**Case 3**

A female infant was born to a primigravid mother at 28+1 weeks of gestational age. Delivery was by cesarean section due to a pathological cardiotocogram and presumed maternal infection (preterm premature rupture of the membranes 9 hours before delivery, preterm labour, increased neutrophile count and elevated CRP). The mother was treated with

**Figure 5.** Bilateral lung infiltrates with consolidation mainly in the middle and right lower lobe in Enterobacter pneumonia (Case 3)

antibiotics. The preterm infant showed clinical and radiological signs of RDS and was intubated 15 minutes after birth. Standard broad spectrum antibiotics were started prophylactically but terminated after 3 days when daily white cell counts and CRP levels revealed no signs of infection. The patient was extubated on day 4 of life and placed on nasal CPAP. On day 6 of life the baby appeared septic with new onset of apneas, skin pallor, poor peripheral perfusion, metabolic acidosis and neurological signs like increased muscle tone and extreme irritability. Due to recurrent apneas despite caffeine therapy the infant had to be reintubated. The septic work up confirmed the clinical diagnosis of sepsis. Enterobacter cloacae, ESBL positive, was found in the blood culture, liquor cerebrospinalis and tracheal aspirate. Peripheral blood count showed leukocytosis, I/T ratio of 0,54, thrombocytopenia of 38 G/l, and elevated CRP values of 68,4 rising to a maximum of > 200 mg/L. Chest radiographs revealed new parenchymal changes compatible with the diagnosis of late onset bacterial pneumonia (Figure 5). The antibiotic regime was changed to meropenem and teicoplanin. As a further complication of sepsis the patient developed transient renal failure and an intraventricular hemorrhage with consecutive hydrocephalus, which was finally treated by insertion of a ventriculo-peritoneal shunt. After a long complicated neonatal period the patient was finally discharged from the hospital at an age of about 3 months in good clinical condition.

#### **Case 4**

26 Neonatal Bacterial Infection

child had a full recovery.

Enterobacter pneumonia (Case 3)

**Case 3** 

developed gastrointestinal symptoms with diarrhea 2 weeks prior to birth after having eaten some cheese made from unpasteurized milk from a local food store. This led us to assume that the pregnant mother had most likely infected the fetus following ingestion of the bacterium, which had then crossed intestinal cells into the bloodstream and passed the placenta (42,43). After initiation of our standard antibiotic therapy the infant recovered quickly and was extubated on day 4 of life. Antibiotics were given for a total of 14 days. The

A female infant was born to a primigravid mother at 28+1 weeks of gestational age. Delivery was by cesarean section due to a pathological cardiotocogram and presumed maternal infection (preterm premature rupture of the membranes 9 hours before delivery, preterm labour, increased neutrophile count and elevated CRP). The mother was treated with

**Figure 5.** Bilateral lung infiltrates with consolidation mainly in the middle and right lower lobe in

A female infant was born at 24+3 weeks gestational age by vaginal delivery after the mother had been admitted to our hospital 1 hour prior to delivery with abdominal pain and onset of labors. The neonate developed RDS soon after birth which led to intubation, surfactant application and mechanical ventilation. Broad spectrum antibiotic therapy was started in case of suspected early onset sepsis. Initial laboratory revealed leukocytosis of 52.00 G/L, increased IL-6 (29,2 pg/ml) but normal CRP values. The chest radiograph on admission was typical for mild RDS but the lung pattern worsened during the first 2 weeks of life showing disseminated streaky-patchy infiltrates and partly cystic changes (Figure 6 and 7), accompanied by an increase in ventilatory requirements suggestive of early BPD changes. Therefore a strategy of moderate early BPD-prevention (48) with a one week course of intravenous steroids (hydrocortisone) was started. Results from routine tracheal aspirate screening for Ureaplasma infection taken during the second day on mechanical ventilation revealed a positive culture test (106) for Uu. In addition the placenta histology showed signs of chorioamnionitis. Under the assumption of early onset ureaplasma pneumonia/ pneumonitis we commenced oral macrolid therapy with clarithromycin (10mg/kg), beginning on day 6 of life for a total of 14 days. A repeat ureaplasma culture taken during treatment was negative. Mechanical ventilation continued for 18 days followed by a prolonged period of NCPAP lasting 7 weeks. Oxygen dependency for more than 8 weeks but not at a corrected gestational age of 36 weeks was compatible with the diagnosis of mild BPD (44,45). At an age of about 4 months of life she was discharged home.

Neonatal Pneumonia 29

**7. Conclusion** 

care.

**Author details** 

Friedrich Reiterer

**8. References** 

203

135-162

Saunders, 5th edition 2001: 1006-1018.

Ed.2005; 90: F2011-F219

infants. Pediatr Res 2993; 61-68

disorders 2003; London: Arnold: 21: 278-310.

infants with pneumonia. Biol Neonate 2011;79:73-78

Despite advances in neonatal medicine pneumonia remains a serious problem even in developed countries, mainly due to the increased survival of very preterm births and their susceptibility for early and late bacterial infections. The clinical spectrum of pneumonia is complex, symptoms are often non-specific and laboratory findings may be of limited value, making a rapid and correct diagnosis difficult. Treatment may also be challenging if no organism can be cultivated or in case of multidrug-resistant bacterial pneumonia. There is no clear evidence from randomized controlled trials favoring a specific antibiotic treatment strategy so that treatment decisions are based on local antimicrobial resistance patterns and clinical experience. Surfactant substitution might be beneficial in selected cases. Preventive strategies like health-care associated infection control and vaccination programs might have the greatest impact and should be further evaluated and applied at all levels of perinatal

*Division of Neonatology, Department of Pediatrics, Medical University of Graz, Austria* 

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**Figure 6.** Streaky-patchy lung changes with partly cystic appearance in Ureaplasma urealyticum pneumonia on day 6 of life (Case 4)

**Figure 7.** Early BPD changes in Ureaplasma urealyticum pneumonia on day 18 of life (Case 4)
