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.