1 Recent Advances in the Diagnosis and Prevention of Neonatal Sepsis Richard A. Polin M.D. Morgan Stanley Children s Hospital Columbia University
2 Top 5 Reasons for Hating the Workup for Neonatal Sepsis There is no glory in performing a sepsis workup Most rule outs occur between 2:00 AM & 5:00 AM Drawing a blood culture from a preterm infant (24 weeks gestation) is like drawing blood from worm (with small veins). Even when the blood culture is negative, everyone usually ignores the results and treats the baby for 7-10 days. The probability that the lab will lose the blood specimen is inversely proportional to how difficult it was to draw the blood (and how critical the specimen).
3 Educational Objectives To discuss the importance of chorioamnionitis in the pathophysiology of neonatal sepsis and highlight the difficulties in making that diagnosis. To present a scientific rationale for the diagnostic workup and treatment of infants at risk for sepsis.
4 Clinical Spectrum of Early-onset Neonatal Sepsis There are ~3300 invasive early-onset sepsis cases and 390 deaths in the United states each year ( data). GBS is the leading pathogen and E coli is second 2/3 E coli isolates are resistant to ampicillin. Rate* Case fatality ratio Black preterm % Non black preterm % Black term % Non black term % */1,000 live births Weston et al Pediatr. Inf Dis. J. 30: 937, 2011
5 The Case Begins This was the first pregnancy for a 22 year-old woman with an unremarkable pre-pregnancy history. At 37 2/7 weeks gestation, her membranes rupture at 2:00 P M. She enters the hospital at 12 noon the following day because of painful uterine contractions. A rapid NAAT for GBS is positive. Following placement of an epidural she develops a temperature of 38.0 degrees C. There is no uterine tenderness and her white blood count is 18,000/mm 3 with 65% PMNS and 4% band forms. The care providers decide to administer broad spectrum antibiotics because of possible chorioamnionitis. The infant appears well at birth. How would you manage this infant?
6 The Case Continued Observation Blood Culture and broad spectrum antibiotics Screening WBC and blood culture
7 Pathways of Neonatal Sepsis Chorioamnionitis is a key step in the pathway of earlyonset neonatal sepsis.
8 Pathogenesis of Chorioamnionitis A. B. Kim MJ, et al. Lab Invest 2009
10 Microbes Responsible for Acute Chorioamnionitis & Subclinical Chorioamnionitis Acute chorioamnionitis Symptomatic mother Group B Streptococcus Escherichia coli Streptococcus viridans Subclinical chorioamnionitis Preterm labor or completely asymptomatic Ureaplasma urealyticum* Mycoplasma hominis* Gardnerella vaginalis Fulminant sepsis at birth Respiratory distress Cardiovascular instability Variable symptoms at birth Brain injury Chronic Lung Disease *~25% of infants < 1500 g are bacteremic with one of those organisms at birth.
11 The Uterus is not Sterile even in Term Pregnancies with no Labor and Intact Membranes Term not in labor (22) Term labor (16) Preterm not in labor (9) Preterm labor (10) PPROM (10) Bacteria Only Bacteria and inflammatory cells No bacteria or inflammatory cells Inflammatory cells only Steel JH et al Pediatr. Res 57: 404, 2005
12 The Microbiology of Intrauterine Infections is Complex PTL: intact membranes PPROM DiGiulio DB. Semin Fetal Neonatal Med 2012
13 Does the Woman in this Case History Have Chorioamnionitis? Fever and painful uterine contractions Epidural
14 Maternal fever, Chorioamnionitis and Epidural Anesthesia The clinical significance of fever following an epidural is controversial. There is an increased risk of fever following an epidural (RR 3.67 CI ); however, most women with intrapartum fever elevation after an epidural have no evidence of infection.
15 Diagnosis of Chorioamnionitis The diagnosis of chorioamnionitis is problematic (and frequently inaccurate) At term gestation, histologic (grade 2) chorioamnionitis is common (8%), but almost always non-infectious (4%). Fever is often used as the sole criteria for chorioamnionitis by obstetricians Fever is significantly more common in women with chorioamnionitis (69%), but is also common in women without chorioamnionitis (26%) Roberts et al PLoS one 2013
16 Clinical Chorioamnionitis: Diagnostic criteria Presence of otherwise unexplained maternal fever (greater than or equal to F, or C) plus at least 2 of the following additional clinical findings: Maternal tachycardia (> 100 bpm) Fetal tachycardia (>160 bpm) Elevated maternal white blood cell count (> 15,000 cells/m 3 ) Uterine tenderness Foul smelling amniotic fluid Gibbs R, et al. Am J Obstet Gynecol Newton ER. Clin Obstet Gynecol. 1993
17 How Good are the Diagnostic Criteria? Clinical Diagnostic Criteria Sensitivity Fever % Maternal tachycardia 50-80% Fetal tachycardia 40-70% Fundal tenderness 4-25% Foul-smelling discharge 5-22%
18 Does a History of Chorioamnionitis Identify Infants at High Risk for Neonatal Sepsis?
20 Case continued The infant is delivered at 37 2/7 weeks gestation following rupture of membranes for 26 hours. Intrapartum antibiotics (ampicillin and gentamicin) were given to the mother (< 4 hours prior to delivery. He was suctioned and dried by the nurse and placed on NPCPAP with 21% O 2. Apgar scores were 6 & 8 and the respiratory distress quickly resolved. The CPAP was discontinued.
21 How should the workup proceed?
22 Symptomatic or Asymptomatic Presence or Absence of Risk Factors
23 Rule out sepsis -The Process Identify the antenatal risk factors for sepsis. Perform a careful physical examination and make an estimate of the probability of sepsis based on those signs & history. Order the appropriate laboratory test and cultures. Decides who need antibiotics based on the above data.
24 Achieving a Treatment Threshold for Early-Onset Sepsis Critically Ill Symptomatic Observe Treatment Abnormal No risk factors (not critically ill) Diagnostic testing Asymptomatic and Risk Factors Chorioamnionitis Treatment Other risk factors (e.g.,prom) Normal No treatment
26 Estimating the Probability of Neonatal Early-Onset Infection on the Basis of Maternal Risk Factors Nested case control study of infants 34 weeks gestation Cases had early-onset sepsis ( 72 hours) n = 350 (1,063 controls) Rather than using cutoff values, risk factors were treated as continuous variables. The two best predictive values were the highest maternal temperature and gestational age, which accounted for 58% and 17% of the predictive model. Puopolo et al Pediatrics 128: e1155, 2011
27 Rate of sepsis according to gestational age
28 Rate of sepsis according to duration of rupture of membranes
29 Rate of sepsis according to highest maternal intrapartum temperature
30 Probability of Neonatal Early-Onset Infection Based on Maternal Risk Factors for Infants > 34 weeks gestation Gestational age (weeks/days) Temperature ROM (Hours) GBS status (positive, negative, uncertain) Maternal intrapartum treatment (GBS specific or broad spectrum) Was IAP given 4 hours prior to delivery Predicted probability(/1,000 live births) = Puopolo et al 2011
31 Probability of Neonatal Early-Onset Infection Based on Maternal Risk Factors for Infants > 34 weeks gestation Gestational age (weeks/days) Temperature ROM (Hours) GBS status (positive, negative, uncertain) Maternal intrapartum treatment Was IAP given 4 hours prior to delivery 34 weeks 2 days F 26 hours Positive Broad spectrum No Predicted probability(/1,000 live births) = Puopolo et al 2011
32 Stratification of Risk Early-Onset Sepsis in Newborns > 34 weeks gestation Retrospective nested case (n = 350) control (n = 1063) study of infants 34 weeks gestation Probability of sepsis based on the risk estimation at birth (historical data pretest probability) and the infant s clinical presentation (clinical Illness, equivocal presentation or well appearing) during the first 6-12 hours of life (post-test probability). Bayesian analysis Pretest Probability Risk of sepsis based on historical data Clinical Presentation Posterior Probability Escobar et al Pediatrics 133: 30-36, 2014
33 Stratification of Risk Early-Onset Sepsis in Newborns > 34 weeks gestation SEPSIS RISK AT BIRTH C A S E S < C O N T R O L S 55.7% 93.7% 23.1% 21.7% 5.08% 1.22%
34 Well appearing Stratification of Risk Early-Onset Sepsis < Probability sepsis (Posterior) NNT Equivocal presentation Probability sepsis (Posterior) NNT Prior Probability: Sepsis risk based on maternal risk factors Clinical Illness Probability sepsis (Posterior) NNT Escobar et al Pediatrics 133: 30-36, 2014
35 Clinical Presentation Sepsis Risk at Birth Estimated from Maternal Risk Factors <0.65/1000 live births /1000 live births 1.54/1000 live births Well Appearing Continued Observation 85% of live births NNT = 9,370 Observe and Evaluate 11% of live births NNT = 823 Equivocal Presentation Clinical Illness Observe and Evaluate 11% of live births NNT = 823 Treat Empirically 4% of live births NNT = 118
36 Our patient: Age 2 hours, estimated gestational age = 37 2/7 weeks, resolved respiratory distress; maternal colonization with group B streptococcus and PROM = 26 hrs, suspected chorioamnionitis. What testing is indicated at this time? Blood culture White blood count and differential count C-reactive protein
37 Blood cultures The key issue is the amount of blood drawn for culture! Up to 1/4 of infants with sepsis have low colony count bacteremia* (4 CFU/ml or less) and two thirds of infants 0-2 months have colony counts < 10 CFU/ml**. In clinical practice the volume of blood inoculated is frequently less than 0.5 ml (the most often recommended amount). *Dietzman et al J Pediatr. 85: 128, 1974: ** Kellogg et al Pediatr. Infect. Dis. 16: 381, 1997
38 Blood Culture Volumes Blood culture vol. CFU = 4 / ml CFU = 1/ ml 0.5 ml ml ml Whenever possible, try to send 1 ml for culture. * Schelonka R L et al J Ped 1996
39 The reliability of a blood culture depends on the volume of blood drawn. An Interventional Study An adequate volume of blood was considered 0.5 ml up to one month of age (in this study adequate volumes increased from 65% to 82%). Blood cultures with an adequate volume were twice as likely to yield a positive result. Connell et al Pediatrics 119: 891, 2007
40 Ancillary Laboratory Studies
41 Laboratory Testing Sensitivity Specificity Positive predictive accuracy Negative predictive accuracy* *The purpose of testing is to exclude infection in healthy babies
42 What is the Rationale for Adjunct Laboratory Tests? In a busy environment, observations occur sporadically Early-onset bacterial sepsis occurs in infants that are initially asymptomatic (Escobar 2000) Tests with a high negative predictive accuracy offer reassurance to the busy clinician that infection is unlikely
44 White Blood Count and Neutrophil Indices The normal range for the total white blood count is broad and not usefully clinically, unless it is low (< 5,000/mm 3 ). Neutrophil indices: absolute PMN count, absolute band count and the immature to total neutrophil (I/T) ratio are more informative. The most sensitive index is the I/T and most specific is neutropenia, but none of them have a good positive predictive accuracy.
45 Neutrophil Indices Suggestive of Sepsis I/T > 0.2 Band Count > 2000/mm 3 Neutropenia < 8,000/mm 3 in a late term or term infant & < 2200mm 3 in a preterm infant
46 Absolute Neutrophil Counts Counts obtained immediately after birth are frequently normal. Therefore if sepsis is suspected, a count obtained 6-12 hrs following birth is more informative.
47 Interpreting Complete Blood Counts Shortly After Birth Retrospective cross-sectional study of term and late-preterm infants (> 34 weeks) who had a blood culture and CBC within 1 hour of each other. Confirmed infection n = 245, no infection n = 67,623 The ability of the ANC and WBC to discriminate infected from non-infected infants improved between < 1hour, 1-4 hours and 4 hours Newman et al Pediatrics 126: , 2010
48 Interpreting Complete Blood Counts Shortly After Birth WBCs ANCs I/T ratio Platelet Counts Newman et al Pediatrics 126: , 2010
49 C-reactive Protein & Neonatal Sepsis CRP is an acute phase reactant synthesized within 6-8 hours of an infective process with a half-life of hours. Sensitivity improves (> 90%) if the first determination is obtained 6-12 hours following birth. When a cutoff value of 1 mg/dl is used, CRP has a high negative predictive accuracy ( %). A variety of non-infectious/stress conditions can elevate the CRP. CRP levels may be slow to normalize, limiting their value in following the response to antibiotics.
50 Algorithms for Diagnosis and Management of Neonatal Sepsis Major Risk Factors for Neonatal Sepsis PROM > 18 hours, signs and symptoms of chorioamnionitis, colonization with GBS* Prematurity` *GBS is not a risk factor if there has been adequate intrapartum treatment or the infant is delivered by elective cesarean section with intact membranes and no labor
51 Evaluation of Asymptomatic Infants (any gestational age) Risk Factor Chorioamnionitis Risk Factors Diagnostic Tests Antibiotics Chorioamnionitis a Blood culture at birth WBC/Diff ± CRP at age 6-12 hours Broad spectrum antibiotics Management Blood culture positive Blood culture negative Infant remains well; Lab data reassuring Continue antibiotics Lumbar puncture b Discontinue antibiotics by 48 hours
52 Evaluation of Asymptomatic Infants 37 Weeks Gestation with Risk Factors for Sepsis: (No chorioamnionitis) Risk Factors PROM 18 hours & IAP inadequate a Observation b Frequent observations possible No testing needed Infant remains well; Discharge by 48 hours d Diagnostic Testing c
53 Evaluation of Asymptomatic Infants (< 37 weeks) with Risk Factors for Sepsis: (No chorioamnionitis) Risk Factors Diagnostic Tests PROM 18 hours or IAP inadequate a WBC/Diff ± CRP at age 6-12 hours No observation antibiotics with needed examinations Observationq b q 2-4h 2-4h Observation b Management Lab data abnormal Lab data normal Infant remains well No antibiotics needed Blood Culture & Broad Spectrum Antibiotics Blood culture positive Continue antibiotics Lumbar puncture c Blood culture negative Infant remains well Discontinue antibiotics after 48-72h
54 Duration of Antimicrobial Therapy Whenever possible, antibiotics should be stopped by 48 hours if the cultures are negative and the infant remains asymptomatic. Antibiotics should be continued for 7 days in any critically ill infant.
55 In a multivariate analysis (adjusted for confounding variables) prolonged therapy with antibiotics ( 5days) in the first few days of life was associated with increased mortality, NEC or the combined outcome of death and NEC. Prolonged initial empirical antibiotic treatment OR (95% CI) NEC or Death 1.30 ( ) <.01 NEC 1.21 ( ).08 Death 1.46 ( ) <.001 P Retrospective cohort study of 4039 ELBW infants who survived at least 5 d. Cotton CM and the NICHD Network Pediatrics 123: 58-66, 2009
56 Conclusions Infants with signs indicative of sepsis should be treated with broad spectrum antibiotics after appropriate cultures are taken. The physical examination is as valuable as any laboratory test. Well-appearing, at-risk infants should not be treated more than 48 hours if the blood culture is negative and the infant remains well. Critically ill babies (with negative cultures) should be treated for 7 days with broad spectrum antibiotics.
57 A Successful Outcome to our case The blood culture was negative and because of the unremarkable laboratory values, the infant was only treated for 48 hours. As the infant grew up he became a politician and eventually became President of the United States. Nuculer
RISK FOR INFECTION IN THE LATE PRETERM INFANT Late preterm infants are at greater risk of having an infection caused by bacteria. An infection in the uterine environment is sometimes the reason for early
Stratification of Risk of Early-Onset Sepsis in Newborns 34 Weeks Gestation New England Association of Neonatologists 16 th Annual Braden E. Griffin, MD Memorial Symposium Karen M. Puopolo, MD, PhD Division
Page: 1 of 9 SUBJECT: PREVENTION OF PERINATAL GROUP B STREPTOCOCCAL DISEASE OVERVIEW This guideline outlines a consistent, evidence-based approach to screening and routine management of Group B Streptococcus
Early Onset Neonatal Sepsis: Update 2011 Mead Johnson Virtual Neonatal Journal Club Karen M. Puopolo, MD, PhD Division of Newborn Medicine, Brigham and Women s Hospital Assistant Professor of Pediatrics,
Early onset GBS disease in Newborn Upender Munshi M.D. Neonatology Division, Department of Pediatrics Albany Medical Center, Albany,N.Y.12208 Early onset Neonatal GBS Disease GBS : Important Pathogen in
Policy Clinical Guideline South Australian Perinatal Practice Guidelines neonatal sepsis (including maternal group B streptococcal colonisation) Policy developed by: SA Maternal & Neonatal Clinical Network
Fetal Therapy Center Phone: 305-585-6636 Fax: 305-325-1282 www.uhealthobgyn.com www.jhsmiami.org AMNIOPATCH INFORMATION PACKET 2 AMNIOPATCH FOR TREATMENT OF PREVIABLE PREMATURE RUPTURE OF MEMBRANES Premature
What is Group B Strep (GBS)? Group B Streptococcus (GBS) is a type of bacteria that is found in the lower intestine of 10-35% of all healthy adults and in the vagina and/or lower intestine of 10-35% of
March 2011 Streptococcal Disease Group B, Newborn Case Definition Confirmed Case Within the first 90 days of life, clinical illness  in an infant, with laboratory confirmation of infection: Isolation
Oxford University Hospitals NHS Trust Newborn Care Unit, John Radcliffe Hospital, Oxford Neonatal Unit, Horton General Hospital, Banbury What is an infection screen? Information for parents This leaflet
Teresa Baker 1 Umbilical Cord Blood as Alternative for Infant Blood in Neonatal Sepsis Evaluation Contact Information: Teresa Z. Baker, MS, APRN, NNP-BC 2401 South 31 st Street Scott & White Children s
Prematurity What is prematurity? A baby born before 37 weeks of pregnancy is considered premature. Approximately 12% of all babies are born prematurely. Terms that refer to premature babies are preterm
Prevention of Perinatal Group B Streptococcal Disease: Updated CDC Guideline COLLEEN K. CAGNO, MD; JESSIE M. PETTIT, MD; and BARRY D. WEISS, MD University of Arizona College of Medicine, Tucson, Arizona
Running head: UMBILICAL CORD BLOOD AS ALTERNATIVE 1 Umbilical Cord Blood as Alternative for Infant Blood in Neonatal Sepsis Evaluation Teresa Z. Baker Texas Woman s University Author Note This Capstone
Maribeth Inturrisi RN MS CNS CDE Perinatal Diabetes Educator firstname.lastname@example.org List the potential complications associated with diabetes during labor. Identify the 2 most important interventions essential
Xpert GBS LB Xpert GBS A complete GBS testing solution Xpert GBS LB & Xpert GBS Only molecular system with moderately complex antepartum and intrapartum tests on a single platform A better way. Now nurses,
Before you begin this unit, please take the corresponding test at the end of the book to assess your knowledge of the subject matter. You should redo the test after you ve worked through the unit, to evaluate
Febrile UTIs in Practice AAP Guidelines and New Evidence Jennifer Chapman, MD Kavita Parikh, MD, MSHS Shilpa Patel, MD, MPH Emergency Medicine Hospitalist Medicine Emergency Medicine June 15, 2016 Future
Musculoskeletal Infection Care Process Model Musculoskeletal infections are serious and potentially life-threatening. Musculoskeletal infections include necrotizing fasciitis, septic arthritis, osteomyelitis,
Oregon Birth Outcomes, by Birth Place and Attendant Pursuant to: HB 2380 (2011) In 2011, the Oregon Legislature passed House Bill 2380, which required the Oregon Public Health Division to add two questions
Sepsis and the Clinical Laboratory Alison Woodworth, PhD Department of Pathology, Microbiology, and Immunology Vanderbilt University Medical Center Nashville, TN Learning Objectives Outline the Pathogenesis
Quality of Birth Certificate Data Daniela Nitcheva, PhD Division of Biostatistics PHSIS Data Quality SC State Law requires that you file the birth certificate within 5 days of a child s birth. Data needs
Original article JOURNAL OF INTERNATIONAL MEDICINE AND DENTISTRY To search..to know...to share ISSN 2350-045X A study to assesss the effectiveness of self instructional module on prevention of nosocomial
MOM'S INFORMATION Final EDC and Gestational Age: # of Fetuses this Pregnancy: Mother's Age: Gravida: Para: Term: Preterm: Abortion: Living: Blood Type/ RH Factor: Antibody Screen: Rh Globulin: Rh Globulin
Umbilical Cord Blood as Alternative for Infant Blood In Neonatal Sepsis Evaluation Teresa Z. Baker, MSN, RN, NNP-BC Mentor of: Stacey Castellanos, BS, RN Addie Lockett-Addison, BS, RN Introduction Early
Using the Electronic Medical Record to Improve Evidence-based Medical Practice P. Brian Smith Duke University Medical Center Durham, NC Disclosure I have no relevant financial relationships with the manufacturer
Midwives o n t a r i o Experts in normal pregnancy, birth & newborn care > Clinical Practice Guideline No.13 Management of Prelabour Rupture of Membranes at Term Association of Ontario Midwives JULY 2010
Glucose Tolerance Testing PROTOCOLS FOR PERFORMING GLUCOSE TOLERANCE TESTS INTRODUCTION Described in this section are the sample requirements, patient preparation instructions, dosages of substances to
U NIT 2: OBSTETRICS S ECTION B: ABNORMAL O BSTETRICS Educational Topic 22: Abnormal Labor Rationale: Labor is expected to progress in an orderly and predictable manner. Careful observation of the mother
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE Interventional procedure consultation document Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean
Innovative use of Neonatal Nurse Practitioners in Rural Hawaii Petri Pate Pieron, MSN, MPH, APRN Rx, CPNP, NNP Presentation was supported by NIH 1 R25 RR019321 Clinical Research Education and Career Development
Infant of Mother/Fetus with Chorioamnionitis Review and Proposed Evaluation And Management at LLUMC T. Allen Merritt, M.D., MHA Chorioamnionitis The term chorioamnionitis is used to describe an intrauterine
A Practical Guide to Diagnosis and Treatment of Infection in the Outpatient Setting Diagnosis and Treatment of Urinary Tract Infections By Gary R. Skankey, MD, FACP, Infectious Disease, Las Vegas, NV Sponsored
Hyperbilirubinemia Care Guidelines for Emergency Department Management Inclusion Criteria: Previously healthy, age 14 days, born at 37 weeks gestational age. Total Serum Bilirubin of 18mg/dl, < 23mg/dl.
Maternity Record Please take care of this record as it is the ONLY paper record of your pregnancy You should bring this record with you when you visit any health care professional CONTACT DETAILS Antenatal
South Asian Federation of Obstetrics Sabera and Khatun Gynecology, et al January-April 2009;1(1):24-28 ORIGINAL STUDIES Low Birth Weight and First Week Neonatal Mortality in a Tertiary Level Hospital in
A8b Resuscitation of a Term Infant with Meconium Staining Karen Wright, PhD, NNP-BC Assistant Professor and Coordinator, Neonatal Nurse Practitioner Program Dept. of Women, Children, and Family Nursing,
for UTI: The Burning Question of Self Diagnosis Overview Review Pharmacist prescribing in Saskatchewan Discuss current management / diagnosis of UTI Appraise the literature for safe and accurate diagnosis
CLINICAL QUALITY MEASURES FINALIZED FOR ELIGIBLE HOSPITALS AND CRITICAL ACCESS HOSPITALS BEGINNING WITH FY 2014 e 55 0495 2 Emergency Department (ED)- 1 Emergency Department Throughput Median time from
L14: Hospital acquired infection, nosocomial infection Definition A hospital acquired infection, also called a nosocomial infection, is an infection that first appears between 48 hours and four days after
Etiology and treatment of chronic bacterial prostatitis the Croatian experience Višnja Škerk University Hospital for Infectious Diseases "Dr. Fran Mihaljevic" Zagreb Croatia Milano, Malpensa, 14 Nov 2008
July 21, 2011 By NeedsFixing  To investigating the relationship between cord blood erythropoietin and clinical markers of fetal hypoxia. Abstract Objective: To investigating the relationship between
Defining Normal Cerebrospinal Fluid White Blood Cell Counts in Neonates and Young Infants: A Scholarly Pursuit Lori A. Kestenbaum, Jessica L. Ebberson, Joseph J. Zorc, Caitlin LaRussa, Richard L. Hodinka
ABSTRACT POLICY Prior to fetal viability, intentionally undertaking delivery of a fetus is the equivalent of abortion and is not permissible. After fetal viability has been reached, intentionally undertaking
C-Difficile Infection Control and Prevention Strategies Adrienne Mims, MD MPH VP, Chief Medical Officer Adrienne.Mims@AlliantQuality.org 1/18/2016 1 Disclosure This educational activity does not have commercial
Neonatal Sepsis 2006 Update Anne Matlow MD FRCPC Director, Infection Prevention and Control Hospital for Sick Children, Toronto Hosted by Jackie Daley email@example.com www.webbertraining.com Objectives
NEONATAL PALLIATIVE CARE DRA. RUT KIMAN Head CPC Team. Hospital Nacional Prof. A. Posadas. Buenos Aires- Argentina Department of Pediatrícs. Faculty of Medicine. University of Buenos Aires Milena was the
Omega-3 fatty acids improve the diagnosis-related clinical outcome 1 Critical Care Medicine April 2006;34(4):972-9 Volume 34(4), April 2006, pp 972-979 Heller, Axel R. MD, PhD; Rössler, Susann; Litz, Rainer
Surviving Sepsis 1 Scope and Impact of the Problem: Severe sepsis is a major healthcare problem that affects millions of people around the world each year with an extremely high mortality rate of 30 to
Risk stratification tool for children aged under 5 years with suspected sepsis Category Age Behaviour No response to social cues Appears ill to a healthcare professional Does not wake, or if roused does
Cardiovascular Disease and Maternal Mortality what do we know and what are the key questions? AFSHAN HAMEED, MD, FACOG, FACC Associate Clinical Professor Maternal Fetal Medicine and Cardiology University
More than Meets the Eye Hemolytic Disease of The Newborn with DAT Negative Anemia March 7, 2007 Cassandra D. Josephson, MD Assistant Director, Children s s Healthcare of Atlanta Blood Banks and Transfusion
Pharyngitis, Acute - Treatment for Adults - OBSOLETE Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to
bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published.
The New England Journal of Medicine Copyright 21 by the Massachusetts Medical Society VOLUME 344 F EBRUARY, 21 NUMBER 7 THE CONTINUING VALUE OF THE APGAR SCORE FOR THE ASSESSMENT OF NEWBORN INFANTS BRIAN
Discuss the post-operative counselling and the implications for future fertility of a woman who had laparoscopic surgery for an ectopic pregnancy. Emily Hutchinson 5 th Year Medical Student Imperial College
SOUTHERN WEST MIDLANDS NEWBORN NETWORK Hereford, Worcester, Birmingham, Sandwell & Solihull Title Management of infants born to an HIV Positive Mother Author Dr Steve Welch Date Guideline Agreed: May 2009
Health Care Decision Making Worksheet Instructions Use this worksheet either to indicate current treatment preferences (which will be reflected in Maryland MOLST orders) or to clarify wishes for future
Listening Test Part B Time allowed: 23 minutes In this part, you will hear a talk on critical illnesses due to A/H1N1 influenza in pregnant and postpartum women, given by a medical researcher. You will
Introduction The NICU Criteria were developed to assist in the authorization for various levels of Neonatal Intensive Care Unit (NICU), as well as assistance in determining the appropriate level of care.
Blood glucose homeostasis in the neonate Julia Petty Glucose homeostasis in the neonate Constant supply is vital Requirements are high in utero and in the neonatal period compared with adult Rate of glucose
Please complete in black ballpoint pen Hospital name: Points to remember: Until completed, keep this form in the Working documents section of the Baby-OSCAR Documentation Box. This form must be completed
Current Statut of Group B Streptococcus Vaccine Research and Development Claire Poyart CNR-Strep, Service de Bactériologie Hôpital Cochin, Université Paris Descartes Current Status of GBS vaccine Research
Burden of Pneumonia in Children Objectives 1. Provide an overview of pneumonia: symptoms and diagnosis 2. Characterize the burden of pneumonia morbidity and mortality globally and in South Asia 3. Characterize
143 Chapter 10 Human Immuno Deficiency Virus Infection Chapter 10 Human Immuno Deficiency Virus Infection...143 HIV infection...144 Clinical Features...146 Clinical Staging of HIV infection recommended
K: Maternal / Newborn Care Alberta Licensed Practical Nurses Competency Profile 103 Competency: K-1 Prenatal Care, Assessment and Teaching K-1-1 K-1-2 K-1-3 Demonstrate knowledge of human anatomy and physiology
American Pediatric Surgical Association Standardized Toolbox of Education for Pediatric Surgery Appendicitis APSA Committee of Education 2012-13 APPENDICITIS Marjorie J. Arca, MD Children s Hospital of
Assessment of Fetal Growth Unit / Trust: 1. INTRODUCTION The aim of this guideline template is to outline the methods used to assess fetal growth and the referral pathways utilising customised antenatal
All new applicants must meet the following requirements as approved by the UNMH Board of Trustees effective: 03/27/2015 INSTRUCTIONS Applicant: Check off the "Requested" box for each privilege requested.
Midwives o n t a r i o Experts in normal pregnancy, birth & newborn care > Clinical Practice Guideline No.11 Group B Streptococcus: Prevention and Management in Labour Association of Ontario Midwives january
Lyme Disease in Pregnancy Dr Sarah Chissell Consultant Obstetrician William Harvey Hospital, Kent Conflict of interest My son has chronic Lyme disease Infections in pregnancy Transplacental infection Perinatal
The Use of Probiotics in Preterm Babies Main Author(s): Ratifying Committee: David Bartle, Paediatrician (RDE) Chris Knight, Paediatrician (TST) Pam Cairns, Neonatologist (UHB) South West Neonatal Network
MINISTRY OF HEALTH PROCEDURE OF CARE AND TREATMENT FOR PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV HA NOI, 2007 1 TABLE OF CONTENTS Decision on the Issuance of the Procedure of Care and Treatment
Effective Communication of Hematology Laboratory Results Linda M. Sandhaus MD, MS Associate Professor of Pathology University Hospitals Case Medical Center Cleveland, OH 44106 Linda.Sandhaus@UHhospitals.org
What is GBS? The bacteria that causes group B strep normally lives in the intestine, vagina, or rectal areas. Group B strep colonization is not a sexually transmitted disease (STD). For most women there
Sepsis - Automate and Streamline the CMS Early Measure Bundle A Conversation with Clinicians About Best Practices to Effectively Meet the Measure Becker s Hospital Review December 1, 2015 Presenters Stacy
Sepsis: Identification and Treatment Daniel Z. Uslan, MD Associate Clinical Professor Division of Infectious Diseases Medical Director, UCLA Sepsis Task Force Severe Sepsis: A Significant Healthcare Challenge
Varicella and Epidemiology and Prevention of Vaccine- Preventable Diseases Note to presenters: Images of vaccine-preventable diseases are available from the Immunization Action Coalition website at http://www.vaccineinformation.org/photos/index.asp
Keeping track of your numbers If you have relapsed or refractory multiple myeloma, keeping track of your numbers can help you take an active role in your care. It s also one way you and your doctor can
Rural Health Advisory Committee s Rural Obstetric Services Work Group March 15 th webinar topic: Rural Obstetric Patient and Community Issues Audio: 888-742-5095, conference code 6054760826 Rural Obstetric