Infectious Diseases

Maternal HIV

Maternal syphilis 

Hepatitis B

TB Exposed Babies

Early neonatal sepsis 

Obstetric risk factors for early neonatal sepsis 

NEC (necrotizing enterocolitis) 

Nosocomial infection control 

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Maternal HIV 

On every new baby you see, check the mother's file for the HIV result.

Mother’s HIV status unknown or previously tested negative and not tested during labour/at delivery/post delivery:

Pre-test counsel and offer HIV testing; if accepted: Perform Rapid HIV testing. If HIV-negative:

• Give result and post-test counsel
• Enquire about partner and other children who may need a test
• Do ELISA (must be sent with a consent form) on Mom or partner if rapids are negative and parent is clinically ill OR discordant rapids
• If ELISA equivocal do PCR on parents

If Mother newly diagnosed HIV-positive OR known positive and not yet on ART:

• Check mom’s CD4 count/creat/HepBsAg if unknown, initiate on ARVs and refer to adult clinic
• Counsel about feeding options. Remember AFASS criteria (affordable, feasible, acceptable, safe and sustainable)
• Do a birth HIV PCR on baby (and a point of care PCR if available), repeat at 10 weeks
• Do a PCR for any case where the maternal HIV status is unknown
• If breastfed: daily Nevirapine for 12 weeks and AZT for 6 weeks
• If exclusive formula feeding: AZT and NVP for 6 weeks
• Well baby clinic visits at 6 and 10 weeks

If Mother known HIV-positive on ARVs:

• Check which ART Mom is taking
• Check mom’s latest viral load. If not done at delivery, repeat ASAP
• Counsel about feeding options. Remember AFASS criteria (affordable, feasible, acceptable, safe and sustainable)
• Do a birth HIV PCR on baby, repeat at 10 weeks
• If VL < 50: daily Nevirapine for 6 weeks
• If VL > 50 and breastfed: AZT for 6 weeks and daily NVP for at least 12 weeks
• If VL > 50 and exclusive formula feeding: AZT and NVP for 6 weeks
• All HIV-exposed infants will be considered high-risk until the delivery VL is known, if the delivery VL is not available at the time of discharge, the HIV exposed infant will be considered high-risk until the result can be reviewed at the 3-6 day postnatal clinic visit. Dispense a full 6 weeks supply of dual prophylaxis. Ask the mother to return with all the medication at the 3-6 day postnatal clinic visit.
• Well baby clinic visits at 6 and 10 weeks

Consult the Empilweni team if there are any questions or concerns, especially if the mother is not virally suppressed despite ART.  All HIV positive neonates must be referred to Empilweni to be seen on the day of diagnosis.  

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Please make sure that all mothers in ward 16B, NICU and KMC have enough ART and do not run out!
Non-admitted babies to HIV-infected women are tested at birth in the postnatal wards.

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Newborns ≥ 2kg and term infants:

		NVP (Daily)	AZT (Twice daily)
Birth - 6 weeks	2.0-2.49kg	1mL (10mg daily)	1mL (10mg twice daily)
	≥2.5 kg	1.5mL (15mg daily)	1.5mL (15mg twice daily)
6 weeks - months		2mL (20mg daily)	6mL (60mg twice daily)
6-9 months		3mL (30mg daily)	Children >6 months of age requiring AZT prophylaxis should be used treatment doses.
9-24 months		4mL (40mg daily)

Preterm newborn < 2kg:

• Nevirapine, oral, daily:

Weight	First 2 weeks after birth (mg of NVP)	After first 2 weeks after birth (mg of NVP)
500 to <625g	1 mg	2 mg
625 to <850g	1.5 mg	3 mg
850 to <1200g	2 mg	4 mg
1.2 to <1.5kg	3 mg	5 mg
1.5 to <2kg	3.5 mg	6 mg
If the infant at the time of discharge is severely underweight-for-age (3 SD or 3 z-scores below the mean), give NVP according to weight (i.e. 4mg/kg/dose daily) until in the normal weight-for-age range.

• Zidovudine, oral, twice daily:

Gestational age at birth	30-35 weeks	<30 weeks
First 2 weeks after birth	2 mg/kg	2 mg/kg
2-4 weeks after birth	3 mg/kg	2 mg/kg
4-6 weeks after birth	4 mg/kg	3 mg/kg
>6 weeks after birth	4 mg/kg	4 mg/kg

ART Prophylaxis for infants who are unable to tolerate oral medication

Infants who are unable to tolerate oral medication/feeds should be initiated on intravenous zidovudine (AZT). On re-establishment of oral feeds/medications, intravenous zidovudine should be stopped, and the infant should commence on the appropriate oral infant prophylaxis regimen. Ideally, gestational age should be used to determine the optimal dose.

Gestational Age	Approximate birth weight	AZT IV dosing for the first 14 days (If unable to tolerate oral agents)
≥35 weeks	≥2.5 kg	3 mg/kg body weight, IV every 12 hours
<35 weeks	<2.5 kg	1.5 mg/kg body weight, IV every 12 hours

Maternal syphilis 

All pregnant women require a test at first antenatal visit and repeat testing at 32-34 weeks if negative in the first trimester.  

If the mother is RPR positive the baby should be examined for signs of congenital syphilis (desquamating rash on palms and soles, pallor, lymphadenopathy, rhinitis, hepatosplenomegaly, jaundice). Signs of congenital syphilis require admission, RPR titre and treatment with IV Penicillin G for 10 days. All treated babies need follow-up at 3 months to confirm a fourfold reduction in RPR titres. Congenital syphilis is a notifiable disease.

In an asymptomatic well baby where the mother is seropositive or has an unknown result, or if the mother is untreated or only partially treated, give the baby Benzathine benzylpenicillin (depot formulation) IM 50 000 IU/kg as a single dose into the antero-lateral thigh.

Make sure both parents receive adequate treatment for syphilis.

Hepatitis B

Pregnant women infected with hepatitis B can transmit the virus to their newborn infant via exposure to their blood during labour and delivery. Affected babies are usually asymptomatic and may only have elevation of liver enzymes starting at 2-6 months of age.  

Babies who are born to mothers who have active hepatitis B infection or mothers who are HBsAg-positive or HBeAg-positive:  

• Infants should receive Hepatitis B immunoglobulin 200 IU IM within 12 hours of delivery (check package insert for product specific dosing)
• PLUS Hepatitis B Vaccine IM into the alternate thigh within 12 hours of delivery

Continue the routine immunization schedule thereafter. Measure the HBsAg and HBsAb at 9 to 12 months of age to assess immunity, if non-immune discuss with Infectious Disease specialist.

TB Exposed Babies

Asymptomatic neonates whose mother is adequately treated (non-infectious):

• A well newborn whose mother does not have infectious TB or who has received more than 2 months of TB treatment and is responding well
• BCG vaccine must be given
• The mother’s TB history must be documented in the RTHC so that the infant is screened for signs and symptoms at each clinic visit and is investigated as needed

Asymptomatic infants whose mother or household contacts have active TB:

• The mother’s placenta should be sent for histology and culture or a post-partum endometrial biopsy can be done
• CXR on mother and sputum results
• The baby will require 2 gastric washings, CXR as well as an abdominal ultrasound if congenital TB is suspected. A mycobacterial blood culture can be taken as well.
• Only give BCG two weeks after completion of prophylaxis or treatment
• If TB is ruled out in the baby then consider prophylaxis with INH for 6 months if HIV-exposed of HIV-positive and on NVP. If HIV-unexposed or not on NVP then Rifampicin/Isonaizid can be given for 3 months. (See weight band dosing in the current Paediatric EML 2023)
• Prophylaxis required if:
  • The mother is still infectious
  • Her sputum is still smear positive at delivery
  • The mother only started TB treatment within 2 months before delivery

Symptomatic neonates:

• Symptoms include tachypnoea, feeding problems, poor weight gain, abdominal distension, hepatosplenomegaly and jaundice
• These neonates require admission for TB-workup and treatment

If there is a concern about perinatal exposure to drug resistant TB then referral or consultation with Infectious Disease is warranted.

Early neonatal sepsis 

Neonatal sepsis is categorized into “early” (at birth or in the first 48 hours of life) or “late” (after 48 hours). The features of either early or late neonatal sepsis may be non-specific e.g. lethargy, apnoea, poor perfusion, hypothermia or pyrexia or may point to a specific system/s involved e.g. respiratory distress, full fontanelle.

Early neonatal sepsis is usually caused by an organism in the maternal genital tract, usually Group B Streptococcus or E coli. Often there may have been specific maternal risk factors (see next section). Check for obstetric risk factors in any case of suspected neonatal sepsis.
Penicillin G and an aminoglycoside are usually adequate initial antibiotic cover.

Obstetric risk factors for early neonatal sepsis

Risk factors include:

• Term PROM>18 hours
• Preterm premature rupture of membranes (i.e. rupture before onset of labour)
• Maternal chorio-amnionitis
• Unexplained maternal temp>37.5^oC
• Previous baby with Group B Strep sepsis

Please note whether the mother was getting antibiotics for these risk factors, how many doses had been given and if they were given more than 4 hours before delivery.

Management if baby looks well:

• FBC/platelets, CRP, blood culture
• Consider Penicillin G/Ampicillin and aminoglycoside IV
• Stop antibiotics after 48 hrs if culture negative and FBC, CRP not suspicious.

Management if baby looks ill:

• Treat sepsis on its merits e.g. O₂, Blood gas, fluids etc.

If Group B streptococcus is isolated please make sure mom receives a letter to receive intrapartum antibiotics in her next pregnancy.

Necrotizing Enterocolitis (NEC) 

Clinically “possible” NEC: large NG aspirates, vomiting, soft abdominal distension.

Large NG aspirates are greater than 20% of feeds received over 24 hours or greater than 50% of a single feed (although in a baby on small feeds, a 1-2ml aspirate is not usually significant). Any bile-stained aspirate is worrying (unless the NG tube is at the pylorus).
Any bile-stained vomiting suggests serious intestinal pathology (if not NEC, then intestinal obstruction etc.)

Probable NEC: bloody stool, tender distended abdomen.
The baby often has other non-specific features of sepsis e.g. lethargy, poor perfusion, high dextrostix, hypothermia.

All “probable NEC” and recurrent (second episode) “possible NEC” need a sepsis work-up, X-ray abdomen (AP and lateral shoot-through), NPO with naso-gastric tube on free drainage, antibiotics.
“Probable” or definite cases (proven on X-ray) should be discussed with the registrar, and should be isolated.

Nosocomial infections

Late neonatal sepsis is more likely to be nosocomial, however, nosocomial sepsis can occur on the first day of life. The commonest nosocomial pathogen in our unit is, Klebsiella species or other gram negatives, usually extended spectrum β-lactamase producers (ESBL i.e. resistant to cephalosporin) and MRSA. Other nosocomial pathogens include Acinetobacter Baumanii and Candida species.
The current first line antibiotics for nosocomial infections (including NEC) are:

• Imipenem/Meropenem
• Vancomycin

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PLEASE BE GUIDED BY SENIOR-IN-CHARGE and/or MICROBIOLOGICAL RESULT

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See formulary for correct dose based on gestational age as well as day of life.

Candida infections occur occasionally, especially when the baby has been on TPN or multiple courses of antibiotics. Antifungal should be started in these patients.

Nosocomial infection is a major problem in the unit, and is most commonly spread by contaminated hands of nursing and medical staff. Please wash your hands thoroughly when you arrive in the unit (nosocomial organisms colonize your hands and build-up over-night) and before and after examining each patient.
Between patients, alcohol-based hand sprays are acceptable alternatives to hand washing. Please read and sign the infection control guidelines.

Patients with definite nosocomial infection or NEC should be considered for isolation. Outbreaks require investigation in conjunction with the microbiologists. See formulary for doses and durations of treatment (for specific organisms).

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Rahima Moosa Mother and Child Hospital - Neonatal Care Handbook 2023; Infectious diseases; Maternal HIV, Maternal syphilis, Hepatitis B, TB-exposed babies, Early neonatal sepsis, Obstetric risk factors for early neonatal sepsis, Necrotizing enterocolitis (NEC), Nosocomial infections
Last checked for updates: January 2024