08-01-2008, 09:32 AM
Thrush
Oral candidiasis; peaks at 14 days of life.
Clinically. White plaques on erythematous base over oral mucosa, tongue.
Treatment. Nystatin suspension 100,000 to 200,000 U PO QID for 7 days. Mycostatin cream to maternal areola and nipple if breast-fed infant.
Neonatal Bacterial Sepsis
General comments. Neonatal bacterial sepsis is associated with 10% to 40% mortality and significant morbidity, especially neurologic sequelae of meningitis. Infants 24 hours), premature labor, maternal fever, UTI, foul lochia, chorioamnionitis, IV catheters (in infant), intrapartum asphyxia, and intrauterine monitoring (pressure catheter or scalp electrode).
Organisms.
Early infection (0 to 4 days of age). Group B streptococci and Escherichia coli 60% to 70% of infections. Also Listeria (rare in United States), Klebsiella, Enterococcus, Staphylococcus aureus (uncommon), Streptococcus pneumoniae, group A streptococci.
Late infection (>5 days of age). Staph. aureus, group B streptococci, E. coli, Klebsiella, Pseudomonas, Serratia, Staph. epidermidis, Haemophilus influenzae.
Signs and symptoms. Presentation may be subtle; thus any febrile neonate must have a septic work-up. Fever may be absent; so watch for symptoms below.
The presentation may include irritability, vomiting, poor feeding, poor temperature control, lethargy, apneic spells.
May progress to respiratory distress, poor perfusion, abdominal distension, jaundice, bleeding, petechiae, or seizures.
Bulging fontanel is a very late sign of neonatal meningitis, and Brudzinski's sign or Kernig's sign is rarely found.
Work-up.
Include LP for cell count, protein, glucose, and culture.
UA, CBC (remember neutropenia or thrombocytopenia are also suggestive of infection) and repeat in 5 hours, CXR and C-reactive protein.
Cultures of blood, urine, and any other site as indicated. Latex agglutination test for pneumococcus, E. coli, H. influenzae, group B streptococci, and meningococcus in blood, urine, and CSF is done even though the usefulness is questionable. Negative latex agglutination tests do not rule out infection, but positive results may help guide therapy.
Associated lab findings. Hypocalcemia, hypoglycemia, hyponatremia, and DIC.
Treatment.
Should be tailored to age of onset, clinical setting, and initial findings.
There should be NO DELAY in antibiotic therapy. Begin empiric therapy after cultures are obtained or before cultures if any delay is anticipated.
Empiric early (0 to 4 days old). Ampicillin 50 mg/kg/day (100 mg/kg/day in meningitis) divided 12 hours IV and gentamicin 5 mg/kg/day divided 12 hours IV.
Empiric late (>5 days old). Depends on cause (for example, methicillin-resistant Staph. aureus outbreak requires vancomycin) ampicillin 100 to 200 mg/kg/day divided Q8h plus (ceftriaxone 100 mg/kg/day IV Q12h or cefotaxime 150 mg/kg/day IV Q8h), or ampicillin-gentamicin as above usually adequate.
Repeat cultures in 24 to 48 hours. In meningitis, repeat LP every day until clear.
There are isolates of Streptococcus pneumoniae that are resistant to penicillin and cephalosporins. Depending on your institution, vancomycin plus rifampin should be added to the above regimens until sensitivities are known.
Other. Hemodynamic, respiratory, hematologic, metabolic, and nutritional support and surveillance are critical. Shock may require volume expansion (FFP preferred) or respiratory depression may require supplemental oxygen or artificial ventilation