Neonatal Septicemia

What are your dddx for a recumbent foal?

Septicemia, neonatal encephalopathy, neonatal isoerythrolysis, hypglycemia, hypothermia, hypoxia, muscle weakness, trauma, can be multiple problems

What is sepsis?

Systemic inflammatory response syndrome (SIRS) caused by any circulating microorganisms and or their products

What is SIRS?

Systemic response characterized by alterations in body temp, HR, RR, and leukogram parameters

What is bacteremia?

Presence of viable circulating bacteria

What is a major cause of morbidity and mortality in equine neonates?

Sepsis

What is responsible for C/S of sepsis?

SIRS

What are some predisposing maternal factors for neonatal sepsis?

In utero infection

What are some fetal predisposing factors for neonatal septicemia?

Failure of transfer of passive immunity

Farm management

Gestational age/length

Primary immunodeficiency (post natal infection)

What are common routes of infection that lead to neonatal sepsis?

In utero infection

Post natal infection through umbilical remnants, GI tract, or resp tract

What can cause failure of transfer of passive immunity?

Maternal or foal factos

How much colostrum do foals need?

1-2 liters

How do you treat a foal with failure of transfer of passive immunity?

Colostrum if less than 6-12 hours

IV plasma

What are the causative species of neonatal sepsis?

Gram negative most common: E. coli, Salmonella, Actinobacillus equuli, Klebsiella, Enterobacter, Pseudomonas

Gram positive: Enterococcus, strep, staph

Fungal is rare but candida albicans

What is the pathophysiology of neonatal sepsis?

Pathogen exposure leading to bacteremia and C/S of SIRS

Can seed to different organ systems

T/F pathogen virulence plays an important role in pathophysiology of sepsis?

True

T/F IgG is the only protection against pathogens in foals?

False, colostrum has other protection in it

What are C/S of sepsis?

Decreased/absent milk intake, lethargy, recumbency. maternal disinterest, diarrhea, dehydration, febrile or hypothermic if in shock

What should you look for on a mares PE with a septic foal?

Evidence of maternal illness

Udder fill

Abnormalities in the placenta

What is on PE of a septic foal?

Dehydrated, tachypnea, tachycardia, febrile or normal, hyperemic injected and petechaited mms, injected and hyperemic sclera, uveitis, hypovolemia

C/S consistent with specific foci of infection

How do you diagnose sepsis?

History, C/S, PE

Clinciopatholoic findings including IgG

Blood culture

Sepsis score

What is the gold standard of sepsis diagnosis?

Blood culture

What are the clin path findings of sepsis?

Leukopenia: neutropenia, left shift, toxic changes

Hyperfibrinogenemia

Elevated serum amyloid A

Hypoglycemia, azotemia, hyperbilirubinemia, acidemia, hyperlactatemia

What coag abnormalities can be present with septic foals?

Thrombocytopenia

Decreased AT III

Prolonged PT and PTT

Elevated FDP and D-dimers

How do you do a blood culture?

Aerobic and anaerobic culture

Identify organism to direct antimicrobials

Collect from a large vein sterilely

What do you treat septic foals?

Antimicrobial therapy

Anti-endotoxin therapy

Cardiovascular support

Nutritional support

Supportive care

Reverse isolation

What antimicrobials do you want for a septic foal?

Aminoglycoside plus beta lactam as long as kidneys are good for 2 weeks unless localizing signs then 4 weeks

Do not delay antibiotics for blood culture

What can you use for anti-endotoxin therapy?

Flunixin, pentoxifylline, polymyxin B, plasma

When do you need to provide cardiovascular support?

Hypovolemia, septic shock, hypotension

How do you provide cardiovascular support?

Maintenance fluids but be careful of volume overload due to sodium retention

Colloids to provide oncotic support, coagulation factors, anti-endotoxin

Pressor agents if needed

What is maintenance of fluids in foals?

100-120 mL/kg/day

How much plasma do you need if there is failure of passive transfer?

20-40 mL/kg

How can you provide nutritional support to a septic foal?

Enteral nutrition (preferred)

Parenteral nutrition

How do you provide enteral nutrition to foals?

Nasoesophageal feeding tube with frequent feeding 10% of BW daiy

Goal is 25% of body weight daily

What supporting care do septic foals need?

Padding, check for corneal ulcers, thermoregulation, urination and defecation, feeding and oxygen tubes, sternal recumbency

When do foals really need supportive care?

If recumbent

What are some sequelae of sepsis?

Can cause issues in other parts of the body like resp, GI, neuro systems, umbilical remnant, septic arthritis and osteomyelitis

T/F presentation with localized infections should warrant examination for sepsis?

True

What is the significance of umbilical remnant?

Omphalitis causing common sources of continual bacterial shedding

How do you diagnose umbilical remnant?

PE and US

How do you treat an umbilical remnant?

Antibiotics and surgical resection if persistent

What is common sequelae to umbilical remnant?

Patent urachus

Uroperitoneum

What is a common sequelae in the neuro system?

Meningitis

What are C/S of meningitis?

Seizures and somnolence

How do you diagnose meningitis?

CSF analysis with neutrophilic pleocytosis and bacteria potentially

How do you treat meningitis?

3rd or 4th gen cephalosporins like cefriaxone

What is the prognosis of meningitis?

Poor to grave

What are C/S of septic arthritis and osteomyelitis?

Joint effusion early

Periarticular swelling, pain, heat, palpation, restricted movement

LAMENESS

How do you diagnose septic arthritis and osteomyelitis?

Synovial fluid analysis with cytology and culture

Rads

How do you treat septic arthritis and osteomyelitis?

Systemic antibiotics

Local antibiotics

Lavage of synovial structure with surgical intervention

What is the prognosis for sepsis?

50% survival with early detection and aggressive therapy giving the best prognosis

How do you prevent sepsis?

maintain clean foaling environment

Reduce bacterial load during udder seeking

Attended foaling

Ensure GI intake of good colostrum

Confirm adequate transfer of passive immunity

Ensure appropriate umbilical care

Monitor foals closely and treat quickly

Client education

How should you maintain a clean foaling environment?

Clean between mares

Clean stall once or twice daily

What is NI?

Neonatal isoerythrolysis

What are risk factors for NE (neonatal encephalopathy)?

Maternal illness like hypoxemia, colic, cardiovascular compromise

Placentitis/placental insufficiency

Premature placental separation

Dystocia

Cesarean section

Induced parturition

Post term pregnancy (fescue tox)

Idiopathic

What are C/S of NE (neonatal encephalopathy)?

Generalized weakness or somnolence, lack of interest in dam, no suckle, weak tongue, dysphagia, vocalization or weird jaw movements, head pressing, cortical blindness, recumbency, seizures, other organs affected like GI or renal

What are the classification of NE?

Mild

Moderate

Severe

How do you diagnose NE?

C/S

History of insult

Exclusion of other things

How do you treat NE?

Maintain hydration and blood glucose

Control neuro signs, especially seizures

NSAIDs and free radical scavengers

Nursing care

How do you control neuro signs with NE?

Reduce cerebral edema with mannitol, furosemide

Control seizures with diazepam or phenobarbital

What anti-inflammatories and free radical scavengers are good for NE?

Flunixin, Vit E, Mg (blocks release of glutamate), Vit C, thiamine, DMSO

What is the madigan squeeze technique?

Stimulate emerging from birth canal to stop producing sedative neurosteroids in NE

When should you never do the madigan squeeze technique?

If there is sepsis or any other illness

What is the prognosis of NE?

Most respond in 3 days with 75% survival

Poor if there are C/S at birth

What is neonatal isoerythrolysis?

Destruction of foals RBCs by maternal antibodies absorbed from colostrum

What is the prevalence of neonatal isoerythrolysis?

1% thoroughbreds

2% standardbreds

Mules (donkey sire and horse dam) 10%

What is the pathophysiology of neonatal isoerythrolysis?

Foal inherits RBC antigen from stallion which differs from the dam who is previously sensitized

Mare produces antibodies against RBC antigen of foal

Foal ingests colostrum with anti RBC antibodies

RBCs removed via reticuloendothelial system or intravascular hemolysis by complement

What are the RBC antigens?

Aa and Qa are most common

Also donkey factor

What are C/S of neonatal isoerythrolysis?

24-36 hours old signs of lethargy, weakness, pale mm, icterus, tachypnea, labored breathing, tachycardia

Seizure like activity as severity worsens

How do you diagnose neonatal isoerythrolysis?

Anemia (autoagglutination)

Hyperbilirubinemia

Thrombocytopenia

Coombs test or flow cytometry for IMHA

Cross match mares serum with foals RBCs

How do you treat neonatal isoerythrolysis?

Exercise restriction and reduce stress

IV luids

Milk restriction not indicated in foals >24 hours

Transfusion if anemia is needed. Can use washed maternal RBCs

How do you prevent neonatal isoerythrolysis?

Screen blood type and anti RBC antibody in serum of mare compared to stallion prior to parturition

Jaundice foal agglutination test prior to allowing consumption of colostrum

What C/S can indicate a specific foci of infection?

Diarrhea, uveitis, joint effusion, lameness, physeal swelling, resp disease, seizures, SQ abscesses, patent urachus, omphalitis

Why do we use sepsis score in addition to blood cultures?

Blood cultures are slow and have low sensitivity due to pri or antimicrobial therapy and low circulating bacterial numbers

What should you do if when giving plasma if you are concerned for the antigenic effects?

Give it slowly at first and monitor for adverse reactions

Why should you recheck your IgG after giving plasma?

Can decrease following transfusion due to catabolism and utilization or increased vascular permeability

What is a very common sequelae to sepsis?

Respiratory disease, can be from in utero aspiration, meconium aspiration, or hematogenous spread

How do you diagnose respiratory disease?

Respiratory exam

US and rads

Arterial blood-gas

How do you treat respiratory disease?

Antimicrobials

Oxygen

Mechanical ventilation

T/F diarrhea is a common sequelae to sepsis?

True, 50% of diarrheic foals are bacteremic

What does placentitis in the dam increase the risk of in the neonate?

Sepsis and neonatal encephalopathy

What can meconium staining mean/

Meconium aspiration which is risk factor for neonatal encephalopathy

What is another name for NE?

Dummy foals

What is HIS or PAS? (hypoxic-ischemic syndrome or perinatal asphyxia syndrome)

Reduced oxygen delivery to neuronal cells in the CNS resulting in neuronal injury and cerebral edema

Usually reversible