Neonatal pneumonia

S.Ghaemi. MD

Pneumonia is the most common form of

neonatal infection and one of the most

important cause of perinatal death.

The incidence in NICU patients is more

than 10%

Etiology:

Pneumonia may be acquired:

1. Tranplacental or congenital

2. Perinatal

3. Postnatal

Riskfactors:

I. Neonatal riskfactors:

A. Prematurity (immaturity of

mucociliary clearance, small size of

the conducting airway)

B. Lowered host defenses

Riskfactors: (cont’)

C. Invasive procedures (tracheal

intubation, barotrauma, hyperoxic

damage to the respiratory tract)

D. Asphyxia

II. Environmental riskfactors:

nosocomial flora of the hospital

nursery (nursery equipment or

unwashed hands of caregivers).

III. Maternal riskfactors:

a) PROM > 18 hr

b) Maternal fever and other bacterial

infection

c) Prolonged labor.

I) Congenital pnumonia or transplacental

pnumonia:

Pnumonia acuquired this route is most

commonly of viral origin.

Often die in uterin or are critically ill at

birth.

Tachypnea, retraction and grunting may be

observed.

Fever may or may not be noted but is often

a prominent sign of neonatal herpes

simplex and enteroviral diseases.

In most cases there is no cough.

Cyanosis may be constant or intermitent.

Periodic breathing and apnea some time

observed.

C.H.F, manifested by cardiac enlargment,

hepatomegaly and tachycardia.

In this pneumonia other organs are

involved (such as hepatomegaly,

spelenomegaly and skin leagen are

prominent) They often die in the first 24h

after birth.

II) Prinatal pneumonia or aspiration

pneumonia:

Neonotal pneumonia is most commonly

acquired during the proces of labor and

delivery. Infection occurs from organism

ascending from the genitalia tract after

PROM, or acquired during passage of

infant through the birth canal.

Respiratory symptoms are often present at

delivery or in the first few days of

life. Infants may have systemic signs:

Fever, reluctance to feed and lethargy.

Respiratory signs may occur early or late in

the course and include:

Coughting, grunting, costal and sternal

retraction, flaring of the alae nasi,

techypnea and cyanosis.

III) Postnatal pneumonia:

Newborns exposed to respiratory

equipment or humidified incubators are at

risk for respiratory infection by

pseudomonas species, flavobacterium,

kelebsiella, or serratia.

Direct contamination by the hands of

caretakers is associated with outbreaks of

staphylococcus aureus and grem-

negative enteric organisms.

Postnatal pneumonia may develop at any

age, often present during first month of

life.

Diagnosis:

1. C-XRay are necessary to support the

diagnosis of pneumonia.

2. CBC the leukocyte count may assist in

differentiation of viral from bacterial

pneumonia.

3. Cultures of blood

Treatment:

Antimicrobial therapy must be started

promptly.

Empirical antimicrobial therapy is the same

for neonatal sepsis.

For early-onset or late onset pneumonia

Ampicillin and either an Aminoglycoside

or Coftaxime.

Nosocomial infection Vancomycin and an

Aminoglycoside

Pneumonia caused by Chlamydia or

pertussis Erythromycin

HSV pneumonia Acyclovir therapy

Treatment is continued for 10-14 days or

longer by the clinical course of the patient.

UTI in newborns

UTI in newborns frequently is associated

with bactermia and may result in long-

term complications.

Newborn with UTI should be evaluated for

associated systemic infection and

anatomic or functional

abnormalities of the urinary tract.

The incidence of UTI in term infant is 0.1-

1% and is higher in preterm infant and

in high risk newborns about 2%-6%.

UTI occurs in 1.5-5 times as many

males as females in the neonatal period

and is higher in uncircumcised than

circumcised males.

The risk of UTI is on average 3-12 fold

lower in circumcised infants.

UTI typically present in the second

week after birth in term infants.

Some what later in preterm infants,

Is unusual during the first 3 days after

birth.

Microbiology:

E.coli, is the most common organism (up

to 80%) isolated in the newborn period.

Fungal infection, predominantly Candida

species, occur commonly in

premature infants.

Most UTIs In newborns represent upper

tract infection rather than simple

cystitis, accompanying bacteremia,

especially in preterm infants.

Ascending infection is associated with

urinary tract abnormalities and

lack of circumcision in males.

Approximately 30%-50% of newborns

with UTI have urinary tract abnormalities,

VUR is most common.

Clinical features

The signs and symptoms of neonatal UTI

are nonspecific most of the times resemble

neonatal sepsis, preterm infants

frequently present with apnea.

The most common clinical findings are:

Fever (20-40%)

Failure to thrive (15-43%)

Jaundice (3-41%)

Vomiting (9-41%)

Loose stools (3-5%)

Poor feeding (3-5%)

Diagnosis

Urine collection:

A – Suprapubic aspiration is the most

reliable technique to identify bacteriuria.

Any growth of urinary pathogens is

significant.

Bladder catheterization:

This technique less reliable than suprapubic

aspiration.

Catheterization culture more than 1000

CFU (colony forming units) ∕ CC pathogens

is significant.

Urinalysis:

WBC ≥ 5 per hpf

Sepsis evaluation:

Blood culture/CSF culture, should be

obtained in infants in whom UTI is

suspected.

Treatment:

Empirical therapy,

Infants<7 days old:

Ampicillin (25-50mg/kg/dose/8 hr/IV)+

Gentamicin (2.5mg/kg/dose/12h/IV or

4mg/kg/dose/24 h/IV).

In infants>7 days old:

Vancomycin (10-15 mg/kg/dose/8 hr) is

substituted for Ampicillin.

Sterilization of the urine must be

documented by repeat culture after 48h/ of

therapy.

Treatment duration:

Is usually 10-14 days, but may be longer

in complication such as:

1. Persistent bacteriuria

2. Anatomic obstruction

3. Perinephric abscess.

In uncomplicated cases of primary UTI,

Parenteral therapy can be given for 5-7

days, followed by oral antibiotic therapy

to complete the course of treatment.

Follow – up:

Another urine culture 3-7 days following

the completion of treatment.

Antibiotic prophylaxis with low dose

Amoxicillin (15-20 mg/kg/d/po) is

started until, a radiographic evaluation

has been performed.

Radiographic Evaluation:

Radiographic evaluation should be

performed in all newborn with UTI.

A. Ultrasonography,

Should be obtained after antibiotic

treatment is initiated, to detect structural

abnormalities

B. VCUG,

Usually is performed 3-6 weeks after

antibiotic treatment is completed, to

identify reflux (VUR).

Earlier examination may be indication in

infants with abnormalities detected on

antenatal utrasound examination.

C. DMSA scintigraphy

To identify renal scarring and

pyelonephritis.

It may be considered if renal damage

is suggested by ulterasonography.

Outcome:

Many newborns with UTI develop renal

scarring

Renal scarring may result in hypertension

and chronic renal disease.