,
first of all,
even if the kids colonized with Group B.
Strep,
uh there's no evidence that you're going to get rid of the strip that the
baby is colonized with.
Ah There's.
What are you gonna do?
You gonna treat the baby gonna give one dose of penicillin?
Well,
what about the babies that really get Group B.
Strep sepsis and meningitis?
Maybe you're going to mask the disease so that you don't pick it
up until it's too late.
If you only give one dose of penicillin,
which babies are you gonna treat?
You're gonna treat every baby whose mother has group B
strep in her vagina?
Or are you gonna treat just the babies who have Group B.
Strep colonized?
Well,
if you wait until treat the babies and your culture comes back
in 24 48 hours.
We already said most babies with Group B strep
sepsis and early onset already
have Are already sick at
24 48 hours.
In addition,
as far as treating the kids with late onset,
that won't help at all,
because we already said that it's very unlikely that
late onset Group B strep even comes from the mother's
vagina probably comes from somewhere else.
There's also recent evidence suggesting
that many cases of early onset
groupie colonization.
Early colonization in the first week of life do
not come from the mother's vagina,
but that the baby may have a negative culture at birth or two
days and then at 345 or six days,
the baby may have a positive culture.
So as far as treating the infamous concern,
we still don't know.
And that's why I don't think that we should routinely
at this time say let's treat every single mother or every
single baby where there's colonized with Group B strep.
I think rather we should keep a very high index of
suspicion.
And in any newborn who is sick,
who has any of those signs.
We mentioned that we ought to consider Group B.
Strep sepsis culture and begin therapy.
Okay.
A few other questions that we have to answer.
What about the role of hospital personnel?
As we said,
a large percentage of hospital personnel may carry Group B
strep.
And what do we do with that?
We don't know.
We just don't know.
We'll have to wait till studies are done.
What about maternal antibodies?
Uh if mother has
antibodies in her blood to Group B strep,
will that prevent the baby from being sick again?
We don't know these are studies that were
very much involved with right now.
And that's why we have requested from every
physician in indiana whenever he gets a baby that has a
positive blood,
urine and spinal fluid culture to call us
immediately so that we can work with him getting
samples of blood and urine from the baby,
Blood from the mother.
Uh so that we can evaluate the effect of
antibodies from the mother on the baby as far as
uh prevention or or whether
it's related at all to whether the kid gets sepsis or meningitis.
In summary.
I'm afraid we've got a lot more questions that we have
answers when it comes to Group B strep and all of those
questions I just proposed to you.
I don't have any answers to it.
This time we have to wait until the research
gives us the answers.
However,
in the meantime I just want to reemphasize.
I think that just with as you're thinking of any
bacteria that causes sepsis in the newborn.
When you're thinking about Group B strep,
any baby who has a history compatible with Group B
strep or has any signs or symptoms
compatible with sepsis,
including just plain old respiratory distress.
one ought to do the cultures blood,
urine,
spinal fluid and start the baby on
antibiotics until the cultures are either positive or negative.
Uh and I think it's only with that type of
approach that we're going to decrease the
mortality from neonatal sepsis and
especially neonatal Group B strep strep
group B strep sepsis.
And I think that's all for this talk.
It's been kind of long uh it's a very important
subject.
I think that you ought to go now and read some
articles and read some books on neonatal sepsis.
And let's see if all of us working together
can decrease the morbidity and mortality from this
devastating disease,
the preceding,
produced by the Medical Educational Resources
Program of the Indiana University School of
Medicine,
Me.
Mm.