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 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 % and is higher in preterm infant and in high risk newborns about 2%-6%.

UTI occurs in 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 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.