MORTALITY

Live, preterm, baby boy Delivered via stat cesarean section due to previous CS in labor 40 yo G3P3 ( ) LMP 31 5/7 weeks; MT 33weeks AGA APGAR score 9,9 BABY M

33 weeks Appropriate for gestational age Birthweight: 1630 g Birthlength: 41 cm Head Circ: 28cm Chest Circ: 25 cm Abd Circ: 21 cm

MATERNAL HISTORY Regular prenatal check-up (+) Chronic hypertension for 7 years maintained on Methyldopamine 500mg every 6 hours during pregnancy (+) Gestational diabetes at 20 weeks AOG advised diet modification (+) UTI during the third trimester, took Cefalexin for 7 days UPON ADMISSION CBC: UA: RBC 6 WBC 6 EC 11 Cast 0 Bacteria 38 HgbHctWBCBandNeutLymMonPlt

Penicillin allergy No asthma No previous hospitalization except during past pregnancies PAST MEDICAL HISTORY

Hypertension – maternal side DM – maternal side FAMILY HISTORY

Nonsmoker Non alcoholic beverage drinker PERSONAL & SOCIAL HISTORY

G , PCS for failed indution in labor, fullterm, F, 6.5 lbs (GDM, HPN) G , repeat CS, full term, M, 7.3lbs (GDM, HPN) G PP OB HISTORY

Clear amniotic fluid HR 150s APGAR SCORE : 9,9 Upon delivery

ASSESSMENT: Live preterm baby boy Delivered via stat CS for repeat CS in labor at 31 5/7 weeks AOG Apgar Score 9,9 ADMISSION

Management Routine newborn care done Admitted to NICU Level 3 NPO O2 support via nasal canula IVF started Calcium gluconate started Septic workup: Blood CS: No growth in 72 hours Ampicillin, Amikacin started HgbHctWBCBandNeutLymMonPlt

Course in the NICU

1 st Day of Life PROBLEMS Prematurity Probable sepsis Patient was placed in an isolette NPO IV fluid continued Hgt monitoring done Ampicillin, Amikacin continued

2 nd Day of Life PROBLEMS Jaundice Apnea – O2 sat 86% – HR 100 Nutritional buildup Phototherapy started Aminophylline started Continue O2 support until weaning Kept on NPO Aminosteril started

3 rd Day of Life PROBLEMS Vomiting of coffee ground material after feeding Kept on NPO Vitamin K given

4 th Day of Life PROBLEMS Nutritional buildup Feeding with expressed breast milk was started Intralipid was started

6 th Day of Life PROBLEMS Apnea – Less than 10 seconds – Improved by stimulation Cyanosis with hemodynamic compromise – HR <60, O2 sat 91%, RR 52, SBP 32mmHg – Thready and variable pulses – Violaceous lower extremities O2 support via nasal canula Resuscitation – Chest compression – Intubation – 2 doses of epinephrine – Fluid resuscitation – NaHCO3 given

Septic Shock – Blood CS Gram (-) cocobacilli after 9.12 hours Acinetobacter baumannii Sensitive to: Amikacin, Ceftazidime, Gentamycin, Ciprofloxcin, Levofloxacin, Pip-Taz, TMP-SMX Antibiotics shifted to Meropenem, Oxacillin and Metronidazole Dopamine drip started HgbHctWBCBandNeutLymMonPlt

VBGMetabolic acidosis pH7.05 pCO242.5 pO237 HCO311.8 BE-19 SO248 NaHCO3 given

VBGMetabolic acidosis Metabolic & Respiratory acidosis pH pCO pO HCO BE SO

CXR Fine reticulonodular opacities seen throughout both lungs, predominantly in the inner lung zones Impression: Consider bilateral pneumonia

t/c DIC – Bleeding at the puncture sites – Fresh blood draining at the OGT – Purpura fulminans – Platelet count of 40,000 Vitamin K Famotidine IVIG Blood transfusion – Platelet concentrate – Fresh frozen plasma – Packed RBC (not given) Hgb Hct

Acute renal failure – No urine output x 12 hours Fluid resuscitation Furosemide

Electrolyte imbalance Calcium gluconate given Na K >9 iCa

Seizure (t/c Intraventricular Hemorrhage) Phenobarbital

7 th Day of Life Desaturation despite bag tube ventilation Bradycardia (HR 40s), Hypotension (Undetectable) Resuscitation with chest compression and epinephrine After 45 minutes of resuscitation, patient was pronounced dead. Postmortem care done.

FINAL DIAGNOSIS Prematurity Septic shock secondary to Acinetobacter baumannii Disseminated Intravascular Coagulation r/o Intraventricular Hemorrhage Neonatal Pneumonia Acute renal failure

Acinetobacter baumannii The most resistant of the genospecies and has the greatest clinical importance

Naturally inhabits water and soil Isolated from foods and arthropods In humans, can colonize: – Skin, wounds – Respiratory – GI Can survive environmental dessication for weeks  promotes transmission through fomite contamination in hospital

RISK FACTORS AMONG NEONATES Low birth weight Total parenteral nutrition Central venous catheters Mittal N, Nair D, Gupta N, et al. Outbreak of Acinetobacter spp septicemia in a neonatal ICU. Southeast Asian J Trop Med Public Health 2003; 34:365. Huang YC, Su LH, Wu TL, et al. Outbreak of Acinetobacter baumannii bacteremia in a neonatal intensive care unit: clinical implications and genotyping analysis. Pediatr Infect Dis J 2002; 21:1105.

Health Care Associated Infection Acinetobacter outbreaks have been traced to: 1.common-source contamination (particularly contaminated respiratory and ventilator equipment) 2.cross-infection by the hands of health care workers caring for colonized or infected patients Hartstein AI, Rashad AL, Liebler JM, et al. Multiple intensive care unit outbreak of Acinetobacter calcoaceticus subspecies anitratus respiratory infection and colonization associated with contaminated, reusable ventilator circuits and resuscitation bags. Am J Med 1988; 85:624. Maragakis LL, Cosgrove SE, Song X, et al. An outbreak of multidrug-resistant Acinetobacter baumannii associated with pulsatile lavage wound treatment. JAMA 2004; 292:3006.

Bloodstream Infection Acinetobacter accounts for 1.5 to 2.4 percent of nosocomial bloodstream infections Most frequent source: vascular catheter, respiratory tract Less common: Wounds, urinary tract Septic shock develops in up to one-third of patients.

Data regarding the prognosis of patients: limited Patients usually have longer ICU stay, higher rate of organ failure and higher mortality rates Risk factors for mortality: – Imipinem resistence – ICU stay – Female gender – Old age – Pneumonia – Diabetes – Septic shock