1. Paediatric Microbiology Dr Amy Chue ID/Microbiology Registrar Dr Peter Munthali Consultant Microbiologist

2. Objectives By the end of this session you should be able to: –Distinguish between the common causes of infections in the neonate and older children –Relate maternal infections to neonates –Interpret CSF findings in relation to clinical presentation in neonates –Demonstrate rational use of antibiotics in neonatal sepsis with regard to possible causative organisms

3. Case One 3 week old baby born at 39/40 Normal vaginal delivery Healthy and feeding well initially Upset and crying Bulging fontanelle noted by parents Taken to ED Hx – admitted a week earlier with bronchiolitis and discharged with no antibiotic treatment

4. Results CSF –Clear and colourless –RBC 84x10^6/L –WCC 236x10^6/L –Gram stain: organisms not seen –Glucose 3.1 mmol/L –Protein 1.4 g/L (0.15 – 0.45) FBC –Hb 101g/L (111 – 141g/L) –WCC 24.85 x 10^9/L (6 – 18.0 x 10^9/L) –CRP 46mg/L (<11mg/L)

5. Questions What is the possible microbiological diagnosis? What antibiotics would you consider commencing and why?

7. Microbiology

8. Management Amoxicillin based regime for 14 days Vaccination (2/12, 4/12, 12/12)

9. Case Two 1 day old baby born at 36+5 Floppy at birth Mother had fever during labour and received some antibiotics Baby started on Cefotaxime and Amoxicillin

10. Investigations LP –Gram Turbid CSF RBC 6x10^6/L WCC 1046x10^6/L 90% Poly Glucose 1.9mmol/L Protein 1.30g/L (0.15 – 0.45g/L) No organism seen CRP 164 FBC –HB 93g/l –WCC 13.09x10^9/L (6.0 – 18.0) Blood culture – Gram positive cocci ?type

11. Questions What is the diagnosis? –What is the possible microbiological diagnosis? Is this infection preventable? Should antibiotics regime be changed? –If so, how?

12. Organisms Group B Streptococcus –Streptococcus agalactiae

13. Management Penicillin based regime (Benzylpenicillin Vs Amoxicillin) Prophylactic antibiotics given during labour Cefotaxime as blind treatment for neonate

14. Case Three 7 day old baby born at term Normal vaginal delivery Presents with fever, irritability and poor feeding

15. Investigations FBC –Hb 115g/l –WCC 24.85x10^9/L CRP 12 Blood cultures: Gram positive bacilli

16. Questions What is your microbiological diagnosis? How would you manage the case: –Antibiotics –Infection control

17. Diagnosis Listeria monocytogenes

18. Gram positive bacillus Pregnant women particularly at risk Certain at risk foods Inherently resistant to cephalosporins

19. Management Amoxicillin for 14 - 21 days Infection control – isolation

20. Case Four Baby born at 38 wks, 2.6Kg Mother had episiotomy Baby discharged well on day 2 Readmitted on day 7 with: –Wt loss –Poor feeding –Abnormal limb movements –EEG – no seizure activity

21. Investigations CRP 158 CSF: –Cell count normal –Glucose normal –Protein 0.85g/L (0.15-0.45g/L) Clotting deranged Low platelets LFTs deranged CT: extensive bleeding on brain and evidence of hypoxic injuries

22. Treatment Initial treatment: Benzylpenicillin and Gentamicin Modified treatment: Meropenem and Vancomycin

23. Further investigations and treatment What further investigations should be done –On CSF –On Blood What is the possible diagnosis? Is the current antibiotic regime adequate?

24. Further Results CSF PCR – HSV 1 positive Blood PCR – HSV 1 positive

25. HSV infection in neonates Usually peri natal and post natal –45% skin, eyes and mouth infections –20% CNS infection –25% disseminated HSV Symptoms Irritability Seizures Respiratory distress Jaundice Coagulopathy Pneumonitis

26. HSV in neonates Rx high dose aciclovir Rx women with lesions –Suppressive therapy Consideration of C-section BASHH guidelines

27. Key points Possible organisms causing neonatal sepsis –Group B Streptococcus –Group A Streptococcus –E.coli –Listeria monocytogenes Antibiotic treatment –If Listeria is suspected, must consider penicillin based regime Important to consider maternal infection