| BackgroundNeonatal septicemia refers to the systemic infection where bacteria invade a neonate’s circulatory system and grow, proliferate and produce toxins there, among which bacterial septicemia is the most common. Being a critical and acute condition in neonatal period, neonatal septicemia is the most common nosocomial infection in NICU, and is associated with high mortality and likely to result in pandemic in NICU. Early diagnosis and treatment are essential for improving its prognosis. However given the insidious onset and atypical early symptoms, and also the inadequate innate immunity of neonates, neonatal septicemia would typically progress rapidly and is very likely to induce severe sepsis, which may lead to multiple organ dysfunctions, septic shock, and eventually multiple organ failure or even death. While blood bacterial culture remains the "gold standard" for diagnosing neonatal, it has produced unsatisfactory positive blood culture rate and is relatively time consuming, thus failing to provide rapid diagnosis and guidance on treatment for septicemia. In this regard, early diagnosis of neonatal septicemia based on clinical symptoms and laboratory indicators would provide evidences for its early treatment, lest it develop into shock, circulatory/respiratory failure, or severe sepsis associated with, e.g., DIC, which may make it more difficult to rescue, thus increasing the mortality. In addition, considering the variation of pathogenic bacteria across different regions and periods, regular monitoring of the flora and drug resistance status of neonatal septicemia in the local area would provide more medical evidences for rational use of antibacterials, which is important for improving the patients’conditions.ObjectiveTo summarize Jiangmen City Xinhui District clinical features of neonatal septicemia, bacterial culture positive rate of common pathogens and their drug resistance,, to compare the risk factors, clinical features and a different distribution of pathogen infection between early onset septicemia(EONS) and late onset neonatal septicemia (LONS) in Xinhui District Jiangmen City.MethodsData of 98 cases newborns with neonatal septicemia from January 2009 to December 2013 were retrospectively studied in the three hospitals of Xinhui district. Risk factors of neonatal septicemia, clinical manifestations, hematology, CRP, PCT and etiological characteristics were statistically analyzed. Patients were divided into early and late neonatal septicemia groups according their age of onset. Risk factors, clinical presentation, pathogen infection rates were compared between two groups. Cases were divided into preterm infants group and full term group according to gestational age also, the same analysis of risk factors, clinical manifestations, pathogen infection and drug resistance were compared between two groups.ResultsPremature birth, premature rupture of membranes, amniotic fluid Ⅲ° cloudy, mother of infection, fetal distress, invasive operation, local infection were risk factors for neonatal septicemia. Clinical manifestations of neonatal septicemia were not typical, poor appetite (80.6%), poor response (78.5%) and fever (59.1%) were more common,55.1% of neonatal sepsis developed shock within hours. Apnea accounted for 23.6%, was more common in preterm infants than in full-term infant, there was a significant difference(χ2= 24.84, P<0.05) between the two groups. There were 43 cases with jaundice (43.8%), six cases with jaundice as the main clinical manifestations. Hematology, CRP and PCT have important reference values in the diagnosis and prognosis of sepsis. Decreased peripheral WBC (18 cases,17.3%) was more prone to cause severe shock performance than increased peripheral WBC (13cases,13.2%), there were statistically significant difference (χ2= 9.194, P<0.05). Changes of WBC counts in 24 to 48 hours after treatment were recorded in WBC reduced group, increased significantly in 13 cases (72.2%), which in 12 cases (66.6%) outcomes were cured or improved, continued to decline in 5 cases (27.7%), which in 4 cases outcomes were not cured or death, the difference was statistically significant (χ2= 6.152, P<0.05). Platelet (PLT)<100× 109/L occurred in 12 cases (12.2%), changes in its PLT counts in 24 to 48 hours after treatment were recorded, increased significantly after treatment in 7 cases, whose outcomes were cured or improved, continued to fall in five cases, whose outcomes were not cured or death, the difference was statistically significant (x2= 8.238, P= 0.004<0.05). CRP in 96 cases were detected, CRP> 8mg in 56 patients (58.3%), of which 30 cases were CRP<6mg in 24 to 72 hours before the onset, but CRP rose more than 4-fold in 12 to 24 hours after the onset. CRP in full-term infants were more likely to increase than those in preterm infants, the difference was statistically significant (χ2= 4.282, P<0.05). CRP increased rapidly in 12 to 24 hours after infection, is a sensitive indicator of neonatal septicemia. Among 98 cases of neonatal sepsis, procalcitonin (PCT)>2ng/ml was detected in 74 cases (75.5%) after the onset of 0.5-3h.. There was no significant difference in the PCT test between preterm infants and full term infants, early-onset and late-onset neonatal sepsis. PCT was high sensitivity, can quickly dropped to the normal range after effective treatment, PCT values were more than 10 ng/ml in 24 hours after the onset in 10 cases among 18 cases of death and not cured. In 98 cases of neonatal septicemia, bacterial culture positive rate was 45.9%, Gram-positive bacteria accounted for 64.4%, Staphylococcus epidermidis, Streptococcus agalactiae were among highest detection rates,41.3%,34.4% respectively. Coagulase-negative staphylococci (CONS) accounted for 35.5%, MRCONS 9.0%, and the detection of two Staphylococcus aureus were non-MRSA. gram-negative bacteria accounted for35.5%. Gram-negative bacteria distributed more evenly, producing ESBLS Gram-negative bacteria and fungi were not detected. Flora Distribution of early-onset neonatal sepsis and late-onset neonatal sepsis were different, with detection of Streptococcus agalactiae up to a total of 8, accounting for 61.5% in EONS, and detection of Staphylococcus epidermidis up to a total of 11, accounting for 57.8% in LONS. There was no significant difference in infection rates of Gram-positive bacteria between early and late onset group (P= 0.615). and in 10 cases of death or abandon therapy, pathogen detection rate was 40%, which Escherichia Salmonella accounted for two cases, Klebsiella pneumoniae subspecies accounted for one case, and Streptococcus agalactiae accounted for one case. Staphylococci had higher resistance rates to penicillin (94.4%), oxacillin (88.8%), erythromycin (66.6%), and lower resistance rates to clindamycin (16.6%), cefoxitin (16.6%). There are three (16.6%) with teicoplanin resistance. The resistance rates of streptococcus accounted for erythromycin (90.0%) and clindamycin (80.0%), no resistance to penicillin (0.0%). Enterococcus faecalis was fully complete (100.0%) resistanc to epenicillin, erythromycin, gentamicin, quinupristin-dalfopristin. Vancomycin was fully sensitive against Gram-positive cocci. Gram-negative bacteria had higher resistance rates to amoxicillin(87.5%), amoxicillin+clavulanic acid (87.5%) and piperacillin (67.5%),, followed by lower rates to cefoxitin and cefuroxime (44.4%), and the lowest rate to ciprofloxacin (6.2%). Maltophilia Aeromonas is naturally resistant to carbapenems, other strains were not resistant to carbapenems. Third generation cephalosporins against gram-negative bacteria tended to decrease sensitivity.ConclusionPremature birth, premature rupture of membranes, amniotic fluid Ⅲ° cloudy, infected mothers are at high risk factors for neonatal septicemia, to those with early neonatal risk factors, early screening, such as hematology, CRP, PCT, blood culture and cavity fluid bacterial culture, etc, should be done. If necessary, preventive antibiotics should be used. There is no specific performance of neonatal septicemia, almost always such as poor appetite, the reaction worse, feeding intolerance, and fever, premature children often have apnea, which is sometimes the only manifestation of sepsis in preterm children. Hospitalized newborns have to monitor carefully, if there is a infection suspected, related laboratory tests and bacterial culture should be done, hematology, CRP and PCT in the diagnosis and prognosis of sepsis have important reference values. Decrease of WBC is more common and more prone to cause severe shock performance than elevated WBC, changes in WBC and PLT have to dynamically monitor, the progressive decline in WBC and PLT indicates a more poor prognosis. So the WBC and PLT can be sensitive to reflect critically children’s condition and prognosis of sepsis, can be used as reliable indicators of effect and prognosis monitoring. CRP increased rapidly in 8 to 12 hours after infection, is a sensitive indicator of neonatal septicemia. Pocalcitonin (PCT) also increased rapidly in 8 hours after infection. Patients with neonatal septicemia (n= 98) were performed with PCT detection, and 74 patients showed elevated PCT (75.5%). There were no significant differences in PCT between premature and full-term infants or between early onset and late onset neonatal septicemia. PCT was highly sensitive, and PCT quickly decreased to the normal range after effective treatments. Among the death and unhealed cases (n= 18), the PCT values in 10 cases were more than 10 ng/ml 24 hours after the onset. It was reflected from a side respect that the PCT values> 10 ng/ml contributed to determining the severity and prognosis of patients associated with severe sepsis.98 cases of neonatal sepsis had blood cultures within half an hour after the onset,45 cases were detected bacterial, the detection rate was 45.9%. Gram-positive bacteria were still main pathogen, accounting for 64.4%, CONS (35.5%) and other opportunistic pathogens remained major causes of neonatal sepsis bacteria, Staphylococcus epidermidis accounted for the highest proportion,41.3%(12/29). Gram-negative bacteria accounted for 35.5%, evenly distributed. Streptococcus agalactiae (61.5%) was the most common in early-onset neonatal septicemia, Staphylococcus epidermidis (57.8%) was the most common in late-onset neonatal septicemia, gram-negative bacteria often occurred in late-onset neonatal sepsis, with severe illness and high mortality. Penicillin, oxacillin, erythromycin are not suitable for clinical use because of high resistance rates against Staphylococcal. There are three teicoplanin-resistant staphylococci. Vancomycin may be the preferred for serious Gram-positive bacterial infections because of no resistant rate against Gram-positive bacteria. Carbapenems against Gram-negative bacteria have a better sensitivity. Ciprofloxacin is also good for the sensitivity of Gram-negative bacteria, for multi-drug resistant strains and severe infections.Third generation cephalosporins can not be used as a regular or neonatal sepsis prophylaxis for their decreased sensitivity. The possibility of fungal infection should be highly alerted in newborns, especially preterm children, with mechanical ventilation and prolonged use of broad-spectrum antibiotics. |
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