WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:13.240 --> 00:13.560 Yeah. 00:14.440 --> 00:14.760 Mhm. 00:15.240 --> 00:15.560 Mhm. 00:16.240 --> 00:16.560 Mhm. 00:30.040 --> 00:30.590 Good day. 00:30.600 --> 00:33.530 Today we're gonna talk about neonatal bacterial 00:33.530 --> 00:34.320 sepsis. 00:34.330 --> 00:37.000 This is a really crucial subject for 00:37.000 --> 00:39.880 everyone who cares for babies to really be very 00:39.880 --> 00:41.090 knowledgeable about. 00:41.100 --> 00:44.020 Uh It is one of the most common causes of 00:44.020 --> 00:46.830 death in both premature and full term infants. 00:46.830 --> 00:49.500 So it's really a crucial subject that we 00:49.500 --> 00:51.860 all know a lot about. 00:52.140 --> 00:52.910 Now. 00:52.920 --> 00:55.560 We're today we're just gonna talk about bacterial sepsis. 00:55.560 --> 00:58.550 We're not gonna talk about acute viral infections 00:58.550 --> 00:59.320 in the newborn. 00:59.330 --> 01:02.180 Uh For one main reason we don't know too much about him and 01:02.180 --> 01:05.120 very few places have the facilities to do viral cultures. 01:05.130 --> 01:05.790 However, 01:05.790 --> 01:07.710 viral infections, 01:07.710 --> 01:10.600 acute viral infections are probably quite common. 01:10.600 --> 01:13.390 Maybe just as or more common than bacterial 01:13.390 --> 01:14.590 infections in the newborn. 01:14.630 --> 01:17.310 But we really don't know too much about them again because we 01:17.320 --> 01:17.760 really, 01:17.770 --> 01:20.730 most places don't have facilities for culturing viruses. 01:20.730 --> 01:23.050 So today we're just gonna talk about neonatal 01:23.070 --> 01:25.140 bacterial sepsis. 01:25.150 --> 01:28.090 And I'm gonna divide the the discussion or talk up 01:28.090 --> 01:29.050 into two parts. 01:29.240 --> 01:31.900 The first half is going to be on general bacterial 01:31.900 --> 01:32.520 sepsis, 01:32.640 --> 01:35.500 And the second half is going to be specifically on 01:35.500 --> 01:36.180 group B. 01:36.180 --> 01:37.940 Streptococcal Septicemia, 01:37.950 --> 01:40.170 which is an extremely common 01:40.180 --> 01:42.990 problem occurring especially over the past five or 01:42.990 --> 01:43.760 10 years. 01:44.640 --> 01:47.260 First let's go and talk about 01:47.270 --> 01:50.170 the pathogenesis of neonatal bacterial 01:50.170 --> 01:50.650 sepsis. 01:50.790 --> 01:53.580 That is how uh the bugs get into the 01:53.580 --> 01:54.020 kid. 01:54.060 --> 01:56.860 And we'll look at the first slide where we 01:56.860 --> 01:59.560 have the three main routes of 01:59.560 --> 02:00.270 infection. 02:00.310 --> 02:02.850 The first one is the trans placental route 02:03.240 --> 02:06.090 and this is pretty uncommon as far as the cause of 02:06.090 --> 02:08.260 bacterial sepsis in the newborn. 02:08.440 --> 02:11.290 Uh And in fact it's quite rare if it occurs much at 02:11.290 --> 02:11.670 all. 02:11.680 --> 02:14.200 Uh The second uh 02:14.210 --> 02:17.050 source of infection in the newborn is the a 02:17.050 --> 02:19.880 sending route now that we mean where 02:19.880 --> 02:22.830 the bacteria comes usually 02:22.830 --> 02:25.610 from the maternal vagina and a sends up through the 02:25.610 --> 02:27.900 birth canal uh and into the 02:27.910 --> 02:30.380 amniotic cavity and infects the 02:30.380 --> 02:30.920 fetus. 02:31.540 --> 02:32.380 This of course, 02:32.380 --> 02:33.810 is probably quite common, 02:33.850 --> 02:36.820 especially when there's evidence of an munitis 02:36.830 --> 02:38.560 or prolonged rupture membranes. 02:39.010 --> 02:41.590 The third type of 02:41.600 --> 02:44.260 of pathogenesis is the postpartum 02:44.270 --> 02:46.950 uh postpartum acquired infections. 02:47.020 --> 02:49.820 And uh in this case as with the a sending 02:49.820 --> 02:50.450 infection, 02:50.450 --> 02:53.140 the bacteria probably comes across the 02:53.150 --> 02:54.610 the gastric 02:54.650 --> 02:57.270 gastrointestinal or the respiratory 02:57.270 --> 02:58.060 mucosa. 02:58.340 --> 03:01.300 It may be acquired during delivery again from 03:01.300 --> 03:04.160 the germs in the bacteria in the maternal vagina. 03:04.440 --> 03:07.270 Uh And it's frequent uh with asphyxia and a 03:07.270 --> 03:10.030 lot of other problems which we're going to discuss in just a minute. 03:10.080 --> 03:11.450 And that's the next slide. 03:11.450 --> 03:14.030 The perinatal events which 03:14.040 --> 03:16.850 make one suspect that a baby, 03:16.850 --> 03:19.240 a fetus or newborn might be 03:19.250 --> 03:20.860 susceptible to infection. 03:20.860 --> 03:23.760 And all these things should make one think 03:23.840 --> 03:25.780 gee this kid might be infected. 03:25.780 --> 03:26.910 I'd better worry about it. 03:27.180 --> 03:28.850 That includes maternal fever, 03:29.340 --> 03:31.270 maternal urinary tract infection, 03:31.440 --> 03:34.150 prolonged rupture of membranes and by prolonged rupture of 03:34.150 --> 03:34.840 membranes. 03:34.850 --> 03:37.450 Uh Most of the time we mean greater than 18 to 03:37.450 --> 03:40.350 24 hours of of of rupture of 03:40.350 --> 03:40.800 membranes. 03:40.800 --> 03:43.640 And of course if there if the amniotic fluid is foul 03:43.640 --> 03:46.540 smelling or there's evidence of Ambien itis doesn't really matter 03:46.540 --> 03:48.450 whether the membranes eruption long time or not. 03:48.460 --> 03:51.070 It's still very suspicious for neonatal 03:51.070 --> 03:51.640 sepsis, 03:51.870 --> 03:53.030 prolonged labor, 03:53.280 --> 03:55.320 low birth weight premature infants. 03:55.630 --> 03:57.150 If there's meconium staining, 03:58.540 --> 04:00.230 if resuscitation is required, 04:00.230 --> 04:03.130 that is the baby had a low app guard if there are congenital 04:03.130 --> 04:03.930 anomalies, 04:04.340 --> 04:07.020 uh if surgical procedures like umbilical 04:07.020 --> 04:08.390 catheterizations, 04:08.400 --> 04:10.820 uh chest tube placement or any 04:10.820 --> 04:13.430 major surgery is required. 04:13.510 --> 04:14.600 And as I said before, 04:14.600 --> 04:15.760 low apgar scores, 04:15.770 --> 04:18.420 all of these things should make us 04:18.430 --> 04:20.910 think gee this kid might be 04:20.910 --> 04:23.210 susceptible to neonatal sepsis. 04:23.440 --> 04:26.420 Uh Now you have to think about it in 04:26.420 --> 04:28.960 order to pick it up and neonatal sepsis. 04:28.960 --> 04:31.870 You don't get too many second chances uh 04:31.880 --> 04:34.850 if you don't make the diagnosis uh and the 04:34.850 --> 04:36.140 baby is not treated, 04:36.150 --> 04:38.170 the chances are the baby will go on and die. 04:38.180 --> 04:40.390 So anytime the history 04:40.400 --> 04:43.250 gives us one of these events 04:43.250 --> 04:45.860 which suggests in neonatal sepsis, 04:45.940 --> 04:48.250 we ought to really think very seriously about it. 04:48.640 --> 04:50.950 Now one other thing that I didn't mention there 04:51.130 --> 04:52.750 is hand washing, 04:53.540 --> 04:56.160 and the next slide shows our 04:56.160 --> 04:57.530 beloved dr smith, 04:57.540 --> 04:58.610 he's a radiologist. 04:58.610 --> 05:01.580 And this is I think the second time in five years that he has ever been in the newborn 05:01.580 --> 05:02.110 nursery. 05:02.120 --> 05:05.090 But it shows that even though he's only been up in the nursery twice in 05:05.090 --> 05:05.650 his life, 05:05.660 --> 05:08.490 he does know that he's got to wash his hands 05:08.490 --> 05:11.430 before touching a baby and I don't know what a radiologist 05:11.430 --> 05:12.430 would do touching a baby. 05:12.430 --> 05:15.250 But sometimes they do uh 05:15.260 --> 05:18.040 washing the hands before examining the baby's 05:18.050 --> 05:19.940 is absolutely crucial. 05:19.950 --> 05:22.930 As far as infections that are required within the nursery. 05:22.970 --> 05:25.920 The most common source of infections are 05:25.930 --> 05:28.750 dirty hands from personnel caring for the 05:28.750 --> 05:29.310 babies. 05:29.320 --> 05:31.860 So it's absolutely mandatory that 05:31.940 --> 05:34.720 anyone who touches a baby in the newborn nursery 05:34.800 --> 05:37.140 must wash their hands before hand. 05:37.150 --> 05:39.780 Things like gowns and gloves and masks 05:39.860 --> 05:42.730 may or may not be used depending on the circumstances. 05:42.740 --> 05:45.650 But washing the hands is absolutely the 05:45.650 --> 05:46.820 most important thing. 05:46.870 --> 05:49.670 And anyone who is caught touching a baby without 05:49.670 --> 05:52.060 washing their hands ought to get their hands slapped. 05:53.040 --> 05:53.650 Okay, 05:53.660 --> 05:53.820 Now, 05:53.820 --> 05:56.660 what about the bacteria that cause neonatal 05:56.660 --> 05:57.170 sepsis? 05:57.170 --> 05:59.220 What type of germs caused sepsis? 05:59.230 --> 05:59.510 Well, 05:59.510 --> 06:02.060 there are a lot different than the types of bacteria that cause 06:02.060 --> 06:05.030 septicemia saying you or I or in a three month old or a 06:05.030 --> 06:06.000 six month old. 06:06.010 --> 06:08.680 And the next slide lips lists The 06:08.690 --> 06:11.690 most common causes of neonatal sepsis over 06:11.690 --> 06:13.600 the past 30 or 40 years. 06:13.840 --> 06:16.440 And as we can see back in the forties, 06:16.450 --> 06:19.350 Group A beta strep was the most common 06:19.350 --> 06:21.040 cause of infection in the newborn, 06:21.040 --> 06:22.430 One of the more common causes. 06:22.440 --> 06:25.010 Now this is the same strep that causes strep 06:25.010 --> 06:27.990 throat and rheumatic fever and and things like that. 06:28.000 --> 06:29.910 Uh Now in the fifties, 06:29.910 --> 06:32.730 staph aureus became a very common cause of neonatal 06:32.730 --> 06:33.390 sepsis. 06:33.400 --> 06:36.290 And in the sixties uh e coli and other 06:36.290 --> 06:38.870 gram negative organisms were the most common 06:38.870 --> 06:40.390 cause Today. 06:40.400 --> 06:41.560 The 1970s, 06:41.570 --> 06:42.580 it's by far, 06:42.720 --> 06:45.560 group B streptococcal infections. 06:45.560 --> 06:45.760 Now, 06:45.760 --> 06:48.710 these are fairly unique to the pregnant 06:48.720 --> 06:49.860 woman in the newborn. 06:49.870 --> 06:52.580 Uh and that's why we're gonna spend an awful lot of 06:52.580 --> 06:54.090 time in the last half of this. 06:54.100 --> 06:57.070 Talk on group B strep infections in the 06:57.070 --> 06:57.560 newborn. 06:58.540 --> 07:01.400 Uh the next slide shows us 07:01.410 --> 07:03.550 the lists of organisms 07:03.560 --> 07:06.000 uh that can cause sepsis 07:06.010 --> 07:07.930 bacterial sepsis in the newborn. 07:07.950 --> 07:10.900 And these include Group B beta streptococcal 07:10.900 --> 07:11.490 infection. 07:11.490 --> 07:13.120 And from now on throughout this talk, 07:13.120 --> 07:16.080 I'm going to use this abbreviation G B B S for 07:16.080 --> 07:18.960 Group B beta hemolytic streptococcal infections, 07:19.140 --> 07:19.570 and E. 07:19.570 --> 07:22.320 Coli is by far the second most common 07:22.320 --> 07:22.700 cause. 07:22.720 --> 07:25.210 These first two causes Group B strep and E. 07:25.210 --> 07:28.180 Coli constitute by far the greatest majority, 07:28.180 --> 07:30.760 the great majority of uh causes of 07:30.760 --> 07:32.190 neonatal bacterial sepsis. 07:32.210 --> 07:34.000 Some other things that can cause sepsis, 07:34.000 --> 07:36.950 other germs are Klebsiella and arab actor 07:36.960 --> 07:39.030 Proteus pseudomonas, 07:39.240 --> 07:40.050 staff, 07:40.520 --> 07:42.450 enterococcus and Listeria. 07:44.040 --> 07:46.040 Now we know what germs, 07:46.040 --> 07:48.880 We know the history that that should make us think of neonatal 07:48.880 --> 07:49.380 sepsis. 07:49.380 --> 07:50.930 We know what bugs cause it. 07:50.940 --> 07:52.400 What about the clinical symptoms? 07:52.400 --> 07:53.050 Pathology. 07:53.060 --> 07:53.460 Well, 07:53.460 --> 07:55.880 and you or I we know what the clinical symptoms are, 07:55.890 --> 07:56.930 high fever, 07:56.930 --> 07:58.280 shaking chills. 07:58.290 --> 07:59.000 Uh, 07:59.010 --> 08:01.410 and same with the six month old baby or, 08:01.410 --> 08:01.600 you know, 08:01.600 --> 08:03.190 two or three year old child. 08:03.190 --> 08:05.250 Those are pretty much the same symptoms 08:05.440 --> 08:07.700 altogether different in the newborn. 08:08.140 --> 08:10.380 The symptoms I have seen on the next slide. 08:10.400 --> 08:11.970 I didn't put much down there all. 08:11.970 --> 08:12.440 I said, 08:12.450 --> 08:15.010 we're symptoms and signs non specific. 08:15.060 --> 08:16.440 And what does that mean? 08:16.450 --> 08:17.070 Well, 08:17.080 --> 08:19.860 that means probably the most common symptom is 08:20.360 --> 08:21.540 the baby is not doing well. 08:21.680 --> 08:23.040 The mother or the nurse says, 08:23.050 --> 08:23.450 chief, 08:23.460 --> 08:23.690 this, 08:23.700 --> 08:25.530 this baby is just not acting properly. 08:25.540 --> 08:26.090 Uh, 08:26.100 --> 08:27.800 maybe the baby is not feeding well. 08:27.800 --> 08:29.410 Maybe the baby spitting up. 08:29.420 --> 08:32.070 Maybe the baby is having a little bit of loose 08:32.070 --> 08:32.990 stools. 08:33.030 --> 08:34.910 Maybe the baby is a little jaundice. 08:35.070 --> 08:37.930 Maybe he's got a high temperature just as likely 08:37.930 --> 08:38.100 though, 08:38.100 --> 08:40.710 that he has a low temperature or a normal temperature. 08:40.940 --> 08:41.130 So, 08:41.130 --> 08:43.760 a normal temperature in a newborn does not 08:43.770 --> 08:46.370 ever rule out the possibility of infection. 08:46.370 --> 08:46.880 As I said, 08:46.880 --> 08:49.860 it's just as likely that the temperature will be normal as it is, 08:49.860 --> 08:52.570 that the baby will have a high temperature or low temperature. 08:52.580 --> 08:53.370 However, 08:53.380 --> 08:55.920 if the temperature is high or low and that 08:55.930 --> 08:58.880 absolutely means the baby has neonatal sepsis 08:58.890 --> 09:01.840 until proven otherwise and a high temperature or a 09:01.840 --> 09:02.560 low temperature. 09:02.560 --> 09:05.180 And a baby is an absolute indication for 09:05.180 --> 09:08.030 doing cultures and beginning therapy for 09:08.030 --> 09:08.990 neonatal sepsis. 09:09.030 --> 09:10.040 Just the other day, 09:10.040 --> 09:12.540 one of our nurses delivered a baby up 09:12.540 --> 09:15.350 here on our nursery and the labor was 09:15.360 --> 09:16.570 totally unremarkable. 09:16.570 --> 09:17.960 The pregnancy was unremarkable. 09:17.960 --> 09:18.790 Full term baby. 09:18.790 --> 09:21.640 The app guards were good membranes were ruptured very 09:21.640 --> 09:22.100 long. 09:22.740 --> 09:25.090 And the only thing in the observation 09:25.090 --> 09:25.870 nursery, 09:25.960 --> 09:28.660 the baby's temperature just wasn't quite normal. 09:28.660 --> 09:31.520 He had to be bundled up in order to keep his temperature normal. 09:31.610 --> 09:32.530 And I asked the nurse, 09:32.530 --> 09:35.290 I said now how often does that occur in a full term 09:35.290 --> 09:35.620 baby? 09:35.620 --> 09:38.260 And the internal resident were with me and she said it's very 09:38.260 --> 09:38.860 unusual. 09:38.860 --> 09:41.850 She said this this almost never happens in the observation nursery. 09:41.940 --> 09:44.860 That we have problems keeping the full term babies temperature up and have 09:44.860 --> 09:47.230 to bundle the baby in order to keep the temperature up. 09:47.240 --> 09:50.060 So the intern and resident immediately uh did 09:50.060 --> 09:51.400 culture started therapy. 09:51.410 --> 09:54.090 And sure enough the next day the blood culture grew up, 09:54.100 --> 09:57.050 Group B strep had they waited on that baby 09:57.050 --> 09:59.940 another 24 hours or so until the baby was really 09:59.940 --> 10:00.560 sick. 10:00.580 --> 10:03.460 The chances are the baby wouldn't be around today. 10:03.740 --> 10:06.400 So when it comes to symptoms and signs of 10:06.400 --> 10:07.630 sepsis in the newborn, 10:07.740 --> 10:09.960 you've got to have a high index of suspicion. 10:10.340 --> 10:13.110 And in general any time a newborn 10:13.110 --> 10:15.100 baby is not acting properly, 10:15.110 --> 10:17.410 you have to consider sepsis. 10:17.480 --> 10:20.340 And usually I like to teach people that anytime a 10:20.340 --> 10:21.610 kid is anything but normal. 10:21.610 --> 10:22.320 A newborn, 10:22.340 --> 10:24.450 there are two things you always have to consider 10:24.460 --> 10:26.410 hypoglycemia and sepsis. 10:26.460 --> 10:29.260 And those are two things that you don't wanna miss because the 10:29.260 --> 10:30.260 longer you miss them, 10:30.440 --> 10:32.810 the more likely the baby is either going to die 10:32.820 --> 10:35.300 or develop long term 10:35.310 --> 10:36.100 uh, 10:36.110 --> 10:39.070 residual central nervous system abnormalities because you 10:39.080 --> 10:41.860 didn't pick up the problem and start 10:41.870 --> 10:43.060 treatment immediately. 10:43.640 --> 10:44.090 Okay, 10:44.090 --> 10:46.000 so symptoms and signs are tough. 10:46.010 --> 10:46.870 But in general, 10:46.880 --> 10:48.340 if a baby is not normal, 10:48.390 --> 10:49.660 think of sepsis. 10:50.240 --> 10:50.590 Okay, 10:50.590 --> 10:52.830 now let's say we've got a baby that, 10:52.840 --> 10:54.820 that we're thinking about sepsis. 10:54.830 --> 10:55.130 Uh, 10:55.140 --> 10:56.170 what does that mean? 10:56.170 --> 10:56.730 You do? 10:56.740 --> 10:57.170 Well, 10:57.170 --> 10:58.340 in an older person, 10:58.350 --> 10:59.230 uh, 10:59.240 --> 11:00.480 you do a culture, 11:00.480 --> 11:02.850 maybe a few cultures and you watch the baby. 11:03.010 --> 11:03.310 Well, 11:03.310 --> 11:04.850 it's a whole different ball game. 11:04.940 --> 11:05.680 Uh, 11:05.690 --> 11:06.420 in the newborn, 11:06.420 --> 11:07.600 Also in an older person, 11:07.600 --> 11:09.180 you look at the white cot If it's normal, 11:09.180 --> 11:09.460 you think, 11:09.460 --> 11:12.390 well that's pretty unlikely whole different ballgame in the 11:12.390 --> 11:12.880 newborn. 11:13.180 --> 11:15.960 There are a few things that must be done in 11:15.960 --> 11:18.520 every newborn that you consider sepsis. 11:18.520 --> 11:21.330 And let's look at these the most important thing. 11:21.340 --> 11:22.420 Our cultures. 11:22.540 --> 11:23.160 Okay. 11:23.540 --> 11:24.670 Blood culture, 11:24.870 --> 11:26.450 preferably two cultures. 11:26.840 --> 11:29.160 CSF spinal fluid, 11:29.160 --> 11:31.150 LP urine culture, 11:31.160 --> 11:33.850 which we're gonna talk about in a minute and a chest x ray 11:33.860 --> 11:36.790 and no evaluation of a baby 11:36.790 --> 11:39.530 for sepsis is adequate without these things 11:39.530 --> 11:39.970 here, 11:39.980 --> 11:41.690 with maybe one or two exceptions. 11:41.690 --> 11:44.090 And now let's talk just a little bit about those, 11:44.100 --> 11:45.350 these different things here. 11:46.440 --> 11:48.060 The blood culture. 11:48.540 --> 11:49.010 Okay. 11:49.010 --> 11:50.230 Where do you do a blood culture? 11:50.240 --> 11:50.790 Well, 11:50.960 --> 11:53.060 if a baby's got an umbilical line in, 11:53.060 --> 11:54.950 its been in for a few hours, 11:54.950 --> 11:57.330 so you can't do the blood culture from the umbilical line, 11:57.360 --> 12:00.200 you've got to do the blood culture sterile e from 12:00.200 --> 12:01.270 peripheral veins, 12:01.270 --> 12:03.890 like the anti cubicle vein or possibly scalp 12:03.890 --> 12:04.350 veins. 12:04.740 --> 12:07.380 Uh preferably you should do to blood 12:07.380 --> 12:10.230 cultures and all of us who have dealing 12:10.230 --> 12:13.110 with newborns know how anemic some of these 12:13.110 --> 12:14.100 blood cultures can be. 12:14.100 --> 12:14.300 You know, 12:14.300 --> 12:17.200 you see someone scored two or three or four red cells in the blood culture 12:17.200 --> 12:17.700 bottle, 12:17.780 --> 12:18.710 that's not adequate. 12:18.720 --> 12:21.530 You should get preferably one cc but 12:21.530 --> 12:24.090 certainly a half a cc of blood when doing a blood 12:24.090 --> 12:24.560 culture. 12:25.640 --> 12:25.980 Now, 12:25.980 --> 12:28.930 what about the blood culture is by far the most 12:28.940 --> 12:31.160 important test that must be done. 12:31.640 --> 12:31.970 Now. 12:31.970 --> 12:33.460 What about the spinal tap? 12:33.840 --> 12:35.140 I think again, 12:35.140 --> 12:37.440 when you're dealing with meningitis in the newborn there, 12:37.450 --> 12:40.180 you can't go by the symptoms and signs that you do with older 12:40.180 --> 12:41.650 Children and adults. 12:41.670 --> 12:44.620 Uh If the baby has a possibility of 12:44.620 --> 12:45.140 being stepped, 12:45.150 --> 12:46.000 have sepsis, 12:46.010 --> 12:47.540 you gotta think of meningitis. 12:47.750 --> 12:49.050 That means you have to do a spinal tap. 12:49.050 --> 12:51.860 There ain't no other way of evaluating a 12:51.860 --> 12:54.160 baby for meningitis without doing a spinal tap. 12:55.240 --> 12:58.160 Now there may be a couple instances where a spinal 12:58.160 --> 13:01.030 tap is not absolutely indicated. 13:01.420 --> 13:04.270 And I think that for example and 13:04.280 --> 13:06.460 the extremely sick 13:06.940 --> 13:09.920 Baby with respiratory distress who comes in 13:09.920 --> 13:12.860 at a few hours of age and is extremely precarious, 13:12.860 --> 13:15.360 you know is intubated on 100 oxygen. 13:15.400 --> 13:18.360 And all you do is touch the baby and he turns black on you. 13:18.370 --> 13:21.060 Uh and he really is precarious. 13:21.140 --> 13:24.020 I think in those babies uh maybe it's 13:24.020 --> 13:26.780 probably all right to do a blood culture and a urine culture 13:26.790 --> 13:27.860 and not do the L. 13:27.860 --> 13:28.220 P. 13:28.220 --> 13:28.960 At that time. 13:29.140 --> 13:30.790 Go ahead and start antibiotics. 13:30.990 --> 13:33.210 But I think that's about the only 13:33.210 --> 13:36.170 situation where and an L. 13:36.170 --> 13:36.540 P. 13:36.550 --> 13:39.380 Is not absolutely necessary for an evaluation of 13:39.380 --> 13:40.530 sepsis in a newborn. 13:40.630 --> 13:43.500 Any baby over a day I think where you're 13:43.500 --> 13:45.700 considering sepsis has to have an L. 13:45.700 --> 13:46.060 P. 13:46.070 --> 13:47.800 And preferably all babies should have an L. 13:47.800 --> 13:48.160 P. 13:48.740 --> 13:49.250 Okay. 13:49.260 --> 13:52.110 What about super pubic uh What about 13:52.110 --> 13:52.840 urine cultures? 13:52.880 --> 13:55.860 Well super pubic urine cultures are the best. 13:55.870 --> 13:58.460 Now let's look at this next slide shows you a picture how to do that. 13:59.540 --> 14:02.540 Uh You feel the baby's 14:02.550 --> 14:04.770 pubis in the midline of course 14:04.780 --> 14:07.180 and the bladder is right 14:07.190 --> 14:08.370 below that. 14:08.380 --> 14:09.660 In a little bit superior. 14:10.340 --> 14:13.000 After one feels the pubis about a half a 14:13.000 --> 14:15.400 centimetre or centimetres above that. 14:15.410 --> 14:18.270 One goes through the abdomen after sterile 14:18.270 --> 14:21.210 prep of course and hopefully enters 14:21.210 --> 14:23.450 the bladder and aspirated the bladder of ignorance. 14:23.840 --> 14:24.320 Now, 14:24.320 --> 14:27.070 obviously one should do this procedure 14:27.080 --> 14:28.860 only when the bladder is full. 14:29.030 --> 14:31.540 Obviously you can't ask the baby if he's got a void. 14:31.550 --> 14:34.330 So preferably what you want to do is make sure the baby has 14:34.330 --> 14:35.750 not avoided for an hour or two, 14:35.750 --> 14:37.060 so that the bladder is full. 14:38.240 --> 14:41.210 Uh Super pubic taps are not 14:41.220 --> 14:42.130 totally benign, 14:42.140 --> 14:43.110 they are dangerous. 14:43.120 --> 14:45.940 Uh uh One has to be 14:45.940 --> 14:48.860 careful of doing super pubic taps and I don't think one should do 14:48.860 --> 14:51.110 them if if you've never seen it done and never 14:51.510 --> 14:54.350 never have the opportunity to observe the procedure. 14:54.440 --> 14:55.630 But you should, 14:55.640 --> 14:57.410 if one is taking care of sick newborns, 14:57.410 --> 15:00.360 they should learn how to do super pubic because it's the only 15:00.360 --> 15:02.260 really good way of getting 15:02.940 --> 15:04.490 urine for culture. 15:04.500 --> 15:07.440 Clean voided catches so called clean voided catches in 15:07.440 --> 15:09.180 the newborn are usually pretty worthless. 15:09.190 --> 15:12.120 Uh They almost always have contaminants, 15:12.180 --> 15:14.580 catheterization certainly can be done. 15:14.610 --> 15:15.850 But again, 15:15.850 --> 15:17.130 I think super pubic taps, 15:17.140 --> 15:19.520 if done by competent people 15:19.530 --> 15:22.050 are safe and 15:22.060 --> 15:24.980 probably the method of choice for doing getting urine for 15:24.980 --> 15:25.450 culture. 15:25.640 --> 15:27.450 Remember I said it done by competent people. 15:27.450 --> 15:30.420 All the most of the complications reported with super pubic taps, 15:30.420 --> 15:32.750 or because they have not been done properly. 15:33.540 --> 15:33.880 Okay. 15:33.880 --> 15:35.770 And then the last of those four tests that were required, 15:35.770 --> 15:36.660 I said was chest X ray. 15:36.770 --> 15:37.190 Again, 15:37.190 --> 15:40.020 that ought to be done in any baby where you're considering sepsis. 15:40.020 --> 15:41.600 Because the possibility of pneumonia, 15:41.610 --> 15:44.490 you can't rule out pneumonia and a baby by listening to his lungs. 15:44.500 --> 15:45.260 A newborn baby. 15:45.840 --> 15:46.240 Okay, 15:46.240 --> 15:46.390 now, 15:46.390 --> 15:48.520 what other tests are done for sepsis? 15:48.520 --> 15:51.060 Let's look at a few other tests on the next slide. 15:52.540 --> 15:54.960 I like to use a platelet count and kind of a screening 15:55.340 --> 15:56.440 tool for sepsis. 15:56.450 --> 15:57.880 It's low in some cases. 15:57.960 --> 15:59.470 In most cases though it's normal. 15:59.940 --> 16:01.030 What about a white count? 16:01.040 --> 16:01.710 Well, 16:01.750 --> 16:03.020 in the first few days of life, 16:03.020 --> 16:05.750 of course the white count can be 2030 40,000. 16:05.760 --> 16:07.500 And it's not really very helpful. 16:07.510 --> 16:10.110 Uh And we're gonna talk about that in just a minute. 16:10.120 --> 16:11.390 What about a said count? 16:11.400 --> 16:14.140 Well in some cases uh it can be 16:14.150 --> 16:16.860 elevated uh babies with 16:16.860 --> 16:17.230 sepsis, 16:17.230 --> 16:19.570 or it can be very low and the band count, 16:19.580 --> 16:20.780 if it's extremely high, 16:20.790 --> 16:22.160 can suggest sepsis. 16:22.840 --> 16:25.690 But we have to worry about these tests for 16:25.690 --> 16:28.530 one main reason they're all too 16:28.530 --> 16:31.120 often normal in the face of florid 16:31.120 --> 16:31.600 sepsis. 16:31.600 --> 16:32.250 In the newborn. 16:32.260 --> 16:33.040 For example, 16:33.040 --> 16:33.840 the white count, 16:33.910 --> 16:34.520 as I said, 16:34.520 --> 16:36.010 in the first few days of life, 16:36.020 --> 16:38.180 it maybe 20 30,000 to be normal. 16:38.190 --> 16:38.930 Uh Now, 16:38.930 --> 16:40.650 if the white count is very low, 16:41.010 --> 16:43.930 Like less than 780 in the first few days of 16:43.930 --> 16:44.270 life, 16:44.340 --> 16:45.880 that is very worrisome, 16:45.900 --> 16:47.150 saying with the sec counter, 16:47.160 --> 16:48.490 that's very low, 16:48.500 --> 16:51.330 like less than 2000 or so in the first day or two, 16:51.340 --> 16:52.860 first first week of life, 16:52.870 --> 16:55.200 that's uh somewhat or less than 16:55.200 --> 16:56.430 1500 say. 16:56.440 --> 16:58.330 Uh That's somewhat worrisome. 16:58.340 --> 17:01.060 Uh But they're too 17:01.060 --> 17:03.810 often cases where the 17:03.810 --> 17:05.300 white count and the said count, 17:05.300 --> 17:08.170 the band count are totally normal and the baby has 17:08.170 --> 17:09.030 floored sepsis. 17:09.030 --> 17:11.460 So if you're gonna use those tests for screening 17:11.460 --> 17:12.100 tool, 17:12.190 --> 17:12.630 that is, 17:12.630 --> 17:15.620 you're going to use these tests to to routine 17:15.620 --> 17:17.860 and look at a whole group of babies and say, 17:17.940 --> 17:19.880 gee that kid has an abnormal white counter. 17:19.880 --> 17:21.170 Platelet counter said Count. 17:21.240 --> 17:23.480 I wasn't thinking about sepsis in him, 17:23.510 --> 17:24.030 but gee, 17:24.030 --> 17:25.010 since this is abnormal, 17:25.010 --> 17:25.980 I better think about it. 17:26.000 --> 17:27.100 I think that's okay. 17:27.110 --> 17:28.560 You must never never, 17:28.560 --> 17:31.470 never use those tests to 17:31.470 --> 17:32.500 say this, 17:32.510 --> 17:34.020 you must never use them to say, 17:34.030 --> 17:34.530 well, 17:34.530 --> 17:37.220 this kid's kind of sick and I had to think about 17:37.220 --> 17:37.710 steps, 17:37.720 --> 17:40.080 but the white count's normal or the said counts normal. 17:40.090 --> 17:42.700 I won't worry about it if you ever do that, 17:42.710 --> 17:44.240 that's when you're gonna get into trouble. 17:44.250 --> 17:46.340 So if you use them as a screening tool, 17:46.350 --> 17:47.350 fine and dandy. 17:47.540 --> 17:50.410 But if you use them to rule out sepsis in a suspicious 17:50.410 --> 17:52.260 infant absolutely wrong. 17:52.640 --> 17:55.430 The same thing goes with other tests like 17:55.440 --> 17:58.230 gastric aspirate for Polly's and cultures. 17:58.240 --> 18:00.710 Uh Said rates. 18:00.720 --> 18:03.640 Nbt tests all the other tests that have been 18:03.640 --> 18:06.270 evaluated as for for sepsis in the 18:06.270 --> 18:07.310 newborn there. 18:07.310 --> 18:09.020 Okay to use the screening tools, 18:09.030 --> 18:09.820 but never, 18:09.820 --> 18:10.270 never, 18:10.270 --> 18:12.560 never find yourself caught in the trap 18:12.840 --> 18:15.370 where you're ruling out sepsis in a 18:15.370 --> 18:16.400 suspicious infant. 18:16.410 --> 18:18.010 Because those tests are normal. 18:18.210 --> 18:20.610 The only way to properly 18:20.620 --> 18:23.190 evaluate a baby for sepsis must 18:23.190 --> 18:25.130 include a blood culture, 18:25.140 --> 18:26.270 a spinal tap, 18:26.640 --> 18:28.610 a urine culture and a chest X ray. 18:28.620 --> 18:29.990 And without those tests, 18:30.000 --> 18:33.000 it's an inadequate evaluation of a baby for 18:33.000 --> 18:33.560 sepsis. 18:34.340 --> 18:34.960 Okay, 18:36.080 --> 18:38.030 let's go on to therapy. 18:38.030 --> 18:39.050 What about therapy? 18:39.440 --> 18:40.010 Well, 18:40.020 --> 18:41.150 what about antibiotics? 18:41.150 --> 18:41.860 First of all? 18:42.340 --> 18:45.150 Uh the antibiotics usually recommended are 18:45.160 --> 18:46.160 ampicillin, 18:46.170 --> 18:48.950 100 to 200 mg per kilogram per day 18:48.960 --> 18:51.460 ivy or penicillin. 18:51.470 --> 18:54.400 100,000 to 200,000 units per kilo per day 18:54.400 --> 18:55.140 ivy. 18:55.150 --> 18:56.380 That's one of those two. 18:56.390 --> 18:57.190 Plus. 18:57.200 --> 18:58.170 The next slide. 18:59.040 --> 19:01.960 Can a Mason 15 mg per kilogram per 19:01.960 --> 19:02.220 day. 19:02.220 --> 19:02.760 I am. 19:03.140 --> 19:04.920 Or Jenna mice in 5 to 19:04.920 --> 19:07.700 7.5 mg per kilo per day. 19:07.700 --> 19:08.170 I am. 19:08.540 --> 19:09.030 Okay. 19:09.030 --> 19:09.470 Now, 19:09.480 --> 19:09.980 there, 19:09.990 --> 19:11.910 those are just kind of rough guidelines 19:11.990 --> 19:13.170 ideally. 19:13.250 --> 19:15.670 The drugs of course should be 19:16.540 --> 19:19.130 decided upon depending what organism grows. 19:19.150 --> 19:20.830 That's what you do in adults frequently. 19:20.840 --> 19:23.770 But you can't do that in the newborn once you suspect 19:23.770 --> 19:24.310 sepsis, 19:24.320 --> 19:26.940 you have to do the cultures and start the antibiotics. 19:26.950 --> 19:27.190 Okay, 19:27.190 --> 19:30.130 you can't wait until the cultures come back because by that time if the 19:30.130 --> 19:32.070 kid truly is septic you'll die, 19:32.140 --> 19:33.710 you'll be dead by that time probably. 19:33.710 --> 19:36.670 So as soon as you suspect sepsis you do the cultures 19:36.840 --> 19:38.270 and you start the antibiotics. 19:38.740 --> 19:39.460 Now. 19:39.470 --> 19:41.460 What about ivy versus I am. 19:42.140 --> 19:45.020 Well certainly any baby that has meningitis must have 19:45.020 --> 19:45.150 I. 19:45.150 --> 19:45.330 V. 19:45.330 --> 19:46.060 Antibiotics. 19:46.540 --> 19:49.490 Any baby who has hypotensive or not 19:49.500 --> 19:52.050 doesn't have good peripheral profusion of the skin 19:52.060 --> 19:52.930 must have I. 19:52.930 --> 19:53.120 V. 19:53.120 --> 19:53.950 Antibiotics. 19:55.140 --> 19:55.560 Now, 19:55.570 --> 19:58.020 any baby problem that is a small small 19:58.020 --> 20:00.790 premature a little teeny weeny 20:00.790 --> 20:01.220 kid, 20:01.230 --> 20:02.550 you can't give shots. 20:02.550 --> 20:03.120 I am too. 20:03.120 --> 20:06.000 He doesn't have enough m muscle to give I am shots too. 20:06.010 --> 20:08.550 So every small premature baby should get I. 20:08.550 --> 20:08.770 V. 20:08.770 --> 20:09.860 Antibiotics also. 20:10.340 --> 20:11.950 Now I don't think that I. 20:11.950 --> 20:12.110 V. 20:12.110 --> 20:15.060 Antibiotics are absolutely necessary in every newborn 20:15.060 --> 20:15.360 baby. 20:15.360 --> 20:16.730 You evaluate for sepsis. 20:16.780 --> 20:19.740 I think that if the baby is tolerating 20:19.740 --> 20:22.610 feedings well which is not very often in kids who are 20:22.610 --> 20:23.920 really concerned about sepsis. 20:23.930 --> 20:26.560 But if that's the case or if the kid is improving 20:26.940 --> 20:29.390 uh and you've already had him on I. 20:29.390 --> 20:29.500 V. 20:29.500 --> 20:32.350 Antibiotics for three or four days and the cultures uh 20:32.360 --> 20:34.880 come back negative but you're gonna continue for a few more days. 20:34.880 --> 20:37.720 And and the kids a big kid he's got good blood pressure, 20:37.720 --> 20:38.780 he's acting fine. 20:38.790 --> 20:41.700 I think that I am antibiotics are okay in that 20:41.700 --> 20:42.240 group. 20:42.250 --> 20:44.800 I don't think that every single newborn has to have I. 20:44.800 --> 20:44.980 V. 20:44.980 --> 20:47.760 Antibiotics but don't extrapolate that 20:47.770 --> 20:49.060 please and don't say. 20:49.140 --> 20:51.630 But I heard Rich Shriners say that you could use I am 20:51.630 --> 20:54.110 antibiotics and all newborns with sepsis. 20:54.110 --> 20:55.210 That's not the case. 20:55.280 --> 20:56.980 Most sick babies 20:56.990 --> 20:59.680 especially premature babies, 20:59.690 --> 21:01.600 babies with meningitis, 21:01.610 --> 21:04.100 babies who have poor profusion meaning their 21:04.100 --> 21:06.640 hypotensive or they're they're not refusing their 21:06.640 --> 21:07.170 skin, 21:07.240 --> 21:09.290 peripheral tissues well must have I. 21:09.290 --> 21:09.460 V. 21:09.460 --> 21:10.060 Antibiotics. 21:10.740 --> 21:11.090 Okay. 21:11.090 --> 21:12.910 What about the drugs? 21:12.920 --> 21:14.250 Well again ampicillin, 21:14.250 --> 21:14.940 penicillin. 21:14.950 --> 21:17.340 Uh generally to cover the grand positive 21:17.350 --> 21:18.810 caucus like Group B. 21:18.810 --> 21:21.570 Strep and Jeremies and contamination to 21:21.570 --> 21:23.520 cover the gram negative organisms like E. 21:23.520 --> 21:24.050 Coli. 21:24.060 --> 21:26.700 Obviously if you're cultures come back positive 21:26.710 --> 21:29.490 and you may want to change your antibiotics 21:29.490 --> 21:32.020 according to the cultures or you may want to discontinue one 21:32.020 --> 21:32.550 antibiotic. 21:33.840 --> 21:36.620 There are some circumstances where you may think of some other 21:36.620 --> 21:39.550 organism like you may think of back to Reuters because the kid 21:39.550 --> 21:40.800 has a perforated gut. 21:40.880 --> 21:43.390 And in which case you might want to use a different drug like 21:43.400 --> 21:46.000 Clarkson or chloramphenicol. 21:46.210 --> 21:49.110 But in general we start out with either with 21:49.110 --> 21:52.110 ampicillin or penicillin and canonizing 21:52.110 --> 21:52.450 Arjuna. 21:52.450 --> 21:55.040 Missing ideally the doses should be 21:55.040 --> 21:57.290 regulated according to the disease. 21:57.300 --> 21:57.750 For example, 21:57.750 --> 21:59.370 meningitis versus pneumonia. 21:59.380 --> 22:02.020 Uh whether the baby's full term or term 22:02.030 --> 22:04.910 and whether the baby's uh less than a 22:04.910 --> 22:06.320 week old or more than a week old. 22:06.330 --> 22:08.330 And your standard textbooks, 22:08.340 --> 22:10.690 the recent ones and recent articles on 22:10.700 --> 22:13.460 evaluate the drug treatment and drug doses. 22:13.540 --> 22:16.500 You can look up these uh specific doses 22:16.500 --> 22:18.860 for each of those circumstances in there if I told you now, 22:18.860 --> 22:20.860 you wouldn't remember him anyway because I can't remember him either. 22:22.040 --> 22:22.630 Okay, 22:22.640 --> 22:25.440 now I just want to reemphasize about treatment. 22:25.450 --> 22:28.430 You've got to start the antibiotics as soon as you do the 22:28.430 --> 22:31.090 cultures after you thought of acceptance and the kid, 22:31.100 --> 22:32.960 you can't wait till the cultures are negative. 22:33.340 --> 22:35.090 Now one other aspect, 22:35.100 --> 22:37.950 there's more than just antibiotics in the treatment of babies with 22:37.950 --> 22:40.850 sepsis and that's the next slide shows the complications of 22:40.850 --> 22:41.300 sepsis. 22:41.300 --> 22:44.070 And essentially what that means is we need to watch for these 22:44.070 --> 22:46.750 complications and we need to treat these complications as they 22:46.750 --> 22:47.260 occur, 22:47.640 --> 22:50.570 disseminated intravascular coagulation and that's why 22:50.570 --> 22:52.330 if the kid is using the acceptance, 22:52.330 --> 22:53.420 we do clotting studies. 22:53.430 --> 22:56.230 And of course we look for platelets because low platelets are 22:56.230 --> 22:57.200 common with sepsis. 22:57.210 --> 22:59.960 Hypertension must be watched for and treated 23:00.440 --> 23:01.330 acidosis, 23:01.340 --> 23:03.910 metabolic acidosis must be watched for and 23:03.910 --> 23:04.400 treated. 23:04.410 --> 23:07.270 Hypoxia must be must be watched for 23:07.270 --> 23:07.430 it. 23:07.440 --> 23:08.570 And of course prevented. 23:08.600 --> 23:11.450 And that's why you want to always provide adequate oxygen to these kids. 23:11.840 --> 23:13.710 Hyponatremia is common again, 23:13.710 --> 23:15.440 must be watched more closely. 23:15.700 --> 23:18.350 These babies frequently have an alias and can't be fed. 23:19.040 --> 23:21.490 Meningitis may develop and that's why of course we always do 23:21.490 --> 23:22.070 lPS. 23:22.100 --> 23:24.770 You may see osteo myelitis, 23:24.770 --> 23:25.920 you may see arthritis. 23:25.930 --> 23:28.610 Otitis hypoglycemia is a common 23:28.610 --> 23:30.030 problem with sepsis and again, 23:30.030 --> 23:31.780 you have to look for it in order to find it. 23:31.850 --> 23:33.260 If you wait till the kid is seizing, 23:33.260 --> 23:36.140 it's too late john this is also common 23:36.150 --> 23:38.400 and you have to watch for secondary abscesses. 23:39.240 --> 23:41.760 So all of these things should be watched 23:41.770 --> 23:44.770 for and hopefully prevented when you're treating a baby 23:44.770 --> 23:45.540 with sepsis. 23:45.580 --> 23:46.000 Now, 23:46.000 --> 23:48.900 one other thing I want to mention about about working a baby 23:48.900 --> 23:49.800 up for sepsis, 23:49.810 --> 23:50.390 neonatal, 23:50.390 --> 23:52.820 bacterial sepsis and your culture, 23:52.890 --> 23:55.830 as far as how often you do it remember that most of the 23:55.830 --> 23:58.820 time your culture is gonna be negative if most of the babies 23:58.820 --> 24:01.160 that you evaluate for sepsis really our septic, 24:01.170 --> 24:02.560 you're not doing a good job. 24:02.740 --> 24:05.690 Uh At least Eight or nine out of 24:05.690 --> 24:08.520 10 babies where you culture and look for sepsis really. 24:08.520 --> 24:11.430 The culture should be negative because if 24:11.430 --> 24:12.900 you're every single baby, 24:12.900 --> 24:14.580 you evaluate perceptions really has sepsis. 24:14.580 --> 24:15.990 You must be missing babies. 24:16.130 --> 24:18.630 There is no one in the world who is good enough to look at a 24:18.630 --> 24:21.520 baby and uh just examine the baby and say 24:21.520 --> 24:23.350 for sure whether he has sepsis or not. 24:23.540 --> 24:23.850 So, 24:23.850 --> 24:26.660 a good physician usually will find that 24:26.670 --> 24:28.680 most of the cultures that he does, 24:28.680 --> 24:29.760 as far as blood cultures, 24:29.760 --> 24:32.550 yearning spinal taps are negative uh and only a 24:32.550 --> 24:34.250 small percentage will be positive. 24:34.260 --> 24:37.160 But when you're talking about a disease as bad as sepsis with 24:37.160 --> 24:38.570 such a high mortality, 24:38.660 --> 24:40.520 that's the way you've got to obviously play the game. 24:40.560 --> 24:42.040 You gotta treat pick up, 24:42.050 --> 24:45.020 you got a suspect and treat more kids than actually have 24:45.020 --> 24:45.170 it. 24:45.540 --> 24:45.780 Now, 24:45.780 --> 24:47.410 when do you discontinue antibiotics? 24:47.420 --> 24:47.880 Well, 24:47.880 --> 24:50.870 if the cultures are negative and the kid is doing fine and 24:50.870 --> 24:52.400 you're convinced it's not sepsis, 24:52.410 --> 24:55.260 I usually stop after 34 or five days. 24:55.270 --> 24:57.990 Uh Of course if the baby has 24:57.990 --> 24:58.900 Septicemia, 24:58.910 --> 25:01.610 then you continue for at least 10 and 25:01.620 --> 25:03.170 possibly 14 days. 25:03.170 --> 25:04.170 And if it's meningitis, 25:04.170 --> 25:05.280 that's a whole different ball game. 25:05.280 --> 25:07.360 And we're not gonna talk about that right now. 25:08.040 --> 25:10.850 Okay now let's the second half of this uh 25:10.860 --> 25:13.180 session let's talk about group B strep 25:13.180 --> 25:16.170 infections and uh that's the reason 25:16.170 --> 25:18.540 I'm doing that is because it's such a common problem. 25:18.540 --> 25:21.380 Now it's by far the most common cause of neonatal 25:21.380 --> 25:21.860 sepsis. 25:22.240 --> 25:24.990 Uh And let's look at the first slide as far as the 25:25.000 --> 25:27.880 classification of of actually this should be just 25:27.880 --> 25:29.560 classification of strep in general. 25:29.940 --> 25:32.880 Uh The strips are classified as far as group A group 25:32.890 --> 25:34.270 being groups et cetera. 25:34.280 --> 25:37.080 As to the policy Sacha ride which is common to 25:37.090 --> 25:39.990 all strep and uh at least all beta 25:39.990 --> 25:40.350 strep. 25:41.240 --> 25:42.290 And so group B. 25:42.290 --> 25:45.090 Has all the group B beta strap have a particular group B. 25:45.090 --> 25:47.450 Policy Sakurai which is common to all of them. 25:47.940 --> 25:48.170 Now. 25:48.170 --> 25:51.010 In addition the group B strep are divided up 25:51.020 --> 25:52.460 into types one A. 25:52.470 --> 25:53.020 B. 25:53.030 --> 25:53.670 C. 25:54.040 --> 25:55.610 Type two and Type three. 25:55.860 --> 25:58.080 And that's cyril logic 25:58.080 --> 26:00.760 classification is determined by the specific 26:01.140 --> 26:02.420 type specific policy. 26:02.420 --> 26:04.920 Sacco ride on the capsule 26:05.010 --> 26:06.360 of the bacteria. 26:07.340 --> 26:09.760 Uh Okay now what about how 26:09.760 --> 26:12.270 common is is group B 26:12.270 --> 26:14.810 strep and how what's the 26:14.810 --> 26:17.430 magnitude of the problem in relation to society in 26:17.430 --> 26:17.910 general? 26:17.920 --> 26:20.800 Well I think the next slide will give you a little bit of idea 26:20.810 --> 26:23.670 as as far as what kind of problem we're talking about. 26:24.040 --> 26:24.270 Mhm. 26:24.840 --> 26:27.670 Roughly 3 to 40% of all 26:27.670 --> 26:29.650 pregnant females have group B. 26:29.650 --> 26:32.010 Strep in their vagina in the third trimester. 26:32.040 --> 26:34.040 Now that's a wide variation of number. 26:34.040 --> 26:37.010 And we'll talk about why that varies so much a little bit later. 26:37.020 --> 26:39.450 It depends upon what study what city you look at. 26:40.240 --> 26:43.240 1 to 20% of all newborns will have Group B 26:43.240 --> 26:46.160 strep on their skin and their mouth throat around the 26:46.160 --> 26:47.050 umbilical cord. 26:47.130 --> 26:48.550 That's a lot of babies. 26:48.560 --> 26:51.020 If it's if it's 20% and even 12 or 26:51.020 --> 26:52.700 3% is a lot of babies. 26:52.700 --> 26:54.550 When you talk about the whole country in the whole world, 26:55.540 --> 26:56.240 neonatal, 26:56.240 --> 26:58.220 Group B strep sepsis and meningitis. 26:58.220 --> 27:00.880 That is positive blood cultures and CSF cultures 27:00.890 --> 27:03.550 occur in 2 to 3 per 1000 live births. 27:03.550 --> 27:03.760 Again, 27:03.760 --> 27:05.040 that's a pretty common problem, 27:05.090 --> 27:07.440 especially when you when you appreciate the 27:07.440 --> 27:09.750 magnitude of the mortality 27:09.750 --> 27:10.450 etcetera. 27:11.940 --> 27:14.820 The fatality of Group B strep 27:14.830 --> 27:17.620 sepsis and meningitis is somewhere between 3 30 27:17.750 --> 27:18.410 80%. 27:18.410 --> 27:20.110 Depending on what series you look at, 27:20.240 --> 27:22.950 that shows you how serious of a disease we're talking about. 27:23.340 --> 27:25.870 And the other very important thing that's just been 27:26.190 --> 27:29.070 that's just come up the past few years is that a very high 27:29.070 --> 27:31.580 percentage of hospital personnel have Group B 27:31.580 --> 27:34.200 strep their colonized with Group B strep in their 27:34.200 --> 27:34.630 nose, 27:34.630 --> 27:35.350 throat, 27:35.360 --> 27:38.090 on their skin or in the vagina and in some series as high as 27:38.100 --> 27:40.750 45% of Obi and nursery 27:40.750 --> 27:42.360 personnel have Group B strep. 27:43.040 --> 27:43.250 Okay. 27:43.250 --> 27:46.080 Group B strep infections in the newborn 27:46.150 --> 27:48.980 have generally been divided into early 27:48.980 --> 27:51.780 onset infections and late onset. 27:51.820 --> 27:53.340 And by early onset infections, 27:53.340 --> 27:56.020 we usually mean infections in the first week of life, 27:56.030 --> 27:58.330 usually in the first day or two of life. 27:58.340 --> 27:59.300 And on late onset, 27:59.300 --> 28:02.300 we usually mean after the first week of life and anywhere 28:02.310 --> 28:04.630 up to about a month or a month and a half of age, 28:04.630 --> 28:05.960 sometimes two months of age. 28:06.640 --> 28:07.240 Okay, 28:07.250 --> 28:10.250 now we're going to the symptoms and signs and 28:10.260 --> 28:12.980 problems with early onset are somewhat 28:12.980 --> 28:15.000 different than late onset infection. 28:15.010 --> 28:17.810 So first let's look at those babies who 28:17.810 --> 28:20.440 present with Group B strep in the first week of life. 28:20.450 --> 28:20.720 Okay. 28:20.720 --> 28:21.670 And this is the next slide. 28:22.040 --> 28:23.560 first of all there frequently, 28:23.560 --> 28:26.450 although not always low birth weight premature babies. 28:27.540 --> 28:30.270 They also frequently present with respiratory 28:30.270 --> 28:30.940 distress. 28:31.060 --> 28:34.060 And uh this is respiratory distress that 28:34.060 --> 28:36.910 clinically can't be differentiated from any other cause of 28:36.910 --> 28:37.950 respiratory distress. 28:38.340 --> 28:39.710 They may have apnea. 28:39.720 --> 28:42.540 And I think that any baby premature or 28:42.540 --> 28:45.390 full term who has apnea in the first day or 28:45.390 --> 28:47.810 day and a half or two days of life must 28:47.810 --> 28:50.800 seriously be considered to have possibility sepsis. 28:50.800 --> 28:52.670 And especially Group B strep sepsis, 28:53.040 --> 28:55.350 they may present with hypotension or shock. 28:56.440 --> 28:57.700 And in general, 28:57.710 --> 29:00.150 the organisms that your culture are the 29:00.150 --> 29:02.830 same as the organisms in the 29:02.830 --> 29:04.050 mother's vagina. 29:04.060 --> 29:06.940 And that's why it's thought that early onset 29:06.940 --> 29:09.700 Group B strep usually uh 29:09.710 --> 29:12.570 comes from uh infection during the birth 29:12.570 --> 29:14.740 process and the baby occurs, 29:14.740 --> 29:16.950 it acquires it from the mother's vagina. 29:17.240 --> 29:17.480 Now, 29:17.480 --> 29:20.370 other things uh as far as early onset Group 29:20.380 --> 29:22.630 B strep include that frequently. 29:22.630 --> 29:24.860 There are obstetrical complications 29:25.290 --> 29:26.880 such as prolonged rupture memories, 29:26.880 --> 29:27.670 but not always. 29:28.640 --> 29:29.780 And as I said before, 29:29.780 --> 29:32.250 the respiratory distress is identical 29:32.250 --> 29:35.120 clinically to respiratory distress syndrome or highland 29:35.120 --> 29:36.040 membrane disease, 29:36.050 --> 29:38.910 or transient to keep near the newborn or wet lung or 29:38.920 --> 29:41.920 RDS type to whatever terminology you like 29:41.930 --> 29:42.520 to use. 29:42.550 --> 29:45.460 And that's why I think that any baby with 29:45.470 --> 29:48.410 serious respiratory distress in the 29:48.420 --> 29:51.030 first day or two of life should have cultures 29:51.030 --> 29:53.920 done and be started on antibiotics until the cultures are negative 29:53.920 --> 29:56.720 because there is no one who can rule 29:56.720 --> 29:59.690 out Group B strep as the cause of that respiratory 29:59.690 --> 30:00.360 distress. 30:00.840 --> 30:01.100 Now, 30:01.100 --> 30:01.980 as we said before, 30:01.980 --> 30:03.280 there's a very high mortality, 30:03.290 --> 30:05.270 especially with early onset strep 30:06.340 --> 30:07.870 When meningitis is present, 30:07.870 --> 30:10.000 which is not very common in the early onset, 30:10.040 --> 30:11.670 it's usually type three. 30:12.140 --> 30:12.640 Okay, 30:12.650 --> 30:14.330 what about the chest x rays? 30:14.340 --> 30:16.330 With early onset? 30:16.340 --> 30:17.320 Group B strep? 30:17.390 --> 30:20.180 The next slide will show you what the chest x 30:20.180 --> 30:21.170 rays can look like. 30:21.320 --> 30:23.880 We already said that clinically the kids can have respiratory 30:23.880 --> 30:26.780 distress quite similar to any other cause of 30:26.780 --> 30:27.790 respiratory distress. 30:28.020 --> 30:30.850 Well frequently the chest X rays are normal and 30:30.850 --> 30:33.360 again that doesn't mean anything as far as ruling out infection. 30:33.840 --> 30:36.370 They also may have a typical pattern of highland membrane 30:36.370 --> 30:38.610 disease and I don't know whether the baby, 30:39.140 --> 30:42.140 the baby probably has both highland memory disease and Group B 30:42.140 --> 30:43.580 strep in those situations, 30:43.590 --> 30:46.460 they also may show a typical pattern of transient ticket 30:46.460 --> 30:48.160 nia or wet long or RDS, 30:48.160 --> 30:48.860 type two. 30:49.440 --> 30:50.890 And many of these babies, 30:50.890 --> 30:51.330 although again, 30:51.330 --> 30:52.000 not all, 30:52.100 --> 30:54.270 but many of them will have pleural effusions. 30:55.040 --> 30:55.880 The last two kids, 30:55.880 --> 30:56.210 In fact, 30:56.210 --> 30:58.450 we had the nursery that came in with respiratory distress. 30:58.660 --> 31:01.480 They had a clinical picture of transient ticket. 31:01.480 --> 31:04.380 I mean a radiographic picture of transient apnea with 31:04.390 --> 31:06.710 good sized pleural effusions and both of them had Group B. 31:06.710 --> 31:07.670 Strep infections. 31:08.640 --> 31:08.960 Okay, 31:08.960 --> 31:10.120 let's look at a couple X rays. 31:10.840 --> 31:11.190 Okay, 31:11.190 --> 31:13.940 now this X ray here looks fairly typical for 31:13.940 --> 31:15.620 transit to keep near wet lung. 31:15.780 --> 31:18.750 There's a patchy kind 31:18.750 --> 31:21.320 of uh interstitial infiltrate 31:21.330 --> 31:22.740 radiating from the highlands. 31:22.810 --> 31:23.920 And as you can see here, 31:23.920 --> 31:25.620 there's some fluid in the fishers. 31:25.630 --> 31:28.530 And this is a baby who won quite likelihoods they 31:28.530 --> 31:30.160 had transit to keep near wet lung. 31:30.240 --> 31:31.420 But this baby had group B. 31:31.420 --> 31:32.300 Strep sepsis. 31:32.440 --> 31:34.910 And that's why you have to think about it anytime. 31:34.910 --> 31:36.940 You have a baby that has an X ray picture like this, 31:37.170 --> 31:40.170 about the next slide shows a baby with an X ray 31:40.170 --> 31:42.640 that looks like severe highland membrane disease. 31:42.870 --> 31:45.680 You can see the endotracheal tube in there's air bronco 31:45.680 --> 31:46.220 grams, 31:46.360 --> 31:48.770 there's a diffused granular appearance. 31:48.770 --> 31:49.440 It's so severe, 31:49.440 --> 31:51.180 you can't even see the hard border hardly. 31:51.190 --> 31:53.610 Uh And the baby has hypo ventilation with the 31:53.610 --> 31:55.670 diaphragms way up in a small chest. 31:56.740 --> 31:56.960 Well, 31:56.960 --> 31:59.810 this these are X rays that are typical 31:59.820 --> 32:02.670 for transit to kidney and highland membrane disease or respiratory 32:02.670 --> 32:03.560 distress syndrome. 32:03.590 --> 32:06.250 But both babies had Group B strep 32:06.250 --> 32:07.160 septicemia. 32:07.330 --> 32:08.090 And again, 32:08.090 --> 32:09.730 that's why I emphasize that. 32:09.730 --> 32:12.710 I think any baby with moderate or 32:12.710 --> 32:15.560 severe respiratory distress should have cultures 32:15.560 --> 32:18.490 done and should be placed on antibiotics as 32:18.490 --> 32:21.040 if he has Group B strep until the cultures are negative. 32:21.050 --> 32:21.410 Again, 32:21.410 --> 32:22.050 if you miss it, 32:22.060 --> 32:22.260 well, 32:22.260 --> 32:22.880 it's too late. 32:22.890 --> 32:23.120 You know, 32:23.120 --> 32:24.050 the baby's gonna die. 32:24.060 --> 32:26.940 Whereas the other supportive treatment like oxygen 32:26.940 --> 32:29.760 and fluids and temperature control and blood pressure 32:29.760 --> 32:31.690 control is the same. 32:31.690 --> 32:34.500 No matter whether the kid has Group B strep or just 32:34.500 --> 32:35.570 highland membrane disease, 32:35.570 --> 32:37.050 or just transient to Kipnis. 32:37.940 --> 32:38.550 Okay. 32:38.560 --> 32:41.380 Uh what about late onset Group B strep? 32:41.390 --> 32:43.850 That is that occurs after the first week of age? 32:44.240 --> 32:45.600 Uh Well, 32:45.610 --> 32:47.000 first of all the types, 32:47.000 --> 32:49.430 that is whether it's type one abc, 32:49.430 --> 32:51.980 type two or type three are usually not the 32:51.980 --> 32:53.770 same as in the vagina, 32:53.770 --> 32:56.730 which makes us uh lead to think, 32:56.740 --> 32:59.150 leads us to think that that the baby does not 32:59.150 --> 33:01.990 acquire this infection from the mother's vagina 33:01.990 --> 33:02.650 during delivery, 33:02.650 --> 33:04.550 but probably acquires it somewhere else. 33:04.940 --> 33:07.780 Meningitis is very frequent and when 33:07.780 --> 33:09.100 meningitis is present, 33:09.110 --> 33:11.440 it's usually Group B A, 33:11.450 --> 33:12.140 Group B strep, 33:12.140 --> 33:12.960 type three. 33:13.340 --> 33:13.540 Okay, 33:13.540 --> 33:15.980 some other characteristics of late onset strip 33:15.990 --> 33:18.970 include that because probably because there's meningitis, 33:19.000 --> 33:21.810 but there's a higher incidence of long term neurologic sequelae. 33:22.540 --> 33:23.260 However, 33:23.270 --> 33:26.270 there's a much lower mortality with the late onset Group B strep 33:26.280 --> 33:27.760 than there is with the early onset. 33:28.140 --> 33:28.920 And again, 33:28.920 --> 33:31.170 you can see other infections like otitis 33:31.180 --> 33:31.970 arthritis, 33:31.980 --> 33:33.020 osteomyelitis, 33:33.020 --> 33:33.830 cellulitis, 33:33.830 --> 33:36.380 conjunctivitis can all present 33:36.390 --> 33:39.290 uh in babies with a Group B strep 33:39.300 --> 33:42.020 uh Meningitis uh in the late 33:42.020 --> 33:43.260 onset type Group B strep. 33:43.640 --> 33:43.840 Okay. 33:43.840 --> 33:46.730 What about the treatment of Group 33:46.730 --> 33:47.870 B strep meningitis? 33:47.870 --> 33:49.150 That is late onset. 33:49.160 --> 33:52.110 Uh Well obviously the same thing 33:52.110 --> 33:55.090 goes as I mentioned in the first part of this talk on 33:55.090 --> 33:55.740 sepsis. 33:55.750 --> 33:58.710 Uh But there's been some problems in the past few years with 33:58.720 --> 33:59.660 Group B strep, 33:59.670 --> 34:02.510 there have been more cases of relapse and apparent 34:02.510 --> 34:03.170 recurrence. 34:03.540 --> 34:05.960 So the doses of antibiotics have been 34:06.340 --> 34:08.860 uh brought upwards a little bit and as far as the 34:08.860 --> 34:10.020 duration of antibiotics, 34:10.020 --> 34:12.280 they've gone upward a little bit over the past few years. 34:12.290 --> 34:14.820 And the next slide shows what we presently recommend 34:14.830 --> 34:17.000 for Group B strep meningitis. 34:17.120 --> 34:19.380 And it must be ivy penicillin, 34:19.380 --> 34:19.550 I. 34:19.550 --> 34:22.240 V 150 to 250,000 34:22.240 --> 34:25.210 units per kilogram per day or ampicillin. 34:25.210 --> 34:28.060 Ivy 100 to 200 mg per kilo per day. 34:28.740 --> 34:31.330 And I prefer the higher doses 34:31.450 --> 34:34.040 rather than the lower doses now. 34:34.050 --> 34:37.030 Also probably one ought to continue Jenna missing or 34:37.030 --> 34:37.870 Kanneh mason, 34:37.970 --> 34:40.510 there is some evidence that 34:40.520 --> 34:42.700 can a missing and Jenna missin. 34:42.700 --> 34:45.390 Maybe synergistic uh with 34:45.390 --> 34:48.220 penicillin or ampicillin for the treatment of group B strep. 34:48.240 --> 34:48.660 Okay. 34:48.660 --> 34:50.830 Number three uh the I. 34:50.830 --> 34:51.000 V. 34:51.000 --> 34:53.940 Antibiotics should be continued for at least 10 to 34:53.940 --> 34:56.700 14 days after the spinal fluid is 34:56.700 --> 34:59.510 sterile And number four after the 34:59.510 --> 35:01.130 antibiotics are discontinued, 35:01.140 --> 35:02.280 72 hours, 35:02.580 --> 35:05.490 repeat culture should be done and the baby watch for another 35:05.490 --> 35:07.460 24-48 hours before being 35:07.470 --> 35:08.560 discharged. 35:09.240 --> 35:09.980 Okay, 35:10.090 --> 35:13.080 there are a few other things as far as Group B strep that I 35:13.080 --> 35:15.650 just want to kind of throw in here in the next few 35:15.650 --> 35:18.270 slides to explain one the variation and 35:18.270 --> 35:19.280 colonization rate, 35:19.290 --> 35:20.330 If we can explain it, 35:20.400 --> 35:23.290 and also to explain some of the problems that we're having 35:23.290 --> 35:25.410 as far as Group B strep and how to approach it. 35:25.830 --> 35:28.350 The next slide uh is an explanation, 35:28.360 --> 35:30.980 possible explanations for various variations and 35:30.980 --> 35:31.890 colonization rates. 35:31.890 --> 35:34.160 Remember I said that in some cities, 35:34.160 --> 35:37.080 three or 4% of the women have Group B strep in the vagina and other 35:37.080 --> 35:37.420 cities, 35:37.420 --> 35:39.680 30 or 40% of the women have group B strep. 35:39.840 --> 35:40.180 Well, 35:40.180 --> 35:41.600 of course it could be geography, 35:41.600 --> 35:42.970 but that's pretty unlikely, 35:43.090 --> 35:44.690 but it's possible 35:45.540 --> 35:46.990 socioeconomic status. 35:46.990 --> 35:49.780 We know that that uh pregnant women 35:49.790 --> 35:52.740 uh in lower socioeconomic groups have a higher incidence of Group 35:52.750 --> 35:53.500 B strep. 35:53.510 --> 35:55.840 But probably the most important 35:55.850 --> 35:58.850 reasons to explain this discrepancy in this 35:58.850 --> 36:01.610 variation and colonization rates are 34 and 36:01.610 --> 36:02.040 five. 36:02.530 --> 36:03.720 A number of cultures. 36:03.730 --> 36:06.330 The more cultures you do want a pregnant woman from 36:06.340 --> 36:07.950 her peri anal area, 36:07.950 --> 36:08.820 her vaginal area, 36:08.820 --> 36:09.880 her cervical area, 36:09.890 --> 36:12.340 the more likely you are to find Group B strep. 36:12.350 --> 36:13.870 Also the sites of cultures, 36:13.880 --> 36:14.980 if you only do this, 36:14.990 --> 36:16.130 the vaginal area, 36:16.140 --> 36:18.800 you're less likely to find it than if you do the cervical area 36:18.810 --> 36:20.850 and especially the peri anal area, 36:21.580 --> 36:22.750 the culture technique. 36:23.130 --> 36:25.310 It's been well shown that 36:25.530 --> 36:28.470 certain types of culture media 36:28.480 --> 36:31.110 are better for culture and group B strep. 36:31.120 --> 36:34.090 And if all you do is culture and the routine sheep blood agar 36:34.090 --> 36:34.530 plate, 36:34.540 --> 36:37.380 you're much less likely to find Group B strep. 36:37.390 --> 36:39.810 Then if your culture on a special culture medium 36:39.820 --> 36:42.530 geared specifically for uh 36:42.540 --> 36:43.350 growing strep. 36:43.930 --> 36:44.550 Okay, 36:44.720 --> 36:46.670 now how do we identify Group B strep? 36:46.670 --> 36:49.530 The next slide shows this uh 36:49.540 --> 36:50.570 and most of us, 36:50.580 --> 36:51.320 none of us, 36:51.320 --> 36:54.320 I guess our microbiologists are bacteriologist and 36:54.320 --> 36:55.820 we have to trust our laboratory, 36:55.820 --> 36:57.350 but there are few things we need to know. 36:58.330 --> 37:01.120 Many hospitals in the past have just screened for 37:01.120 --> 37:04.010 Group B strep by looking for beta hemodialysis that 37:04.020 --> 37:05.460 is not adequate. 37:06.030 --> 37:08.910 A significant percentage of groupie straps 37:08.920 --> 37:10.690 will not be beta hemolytic, 37:10.690 --> 37:13.160 there'll be non hemolytic or gamma hemolytic. 37:13.530 --> 37:16.450 Even if you do subsurface cultures, 37:16.460 --> 37:19.370 even if you culture and aerobically a lot a 37:19.370 --> 37:20.390 significant percentage, 37:20.390 --> 37:23.370 it's small but significant will be gamma or non 37:23.370 --> 37:24.050 hemolytic. 37:25.130 --> 37:27.270 So you have to do 37:27.270 --> 37:29.660 biochemical and immunological methods or 37:29.660 --> 37:32.370 serological methods to rule out Group B 37:32.370 --> 37:32.850 strep. 37:33.230 --> 37:33.560 Okay, 37:33.560 --> 37:33.750 now, 37:33.750 --> 37:36.210 what does that mean for the practicing 37:36.210 --> 37:36.850 physician? 37:37.530 --> 37:40.460 Well if you get a result back 37:40.470 --> 37:42.940 that says strep gamma 37:42.940 --> 37:45.350 strep and if it's from the blood urine, 37:45.350 --> 37:46.960 are spinal fluid in a newborn, 37:46.960 --> 37:47.890 baby or an infant. 37:47.900 --> 37:50.900 You better worry that that still is Group B 37:50.900 --> 37:51.550 strep. 37:51.560 --> 37:54.400 And you ought to make sure the laboratory totally 37:54.400 --> 37:56.730 evaluates it biochemically immunologically or 37:56.730 --> 37:59.620 psychologically for whether 37:59.620 --> 38:01.850 it's Groupie or non groupie, 38:01.860 --> 38:04.680 uh whether it's uh gamma hemolytic 38:04.690 --> 38:05.930 or beta hemolytic. 38:05.940 --> 38:08.880 So no matter whether you're result comes back, 38:08.890 --> 38:11.250 beta hemolytic strep or gamma he gamma 38:11.250 --> 38:11.930 strap, 38:11.940 --> 38:14.640 make sure the laboratory in every 38:14.640 --> 38:17.060 strep that's grown uh from a 38:17.060 --> 38:19.890 baby who has from his blood, 38:19.900 --> 38:20.970 urine or spinal fluid. 38:20.980 --> 38:23.470 Make sure whether it's gamma or beta. 38:23.480 --> 38:26.310 That they totally evaluated for whether it's Group A group B 38:26.310 --> 38:26.840 etcetera. 38:27.520 --> 38:28.030 Okay, 38:28.420 --> 38:31.230 now what kind of problems do we still 38:31.230 --> 38:31.520 have? 38:31.520 --> 38:34.440 We got some real critical answers as far as Group B strep that 38:34.440 --> 38:37.140 we need to get questions that we need to get the answer 38:37.140 --> 38:37.670 to. 38:37.680 --> 38:40.330 And this is what a lot of the research is going around the 38:40.330 --> 38:42.890 country uh is concerned with right now. 38:42.890 --> 38:45.460 And the next slide shows some of these uh 38:45.470 --> 38:47.110 shows some of these questions. 38:47.120 --> 38:48.030 Number one, 38:48.220 --> 38:51.150 what about antibiotic treatment in pregnant females? 38:52.320 --> 38:55.130 Uh And it would seem that gee why 38:55.130 --> 38:58.020 not take every woman who has Group 38:58.030 --> 38:58.190 B. 38:58.190 --> 39:00.680 Strep and culture and treated with penicillin? 39:00.690 --> 39:01.130 Well, 39:01.130 --> 39:02.340 there a number of problems there. 39:02.720 --> 39:03.560 Number one, 39:04.320 --> 39:05.790 as I just mentioned before, 39:05.800 --> 39:08.790 if you just do one culture or two cultures are three culture 39:08.790 --> 39:11.620 and you just culture the cervical or the vaginal 39:11.630 --> 39:14.070 or the peri anal area, 39:14.120 --> 39:16.620 you're quite likely not to find group B strep. 39:16.630 --> 39:18.380 And then if you do a whole bunch of cultures, 39:18.380 --> 39:19.250 a whole bunch of sites. 39:19.620 --> 39:20.130 In addition, 39:20.130 --> 39:22.810 if you just use a regular sheep blood agar that most 39:22.810 --> 39:23.710 laboratories use, 39:23.710 --> 39:26.120 you're not nearly as likely to find a group B strep. 39:26.130 --> 39:27.750 And if you use special culture medium. 39:28.120 --> 39:28.870 In addition, 39:28.880 --> 39:31.880 there is no evidence whatsoever that if you treat the 39:31.880 --> 39:34.840 mother for a week or 10 days that you'll get rid 39:34.840 --> 39:35.520 of the strip. 39:35.530 --> 39:36.260 And in fact, 39:36.270 --> 39:38.620 in newborn babies with Group B 39:38.620 --> 39:40.610 strep sepsis or meningitis, 39:40.610 --> 39:41.930 who received 10 14, 39:41.930 --> 39:44.450 21 days of parental penicillin or 39:44.450 --> 39:45.250 ampicillin. 39:45.520 --> 39:48.250 Many if not most of those babies, 39:48.320 --> 39:50.620 we'll still be colonized on the skin, 39:50.620 --> 39:53.510 nose or throat or pharynx with Group B 39:53.510 --> 39:55.070 strep when they're done with antibiotics. 39:55.080 --> 39:57.580 So there's a real question whether even treating the woman will get 39:57.590 --> 40:00.340 rid of the get rid of the Group B 40:00.340 --> 40:00.740 strep. 40:01.710 --> 40:01.980 Now, 40:01.980 --> 40:04.870 remember also the number of women that you're talking about if 40:04.870 --> 40:06.210 in fact 10, 40:06.210 --> 40:08.590 20 or 30% of women have Group B strep in their 40:08.590 --> 40:09.290 vagina. 40:09.300 --> 40:12.200 You're talking about treating hundreds of thousands and 40:12.210 --> 40:15.200 millions of women uh in 40:15.200 --> 40:17.460 the world with large doses of penicillin. 40:17.460 --> 40:20.320 And what effect is that going to have on those women as far 40:20.330 --> 40:22.910 as uh causing 40:22.910 --> 40:23.440 penicillin, 40:23.440 --> 40:24.570 allergy and anaphylaxis? 40:24.580 --> 40:27.360 While we might be killing more women from penicillin 40:27.360 --> 40:29.520 anaphylaxis than saving babies. 40:29.530 --> 40:32.000 Because remember that only about one out of 40:32.070 --> 40:35.060 100 of those mothers and probably not even quite that 40:35.060 --> 40:37.860 many will have a baby who gets sick with the 40:37.860 --> 40:38.700 Group B strep. 40:38.710 --> 40:40.360 So just saying, 40:40.360 --> 40:43.110 we're gonna culture every pregnant woman with group B strep in the vagina is 40:43.110 --> 40:44.130 not the answer. 40:44.140 --> 40:45.640 Only research is going to tell us. 40:46.010 --> 40:46.150 Now. 40:46.150 --> 40:47.410 The next question there is. 40:47.410 --> 40:49.240 What about venereal transmission? 40:49.610 --> 40:51.490 And then what about treatment of the infants? 40:51.490 --> 40:53.140 And we'll talk about both of those now. 40:54.510 --> 40:54.880 Well, 40:54.880 --> 40:57.370 there's good evidence now that the male can have Group B strep 40:57.380 --> 40:57.930 too. 40:57.940 --> 40:59.610 And if you treat the mother, 40:59.610 --> 40:59.970 of course, 40:59.970 --> 41:02.890 you've got to treat the mail and of course that just doubles the number of 41:02.890 --> 41:03.960 patients you're gonna treat. 41:03.970 --> 41:06.780 Uh if you're talking about treating pregnant women with Group B 41:06.780 --> 41:07.130 strep. 41:07.140 --> 41:09.760 And so we don't know enough about the venereal 41:09.760 --> 41:12.320 transmission of it yet to to make that decision. 41:12.330 --> 41:13.830 What about treating the infant? 41:14.610 --> 41:15.040 Well, 41:15.040 --> 41:15.750 as I said, 41:15.950 --> 41:16.630 first of all, 41:16.630 --> 41:18.860 even if the kids colonized with Group B. 41:18.860 --> 41:19.440 Strep, 41:19.450 --> 41:22.390 uh there's no evidence that you're going to get rid of the strip that the 41:22.390 --> 41:23.720 baby is colonized with. 41:24.110 --> 41:26.240 Ah There's. 41:26.710 --> 41:27.520 What are you gonna do? 41:27.530 --> 41:29.820 You gonna treat the baby gonna give one dose of penicillin? 41:29.830 --> 41:30.470 Well, 41:30.480 --> 41:32.580 what about the babies that really get Group B. 41:32.580 --> 41:34.210 Strep sepsis and meningitis? 41:34.220 --> 41:37.120 Maybe you're going to mask the disease so that you don't pick it 41:37.120 --> 41:38.170 up until it's too late. 41:38.180 --> 41:40.030 If you only give one dose of penicillin, 41:40.510 --> 41:41.950 which babies are you gonna treat? 41:41.960 --> 41:44.900 You're gonna treat every baby whose mother has group B 41:44.900 --> 41:45.940 strep in her vagina? 41:46.310 --> 41:48.860 Or are you gonna treat just the babies who have Group B. 41:48.860 --> 41:49.880 Strep colonized? 41:49.880 --> 41:50.060 Well, 41:50.060 --> 41:53.050 if you wait until treat the babies and your culture comes back 41:53.050 --> 41:54.530 in 24 48 hours. 41:55.010 --> 41:57.820 We already said most babies with Group B strep 41:57.820 --> 42:00.800 sepsis and early onset already 42:00.800 --> 42:03.080 have Are already sick at 42:03.080 --> 42:04.470 24 48 hours. 42:05.100 --> 42:06.000 In addition, 42:06.030 --> 42:08.320 as far as treating the kids with late onset, 42:08.330 --> 42:09.190 that won't help at all, 42:09.190 --> 42:11.940 because we already said that it's very unlikely that 42:11.940 --> 42:14.710 late onset Group B strep even comes from the mother's 42:14.710 --> 42:16.640 vagina probably comes from somewhere else. 42:17.300 --> 42:20.070 There's also recent evidence suggesting 42:20.070 --> 42:22.430 that many cases of early onset 42:22.440 --> 42:24.070 groupie colonization. 42:24.080 --> 42:26.860 Early colonization in the first week of life do 42:26.860 --> 42:29.130 not come from the mother's vagina, 42:29.130 --> 42:31.870 but that the baby may have a negative culture at birth or two 42:31.870 --> 42:34.220 days and then at 345 or six days, 42:34.800 --> 42:36.450 the baby may have a positive culture. 42:36.900 --> 42:39.060 So as far as treating the infamous concern, 42:39.060 --> 42:40.690 we still don't know. 42:40.720 --> 42:43.570 And that's why I don't think that we should routinely 42:43.580 --> 42:46.560 at this time say let's treat every single mother or every 42:46.560 --> 42:49.410 single baby where there's colonized with Group B strep. 42:49.420 --> 42:52.070 I think rather we should keep a very high index of 42:52.070 --> 42:52.750 suspicion. 42:52.760 --> 42:55.020 And in any newborn who is sick, 42:55.600 --> 42:56.960 who has any of those signs. 42:56.960 --> 42:58.990 We mentioned that we ought to consider Group B. 42:58.990 --> 43:01.320 Strep sepsis culture and begin therapy. 43:01.700 --> 43:01.980 Okay. 43:01.980 --> 43:03.850 A few other questions that we have to answer. 43:03.880 --> 43:06.040 What about the role of hospital personnel? 43:06.450 --> 43:06.990 As we said, 43:06.990 --> 43:09.580 a large percentage of hospital personnel may carry Group B 43:09.580 --> 43:10.010 strep. 43:10.700 --> 43:11.810 And what do we do with that? 43:11.820 --> 43:12.410 We don't know. 43:12.420 --> 43:13.250 We just don't know. 43:13.250 --> 43:14.620 We'll have to wait till studies are done. 43:15.000 --> 43:16.620 What about maternal antibodies? 43:17.100 --> 43:19.760 Uh if mother has 43:19.770 --> 43:21.870 antibodies in her blood to Group B strep, 43:21.880 --> 43:24.430 will that prevent the baby from being sick again? 43:24.430 --> 43:27.190 We don't know these are studies that were 43:27.190 --> 43:29.310 very much involved with right now. 43:29.320 --> 43:31.900 And that's why we have requested from every 43:31.900 --> 43:34.820 physician in indiana whenever he gets a baby that has a 43:34.820 --> 43:35.720 positive blood, 43:35.720 --> 43:38.100 urine and spinal fluid culture to call us 43:38.100 --> 43:40.970 immediately so that we can work with him getting 43:40.980 --> 43:43.960 samples of blood and urine from the baby, 43:43.970 --> 43:45.080 Blood from the mother. 43:45.090 --> 43:47.830 Uh so that we can evaluate the effect of 43:47.830 --> 43:50.430 antibodies from the mother on the baby as far as 43:50.440 --> 43:53.410 uh prevention or or whether 43:53.410 --> 43:56.230 it's related at all to whether the kid gets sepsis or meningitis. 43:57.000 --> 43:57.990 In summary. 43:57.990 --> 44:00.660 I'm afraid we've got a lot more questions that we have 44:00.660 --> 44:03.600 answers when it comes to Group B strep and all of those 44:03.610 --> 44:05.670 questions I just proposed to you. 44:05.680 --> 44:06.870 I don't have any answers to it. 44:06.870 --> 44:09.350 This time we have to wait until the research 44:09.360 --> 44:10.830 gives us the answers. 44:10.840 --> 44:11.420 However, 44:11.420 --> 44:13.880 in the meantime I just want to reemphasize. 44:13.890 --> 44:16.790 I think that just with as you're thinking of any 44:16.800 --> 44:19.440 bacteria that causes sepsis in the newborn. 44:19.460 --> 44:21.800 When you're thinking about Group B strep, 44:21.810 --> 44:24.760 any baby who has a history compatible with Group B 44:24.760 --> 44:27.430 strep or has any signs or symptoms 44:27.430 --> 44:28.480 compatible with sepsis, 44:28.480 --> 44:30.810 including just plain old respiratory distress. 44:31.290 --> 44:33.420 one ought to do the cultures blood, 44:33.420 --> 44:33.700 urine, 44:33.700 --> 44:36.170 spinal fluid and start the baby on 44:36.170 --> 44:38.920 antibiotics until the cultures are either positive or negative. 44:39.290 --> 44:42.250 Uh and I think it's only with that type of 44:42.250 --> 44:44.390 approach that we're going to decrease the 44:44.390 --> 44:47.020 mortality from neonatal sepsis and 44:47.020 --> 44:49.740 especially neonatal Group B strep strep 44:49.750 --> 44:51.610 group B strep sepsis. 44:52.090 --> 44:54.010 And I think that's all for this talk. 44:54.020 --> 44:56.850 It's been kind of long uh it's a very important 44:56.850 --> 44:57.550 subject. 44:57.560 --> 45:00.460 I think that you ought to go now and read some 45:00.460 --> 45:02.890 articles and read some books on neonatal sepsis. 45:03.090 --> 45:05.930 And let's see if all of us working together 45:06.080 --> 45:08.650 can decrease the morbidity and mortality from this 45:08.650 --> 45:09.720 devastating disease, 45:14.280 --> 45:15.280 the preceding, 45:15.290 --> 45:17.900 produced by the Medical Educational Resources 45:17.900 --> 45:20.600 Program of the Indiana University School of 45:20.600 --> 45:22.110 Medicine, 45:23.490 --> 45:24.000 Me. 45:24.690 --> 45:25.710 Mm.