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• W2752514219 abstract "A Hispanic baby girl born at 42 weeks gestational age develops poor perfusion and respiratory distress at 28 hours after birth. She was born to a 17-year-old G1 P0 mother via cesarean section for failure to progress. The mother’s pregnancy was uncomplicated. Prenatal laboratory results were unremarkable; a vaginal culture for group B Streptococcus was negative. The mother had prolonged rupture of amniotic membranes for 19.5 hours. She developed a temperature of 100.3°F (38.0°C) during labor. No antibiotics were administered preoperatively. The amniotic fluid was stained with thick, “pea soup” meconium. The infant was vigorous at birth, with Apgar scores of 8 at 1 minute and 9 at 5 minutes, and a weight of 2.91 kg. Vital signs were initially stable. She fed and displayed normal newborn behavior during the first postnatal day.The next day, the baby appears dusky and experiences respiratory distress and periods of apnea. She also displays seizurelike activity. On physical examination, her temperature is 98.6°F (37°C), pulse is 165 beats/min, respiratory rate is 42 breaths/min, blood pressure is 56/32 mm Hg, and oxygen saturation is 38% on room air. The anterior fontanelle is open, soft, and flat. The heart has a regular rate and rhythm with no murmur. Lung examination reveals subcostal and suprasternal retractions with bilateral diffuse crackles. Extremities are cool, with a 3-second capillary refill.Laboratory analysis reveals a total peripheral white blood cell count of 8.7×103/mcL (8.7×109/L) with 17% neutrophils, 66% bands, 7% lymphocytes, and 1% monocytes. The hemoglobin is 15.1 g/dL (151 g/L), and the platelets are 185×103/mcL (185×109/L). A venous blood gas has a pH of 7.19, Pco2 of 48 mm Hg, Po2 of 72 mm Hg, bicarbonate of 18 mEq/L (72 mmol/L), and a base deficit of −10.2 mEq/L. Electrolyte and serum glucose values are normal. Blood, urine, and cerebrospinal fluid (CSF) cultures are collected. A chest radiograph shows diffuse bilateral ground-glass opacities and a normal heart size.The baby’s blood culture grew gram-positive cocci in chains within 13 hours. The organism was identified as Streptococcus pneumoniae that was sensitive to penicillin. An endotracheal tube aspirate obtained after intubation also grew S pneumoniae sensitive to penicillin. CSF fluid was of insufficient quantity for bacterial culture or analysis. A urine culture was negative. The baby was treated for S pneumoniae bacteremia and pneumonia as well as possible meningitis with penicillin for 3 weeks.The infant’s mother developed postpartum abdominal pain and high fevers. She was treated with antibiotics for suspected endometritis. A blood culture was negative. A vaginal culture was not obtained.Sepsis is an immediate concern in an infant who has poor perfusion and respiratory distress. Other common and often concurrent infections, such as pneumonia and meningitis, are also likely. Noninfectious causes, such as congenital heart disease, meconium aspiration, and seizures, also should be considered.The most common sepsis pathogens in the neonatal period are S agalactiae (group B Streptococcus) and Escherichia coli. S pneumoniae is an uncommon cause of sepsis in the newborn. The exact percentage of neonatal sepsis cases due to S pneumoniae is uncertain. Most reviews suggest it accounts for 1% to 8% of cases, (1)(2)(3) although a recently published review of neonatal sepsis cases in a 14-year period found no documented cases of S pneumoniae at one institution. (4) In the prior 9 years, S pneumoniae was documented in 1% of neonatal sepsis cases at the same institution. The authors speculated that S pneumoniae was declining as a cause of neonatal sepsis, (4) but others have suggested that the incidence actually is increasing, (5)(6) possibly reflecting the variability of organisms responsible for infection at different institutions. What is not disputed is the significant morbidity and mortality associated with invasive S pneumoniae neonatal infections. In the past 15 years, the documented mortality has been as high as 14% to 35%, (5)(7) with death occurring within 36 hours after presentation in one review. (7)There is strong evidence of intrapartum maternal vertical transmission of S pneumoniae causing early-onset infection in neonates, (7)(8) often associated with perinatal risk factors such as prolonged rupture of membranes, maternal infection, and prematurity. However, the largest and most recent review of S pneumoniae infection in neonates by Hoffman and colleagues in the United States Pediatric Multicenter Pneumococcal Surveillance Group described 20 cases of invasive neonatal S pneumoniae infections that had a mean age of presentation of 17.8 days. (7) In this series, only three infants presented within the first 72 postnatal hours, two with bacteremic pneumonia, and one with meningitis. In two of these early-onset cases, the mothers had symptoms consistent with intrauterine or systemic infections, and one of the mothers had prolonged rupture of membranes. Ninety percent of infants in the series were born at term, yet infants who had invasive disease had a statistically significant lower average birthweight compared with infants who had noninvasive disease. Perinatal risk factors were not significant in most of the neonatal S pneumoniae infections.Overall, the current literature suggests that a minority of infants who develop invasive S pneumoniae infections present within the first few days after birth and may have risk factors associated with early-onset sepsis; the peak age of infection is 2 to 3 weeks after birth. Appropriate empiric antimicrobial treatment is important in any neonate suspected of having an invasive pneumococcal infection because of the high mortality risk.It is common practice to treat neonates in whom sepsis is suspected with empiric ampicillin and gentamicin. This therapy provides adequate coverage for the major pathogens of neonatal sepsis, although it is not the empiric treatment of choice for S pneumoniae sepsis. Penicillin-resistant S pneumoniae has been increasing over the past 15 years and is now estimated to represent nearly 35% of the isolates. (9) The highest resistance rates occur in noninvasive infections and in children ages 0 to 2 years, (10) although data suggest that neonates may be infected at lower rates with nonsusceptible isolates compared with older children. In the case series by Hoffman and associates, (7) the rate of infection with penicillin-resistant isolates in neonates was 21.4% compared with 33.8% for non-neonates. Regardless, resistance rates are significant in all age groups. Of even greater concern is that approximately 50% of penicillin-nonsusceptible strains also are not susceptible to third-generation cephalosporins. (11) There are no reports of vancomycin-resistant S pneumoniae in the United States at this time. (11) Thus, for invasive pneumococcal disease, the current recommended empiric therapy is cefotaxime or ceftriaxone plus vancomycin until antimicrobial susceptibilities are determined. Fortunately, the pneumococcus isolated from our patient was susceptible to penicillin.S pneumoniae is an uncommon but important pathogen to consider in any neonate who has sepsis. The usual empiric antimicrobials used for neonatal sepsis may not be effective in pneumococcal disease. All neonates who have invasive pneumococcal infections should be treated empirically with cefotaxime and vancomycin until antimicrobial susceptibilities are determined." @default.
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• W2752514219 title "Index of Suspicion in the Nursery" @default.
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• W2752514219 doi "https://doi.org/10.1542/neo.7-10-e546" @default.
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