Pneumonias in newborn babies

S y m p o s i u m : I n f e c t i o u s D i s e a s e s Indian J Pediatr 1995; 62 : 293-306,

Pneumonias in N e w b o r n Babies

Meharban Singh and Ashok K. Deorari

Neonatal Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi

Respi ra tory pathology is the commonest autopsy finding among early neonatal deaths. Of the four million child deaths due to acute respiratory infections every year, most deaths occur during the first year of life and a significant number of these in the first few weeks'of life. Almost 25-35 percent of deaths due to pneumonia in children under five years of age occur during neonatal period. In developing countries., pneumonia account for more than 50 percent cases of respiratory d is tress in the newborn. I,~ Autopsy data from Indian studies show that 26.0 to 34.6 percent of all neonatal deaths are associated with pneumonia. ~7 The clinical incidence of pneumonia during the neonatal period among hospital born babies varies from 1.5 to 4.5 percent of all live births (Table 1). 2~.9

Pneumonias in newborn babies can be divided into three categories on the basis of route and mode of acquisition of infection and age at presentation. !~

(a) Intrauterine or congenital pneumonia is acquired as ascending transvaginal infection just before or during labour. It is usually characterized by respiratory distress having onset during first 48 hours of life. (b) Nosocomial pneumonia is acquired at birth or during early neonatal period and

Reprint. requests: Dr. Meharban Singh, Professor, Neonatal Division, Department of Pediatrics, All India Instiitute of Medical Sciences, New Delhi-ll0 029.

usually manifests as a clinical picture c~ septicemia with radiological evidences d pneumonitis. (c) Aspiration pneumonias are extremely common in developing countries especially among low birth weight and preterm babies. The aspiration may occur during labour (clear amniotic fluid or meconium stained liquor), at birth ov post natal period. It may produce transient respiratory difficulty or may lead to intractable pneumonia due to suppurative bacterial infection.

Epidemiology

Various maternal and neonatal factors responsible for increased incidence of pneumonia are enumera ted below12-~4: (A) Intrapartum pneumonia. The predisposing factors include prolonged rupture of membranes (more than 12 hrs), unhygienic and multiple vaginal examinations and prolonged labor i.e. durat ion of labor more than 24 hours. The risk of infection is higher in primipara, young mothers (age 20 years or less), poor antenatal care, abnormal delivery and poor personal hy- giene.

The above factors lead to ascending infection of the amniotic fluid leading to ver- tical transmission of pathogens from the mother to the fetus. Other complications of pregnancy e.g. materr~al infections especially E. colt urinary tract infections, prematurity, toxemia, abnormalities of the

294 TftE INDIAN JOURN/d, OF PEDIATRICS 1995; Vol. 62. No. 3

TaULE 1. Incidence of neonatal pneumonia (% of live births)

Chandigafll (8) Lucknow (2) New Delhi (9) (1980) (1987) (1981)

Meconium aspiration

Other types of aspirations

Congenital pneumonia

1.1 0.6 1.0

0.2 0.5 -

0.4 0.7 3.6

Total 1.7 1.8 4.6

cord, prolapse or cord compression, maternal fever during peripartal period, meconium stained amniotic fluid and fetal tachycardia or bradycardia, may also make newborn infant more vulnerable to develop pneumonia.

Chorioamnionitis is a relatively reliable sign of bacterial invasion of the amniotic fluid and correlates well with intra-uterine pneumonia.

A number of infections e.g. listeria monocytogenes, Gonococci, B Streptococcus, Candida albicans, Escherichia coli, Herpes virus hominis etc. may be contracted by the baby during its transport through the birth canal. (B) Post natal pneumonia. Difficult delivery with instrumentation, birth asphyxia with active efforts at resuscitation and mouth- to-mouth breathing are important predisposing factors.

Preterm and low birth weight babies are more susceptible to develop nosocomial infections due to deficient humoral and cellular immune mechanisms. The babies with congenital anomalies" e.g. esophageal atresia with tracheo-esophageal fistula, cleft palate and thymic aplasia etc. are more Susceptible to develop infections. Male infants are two times more suscep-

tible to develop neonatal pneumonia as ~ompared to females.

Several predisposing and adverse factors operating in the NICU include lack of

' adequate handwashing practices; over- crowding; lack of disposable and proce- dures which breach the primary defence mechanisms. Nosocomial infections with several resistant organisms e.g. Pseudo- monas aeruginosa, acinetobacter-and candida species may occur in infants with respiratory failure requiring prolonged ventilatory support. (C) Aspiration pneumonia. It usually occurs in centers wher~ trained nursing personnel are not available to look after high risk babies. Infants with prematurity, birth asphyxia, congenital malformations like cleft palate, macroglossia, glossoptosis, esophageal atresia etc. are at increased risk to develop aspiration. There is a history of choking or regurgitation during feeds followed by sudden dyspnea and cyanosis. The commensals in the oropharyngeal pas- sages and anaerobes are common etiologic agents.

Etiopathogenesis

Etiology. Transplacental pneumonia ust,-

1995; Vol. 62. No. 3 THE INDIAN JOURNAL OF PEDIATRICS 295

ally occurs in association with congenital syphilis, cytomegalo virus, herpes virus hominis, rubella, toxoplasma, Listeria monoQ/togenes and mycoplasma infections. These infants usually show involvement of many organ systems and manifestations of pneumonit is may be obscured. The acquired pneumonia may be caused by bacteria, viruses, fungae or chlamydiae agents. It is most frequently broncho- pneumoni c or interstitial type.

The major bacterial isolates responsible for acquired neonat/d pneumonia have been varying from time to time. Strepto- cocci @ere the predominant organisms in the 1930s and early 1940s and were re- placed by Staphylococcus aureus in 1950s. Group B streptococci (GBS) and 4oliforms particularly Escherichia coli have been the most common causative organisms since 1965. Staphylococcus aureus and Strepto- coccus viridans have recently emerged as important pathogens. 1~ There is changing trend of etiologic organisms from various parts of India. 8,t4'ts The incidence of Kleb- siella is increasing over the last 10-15 years. Staphylococcus aureus infections still play an important role in most Indian centers except our hospital. Thus, in India, the predominant aerobic bacterial agents are Es- cherichia coli, KlebsieUa, Staphylococcus aureus, pneumococcus and Pseudoraonas aeruginosa. It must be emphasized that GBS is extremely rare in India apparently due to lack of sexual promiscuity and en- hanced competitive colonization of vagina and cervix by heavy load of Gram-negative organisms due to poor hygienic practices. 16 I~afants supported by respirators and other life supporting modalities may' develop.s~econdary low grade chronic pneumonias due to organisms such as Pseudomonas aeruginosa, Alcaligense fecalis

and Klebsiella. These organisms are frequently water.-borne and are usually transmitted from humidifiers, suction catheters and other equipments. The predominant anaerobic organisms in Western studies include Bacterioides sp, Peptococcus, Peptostreptococcus and Clostridium per- fringes. 17 Listeria monocytogenes and Candi- da have been recognised occasionally in India.9.14.18,19

Viral agents such as parainfluenza group have been identified in neonatal pneumonia but their role is questionable. Nosocomial viral infections causing pneumonia include Coxsackie viruses, Echo viruses, adenovirus, respiratory, syncytial virus, influenza A and B virus and herpes virus. These agent are transmitted to neonates from personnel, mother or father, and other infants and attendants. Acquisi- tion of Chlamydia trachomatis in the intrapartum period may result in pneumonia as well as conjunctivitis, usually pre- senting between the fourth to twelveth weeks of life.

Pathogenesis

Congenital pneumonia (Transplacental) can be acquired, from hematogenous placeto-feta! spread in the presence of ma -'z ternal infection. Listeria monocytogenes pneumonitis has been documented in infants born to mothers having unexplained febrile illness during the tl3ird trimester of pregnancy. Examination of the placenta often shOws characteristic focal granulomas on the cord, fetal membranes and decidua. Tuberculosis and syphilis can be .transmitted by placento-fetal route e i the r hematogenously from the mother or after primary placental invasion by these organisms. Viral infections such as cytomegalo-

296 THE INDIAN JOURNAL OF PEDIATRICS 1995; Vol. 62. No. 3

virus, rubella and varicella are acquired during intrauterine life by hematogenous dissemination across the placenta. Toxoplasmosis has also been found as a causative organism in neonatal pneumonia. In these infants maternal titers suggestive of recent infection and placental villitis are also frequently observed.

Herpes simplex pneumonia is usually acquired during the passage through the birth canal by the infant born to a mother with herpes progenitalis. Manifestations may appear a few days to one week after birth. The virus infects the fe tus 'by oronasal route with manifestations of pneumonia and skin lesions. Candida albicans infection may occur in a similar way.

Recently, the increased pathogenicity oi bacterial infections i_n infants has been ex- plained on the basis of both bacteriologic and host factors. Blood stream infection in infant rats or mice caused by E. coli KI or any of the Group B streptococcus sero- types can be prevented by pretreatment by type specific capsular polysaccharide antibody. 2~ The orogastric route for E. coli KI in the infant rat and the inhalation of amniotic fluid infected with Group B streptococci in the rhesus monkey produce ill- nesses closely paralleling the human syndrome.12~ 1.2~ The importance of type-specific antibody (BIII) in protection of infant against Group B streptococcus infection has been well documented and underlines the maternal contribution to neonatal im- munity.

In meconium aspiration syndrome (MAS), the passage of meconium in-utero is related to degree of birth asphyxia and post maturity. 1~" The amniotic fluid is nor- mally swallowed by the fetus in-utero but the fluid usually does not enter the trachea

except during episodes of severe asphyxia. It appears that hypoxic insult causes aspiration of a large quantity of amniotic fluid. The aspiration of meconium contaminated amniotic fluid may lead to complete obstruction of the bronchioles leading to atelectasis or incomplete obstruction causing a ball-valve mechanisms leading to development of obstructive emphysema and increased risk of pneumothorax and pneumomediastinum. The irritation of the bronchial mucosa may cause chemical pneumonitis and meconium may also enhance the bacterial growth. This leads to hypoxia, hypercapnia and acidosis. The pulmonary functions in neonates with severe M.AS reveals marked reduction in dy- namic compliance due to changes in lung elasticity. Increased functional residual ca- pacity is suggestive of gas trapping. Tidal volume is decreased but minute ventila- tion is increased as a result of an increased airways resistance and rapid respiratory rates. The newborns with meconium aspiration are more prone to develop persistent fetal circulation (PFC). The exact cause of PFC is not knbwn but pulmonary vascular constriction with or without increased pulmonary vascular smooth muscle mass following hypoxia and acidosis may be related to the development of PFC secondary to MAS.

Clinical Picture

Infants with intrapartum (congenital) pneumonia usually show evidences of pneumonia as well as generalized illness within 48 hours. Occurrence of respiratory distress soon after birth in an infant born following known predisposing factors for development of ascending bacterial infections is highly suggestive of congenital


pneumonia. Pneumonia may follow in- utero or at birth aspiration of clear or meconium contaminated amniotic fluid and at times aspiration may occur postna- tally any time during feeding of preterm and sick newborn babies. The onset of postnatal pneumonia depends upon the time of acquisition of infection, birth weight and maturity of the infant. The clinical picture is usually characterized by one or more of the following features : tachypnea, respiratory distress with subcostal and intercostal retractions, expi- ratory grunt and cyanosis. Many a times, the pneumonia may be silent and without any respiratory distress. Cough is rarely present in neonates with pneumonia but when present, it is invariably indicative of pneumonia rather than upper respiratory infection. Ausculatory findings are non specific and localized or generalized tales may be audible. The clinical examination of chest is difficult to interpret in a newborn baby due to cross conduction of ad- ventitious sounds. Many a times there are no clinical signs in the chest while skiagram shows gross evidences of pneumonia. The baby may exhibit greyish-blue circumoral cyanosis and vacant stare. Hy- pothermia is usual while fever may be seen with Gram-positive infections. Hyper- bilirubinemia, diarrhea, vomiting, abdominal distension and hepatosplenomegaly may be present. In case of severe generalized pulmonary involvement, infant may show recurrent episodes of apnea, cardiovascular collapse and disseminated intra- vascular coagulation. The latter manifests with generalized bleeding diathesis in the lungs, GIT, skin and CNS. In advanced cases, sclerema may develop.

Different etiologic agents produce iden- tical clinical picture with following excep-

tions. Staphylococcal infections are usually characterized by onset of symptoms after 72 hours of age and evidences of superfi- cial infections like conjuctivitis, pyoderma, umbilical sepsis, and abscesses etc. Early- onset Group B Streptococcal infection usually manifests with respiratory distress in- distinguishable from hyaline membrane disease. The onset of RDS is usually, within 2 hours of birth. Apneic attacks and shock occur early and disease runs a fulminant course. The lung compliance, however, is unaffected in GBS infection. In neonatal listeriosis, peripartal flue like maternal illness, fever or gastroenteritis are commonly associated. The liquor is often meconium stained or greenish in color due to fetal diarrhea. Infant shows respiratory difficulty in the form of shallow breathing, mild respiratory distress associated with skin rash, apneic attacks and hepatosplenomegaly. In pseudomonas aeruginosa infection, there is development of greyish-black gangre- nous patches on the skin. The occurrence of purulent conjuctivities during faa'st week of life followed by development of spasmodic cough and interstitial pneumonitis after 2-3 weeks are suggestive of chlamy- dial infection. Pertussis is known to produce intractable spasmodic cough during neonatal period and carries poor prognosis especially in female infants. The knowl- edge of the prevailing bacterial flora in the nursery during a particular period and their sensitivity pattern is helpful to sus- pect the probable pathogens and initiate appropriate antibiotic therapy.

In meconium aspiration syndrome, the infant may appear long and thin with loose folds of skin at the buttocks due to placental dysfunction and dysmaturity. The nail% cord and skin may be stained yellow with meconium. The cord is thin shrivelled and


devoid of Wharton's jelly. The skin is more keratinized than usual and vernix often ab- sent and there may be extensive peeling. The chest is usually hyperinflated with increased antero-posterior diameter and rales and rhonchi are common.

Diagnosis

Culture and Gram's stain. In early-onset pneumonia, the bacterial cultures should be obtained from liquor amnii, gastric aspirate, external ear, throat, umbilical stump and blood. In cases of prolonged rupture of membranes and onset of.respiratory distress soon after birth, gastric fluid should be examined for polymorphs. The presence of more than 5 polymorphonuclear leukocytes per high power filed or when their number exceeds three times the epithelial cell count, it is suggestive of intrauterine or congenital pneumonia. Buffy coat smear examination, if carefully done, may detect micro-organisms in 50-70 percent cases of sepsis, z~ Tracheal aspirate and lung puncture aspirate can be cultured and provide a good yield of pathogens24

Radiology

Skiagram of the chest may show bilateral opacities or evidences of atelectasis and consolidation. Worsening of opacities on serial roentgenograms during next 24-48 hours suggest pneumonia while prompt resolution of opacities favours the diagnosis of massive meconium aspiration (Fig. 1). In infants with Group B streptococcus infection, a variety of abnormalities on chest radiograph have been reported e,g, normal, pneumonia, delayed fluid re- sorprio, n, pleural effusion and a coarse nodular pattern etc. In infants weighing

Fig. 1. Diffuse bilateral opacities due to massive meconiurn aspiration.

less than 1500 g, the predominant radiological findings are similar to hyaline membrane disease in 80 percent of cases. In larger premature or full term infants, the radiographic findings are neither specific nor helpful in distinguishing GBS infection from other respiratory disorders in the newborn.

In staphylococcal pneumonia, chest film frequently shows consolidation in a lobar distribution. Pleural fluid may accumulate and require evacuation. Pneumatoceles of varying size may be present and their spontaneous rupture may cause pneumothorax. Progression over a few hours from bronchopneumonia to effusion or pyopneumothrax with or without pneumatoce!es is highly suggestive of staphylococcal pneumonia.

When a lobar infiltrate is associated with a bulging interlobar fissure on the film, Klebsiella pneumonia should be considered. Streptococcal and Gram-negative

1995; Vol. 62. No_ 3 THE INDIAN JOURNAL OF PEDIATRICS 299

pneumonias are usually widely distributed throughout both the lungs without lobar localization. They resolve completely without any pulmonary sequelae if the infant survives. In listeriosis, the chest roentgeno- gram shows parenchymal infiltrates suggestive of aspiration pneumonitis. A mili- ary type of bronchopneumonia can also be observed in some cases.

In meconium aspiration syndrome, the chest film shows patchy densities inter- spersed with radiolucent areas due to over inflation. In postnatal aspiration, pneumonitis is usually seen in the right upper zone especially in infants with tracheoesophageal fistula (Fig. 2).

Ind irec t Markers o f In fec t ion

Leukocytes. The normal count varies from 8000 to 20,000 per ram: Neonatal infection is usually associated with leukopenia (< 5000/ram3). The neutrophils may demon- strate abnormal morphology with the ap- pearance of Dohle bodies (aggregates of rough endoplasmic reticulum staining light blue with Giemsa stain), toxic granu- lations (deeply stainingeosinophilic gran- ules in the cytoplasm of neutrophils) and vacuolization. Band cell count to total neu- trophil ratio of equal to or more than 0.2 has a sensitivity of 68 to 80 percent for the diagnosis of life threatening bacterial infections. ~

Micro-erythrocyte sedimentation rate (m- ESR). During the neonatal period, a value of more than 10 mm is considered to be suggestive of infection in 64 to 74 percent of infected babies, z~

Acute phase reactants. The best studied acute lbhase protein is C-reactive protein. A level of more than 8 pg/ml is considered abnormal in the neonate. The CRP levels

Fig. 2. Pneumonitis in the right upper zone area due to postnatal aspiration.

have a sensitivity and specificity of 87.5 percent and 83.3 percent respectivelyd ~ CRP has been found to be useful and reliable to differentiate pneumonia from other causes of neonatal respiratory distress syndrome. ~

Placental examination. It may provide a useful clue to the diagnosis of congenital pneumonia. Chorioamnionitis, malodor- ous membranes, granulomas on the fetal membranes, focal necrosis with pseudohyphae and viUitis are suggestive of intrauterine infection.

Frozen sections of the umbilical cord showing abundant polymorphonuclear cells are highly predictive of chorioamnionitis and bears good correla- tion with congenital pneumonia in the newborn.

Postmortem examination of lung .. Post: mortem diagn.~sis of;pneumonia in the newborn infant requires histologic examination. The pathologic finding s vary de-

300 THE fl~'DIAN ]OL"RNAL OF PEDIATRICS 1995; VoL 62- No. 3

pending upon the onset and duration of the disease, the causative agent, the maturity of the infant and other coexistent abnormalities. Infants dying soon after delivery show acute inflammatory exudates dis- persed throughout the lungs filling mainly alveo[i, ducts and bronchioles with varying. degrees of infiltration of pulmonary parenchyma. At times, autopsy may show evidence of fulminant hemorrhagic pneumonia in the absence of any specific clinical manifestations referable to the respiratory system. Particulate aspirate matter in- cluding degenerated leukocytes, meconium particles, squamous ep\itheliaI ceils etc. may be admixed with the exudate. The examination of placenta reveals association of early-onset neonatal pneumonia with inflammation of the placental membranes (chorioamnionitis or membranitis). The leukocvtic infiltration of the chorion, amnion and umbilical blood vessels is found in all cases of congenital bacterial pneumonia. The common clinical correlates of both congenital pneumonia and choriamnionitis include premature or prolonged rupture of the membranes, prolonged labor, premature labor and mater- hal fever. Nevertheless, the amniotic infection syndrome may also occur in the absence- of recognized prenatal or intrapartum abnormalities-. In such cases, the examination of the placenta may provide the sole clue to the diagnosis of congenital pneumonia in the infant.

Management

1. Support ive care

(1) Place the infant under a radiant heat source or in an incubator, Maintain skin temperature around 36.5~ The baby

should be nursed in a Ihermoneutral envi- ronment or servo-controlled system. (2) El- evate the shoulders slightly with a folded

. towel to facilitate respiratory efforts. The abdominal distension should be relieved by decompression of stomach by orogastric aspiration. (3) Administer suffi- cient oxygen with a hood to relieve cyanosis. Maintain PaO 2 between 50 to 70 mm Hg (or 45 to 50 mm Hg when warmed heel capillary b.lood sample is used). In First Referral Units, oxygen can be admin- istered effectively with a nasal catheter. In- 'sert 8 FG nasal catheter into the baby's nose to depth equal to the distance from external naris to the ear lobule. Administer oxygen at a rate of 0.5 liter per minute. Higher flow rates are associated with abdominal distension and respiratory embar- rassment. The nasal catheter should be taken out and cleaned at least twice a day. (4) Ensure patent airway and use intermit- tent suction whenever secretions accumulate. (5) Monitor respiration, heart rate and blood pressure. (6) Administer parenteral fluids through a peripheral vein. Fluids should be ~ t r i c t e d to two-third of the normal maintenance. Oral feeds should be gradually introduced once the condition shows improvement. (7) Arterial blood gases and acid base parameters should be frequently monitored and appropriately managed. Ventilatory support should be provided when respiratory failure is immi- nent. (8) Correct anemia, if hematocrit is less than 40 percent by transfusing fresh packed cells (10 ml/kg will raise the hematocrit by about 5%). (9) Use appropriate antimicrobials as given below. (10) In neonates with septic shock, administration of plasma expanders, whole blood, ventilatory assistance and other life support measures are indicated.

1995; Vol. 6Z No. 3 THE INDIAN JOURNAL OF PEDIATRICS 301

2. Antimicrobial therapy

The diagnosis of pneumonia in a neonate is often difficult because of the problems in interpreting the portable skiagrams of chest. The radiologic features of Group B streptococcal pneumonia are indistin- guishable from those of hyaline membrane disease. In infants with early-onset RDS persisting for more than 4-6 hours, it is a common practice to initiate antibiotics after faking appropriate cultures. The antimicrobial therapy can be stopped once laboratory data, culture results and the clinical course of the infant rule out infection. The radiographic findings in infants with transient tachypnea of the newborn are difficult to distinguish from flaose seen in neonates with pneumonia or aspiration. Careful observation is warranted in such cases and antibiotics may be started if pneumonia cannot be excluded. Infants with meconium aspiration syndrome do not require antimicrobial therapy. Choice of Antibiotics Pneumonia is a life - threatening infection and is treated with the same concern and vigour as septicemia in the newborn. The following groups of antimicrobial agents are currently used (Table 2) Aminoglycosides. 11.13z~ It includes kanamycin, gentamicin, iamikacin, tobraymcin, netilmicin and sisomicin. Gentamicin still remains the drug of choice for most Gram-negative organisms except Pseudomonas aeruginosa. Amikacin is useful against enterobactericae resistant to gentamicin while tobramycin is relatively more effective against Pseudomonas aeruginosa. Experience with netilmicin and sisomicin is limited in the neonate but some strains of Escherichia coli and Kleb- siella-Enterobacter group resistant to

gentamicin are found to be sensitive to netilmicin.

Cephalosporins. 13-3~ The spectrum of first generation cephalosporins include Gram- positive bacteria while their activity against Gram-negative organisms is generally unpredictable. The second generation cephalosporins are more effective against Gram-positive cocci, Escherichia coli and Klebsiella than cephaloridine. The third generation cephalosporins include eefotaxime and ceftriaxone. Both are effective against Escherichia coli, Klebsiella, Enterobacter, Proteus and Citrobacter resistant to aminoglycosides. In addition, cefotaxime is also effective against Staphy- lococcus aureus and Staphylococcus epidermidis. Ceftazidime, another third generation cephalosporin, is the drug of choice for treatment of infections due to Pseudomonas aeruginosa but has poor ef- ficacy against Gram-positive organisms and anaerobes.

Penicillins. Benzyl penicillin is most suit- able for treatment of Group B streptococci. Ampicillin is the drug of choice for treatment of an occasional case of listeriosis. In our hospital, practically all Gram-negative bacilli are resistant to ampicillin and most isolates of Staphylococcus aureus are resistant to penicillin and ampicillin. Newer penicillins include ticarcillin, carbenicillin, acylamino-penicillins (e:g. mezlocillin, azlocillin and piperaciUin). TicarciUin is effective for the treatment of infections due to Pseudomonas aeruginosa. Its in-vitro activity against Pseudomonas aeruginosa is su- perior to carbenicillin. Acylamino-penidUins have in-vitro activity against some strains of Escherichia coil, Klebsiella-enterobacter species, Group B Streptococci, Listeria, and

�9 Pseudomonas aeruginosa.

302 THE INDIAN JOURNAL OF PEDIATRICS 1995; "4ol. 62. No. 3

T~eLE 2. Dosage Schedule for Commonly Prescribed Antibiotics

Antibiotic Susceptible Spectrum Dose mg/kg /day (frequency of administration of divided doses)

0-7 days of age > 7 days of age

Crystalline penicillin

A mpi-cillin

Carbenicillin

Ticarcillin Cloxacillin,

methicillin, naficillin

Vancomycin

Cephalothin, cephaloridine, cephalexin

Cefotaxime, ceftriaxone

Gentami.c'm

Tobramycin

Amikacin Chloramphenicol

Group A &B S'trept- 50,000 U-75,000 75,000 U- occocci, Gonococci, U !2) 100,000 U (3) Bacteroids sp, Clost- ridium sp. Group A & B Strepto- 50-75 (2 or 3) 75-100 (3 or 4) cocci, Staphylococci', E coli, Salmonella sp. Listeria monocytogenes, Enterococci, Chlamydiae Pseudomonarts aeruginosa, 200-300 (2) 300-400 (3 ro 4) Proteus. Pseudomonas aeruginosa 150-225 (2 or 3) 225-300 (3 or 4) Penicillinase producing 50-75 (2 or 3) 75-100 (3 or 4) staphylococci

Staphylococci especially those resistant to cloxacillin and methicillin Staphyloccci, Group A & B Streptococci, E coli, Klebsiella sp, Neisseria.

Staphyloccci, group A & B streptococci, E coli, Klebsiella, Proteus, Citrobacter, Enterobacter Staphylococcus aureus, E col~, Klebsiella, Citrobacter, Enterobacter, Enterococci, Pseudomonas, Listeria monocytogenese More active against Pseudomonas Similar to that of gentamicin Many strains of Stap- hylococci, Streptococci, E coli, Klebsiella, Proteus, Chlamydiae, Bacteroides sp.

30 (2) 45 (3)

40-60 (2 or 3) 60-80 (2 or 3)

100 (2) 150 (3)

5.0 (2) 7.5 (3)

4 (2) 6 (3)

15-20 (2) 20-30 (3) 25 (1) 5O (2)

(Table Contd.)


(Table 2 Contd.) r

Antibiotic Susceptible Spectrum Dose mg/kg/day (frequency of administration of divided doses)

0-7 days of age > 7 days of age

Co-trimoxazole

Eryt~omycin sucdnate

Erythromycin estolate

Staphylococci, Strepto- cocci, E coli, Klebsiella, Proteus

Staphylococci, Strepto- cocci, Neisseria, Chlamydiae,

Campylobacter, Border- ella pertussis

2 mg (TMP) and 10 mg (SMX) loading dose then 1.2 mg U'MP) and 6 mg (SMX) per dose every 12 hours

40 (4) 40 (4)

30 (3) 30 (3)

Other antibiotics like chl0ramphenicol an co-trimoxazole can be used if organisms are found to be sensitive. However, they should be used with caution. Erythromy- cin is effective for the treatment of chlamy- dial pneumonia and an occasional case of pertussis in the newborn.

3. Selection of antibiotics

It depends on the prevalence of bacterial isolates in a given setting and their antimicrobial sensitivity pattern. Since in our country, the major organisms causing neonatal sepsis are Escherichia coli, Klebsiella, Staphylococcus aureus and Pseudomonas aeruginosa, the desirable initial choice should be a combination of aminoglycoside (gentamicin/amikacin) along with a penicillin (benzyl penieillin/ampicillin). In centers, where resistant coliform organisms are prevalent, cefazoline can be com- bined with an aminoglycoside. When epi- demiologic experience suggests infection due to Pseudomonas aeruginosa, ticarcillin or ceftazidime should be used. When the infecting organism is known, the antimi-

crobial therapy is more rational. Table II provides guide-lines for the use of different antibiotics in relation to specific organisms. Parenteral therapy should be institut- ed for at least 10 to 14 days. There is no convincing evidence that antiviral chemo- therapy is effective in infants with viral pneumonias. Vidarabine or acyclovir are effective if given early for treatment of pneumonia due to herpes virus hominis while gancyclovir is effective for cytomeg- alovirus pneumonitis.

4. Immuno therapy

Exchange blood transfusion can theoreti- cally help by improving oxygen delivery, correction of coagulation abnormalities, re- moval of toxins and other bacterial prod- ucts. It may also provide specific antibodies, complement and phagocytic cells. 32 Vain et al ~ in an uncontrolled study, documented improved outcome following exchange blood transfusion in critically ill septicemic neonates with sclerema. Further controlled studies are needed to substanti- ate these observations.


Simple plasma or Whole blood transfu- sions have been found useful in Group B streptococcal septicemia when type-specific opsonins against infecting organisms are present in the infusate, u Polymorphonu- clear leukocyte transfusion is documented to be useful modality in the management of neonatal septicemia ~s but several serious potential risks such as graft versus host disease require cautious approach- Recent- ly, administration of antibodies to endo- toxin (antipolysaccharide) given intramus- cularly did not reduce mortality in low birth weight babies suffering from pneumonia or septicemia. 36 The possibility of immunising those mothers, who have low antibodies to Group B streptococci, in or- der to achieve adequate levels of protec- tive antibodies in their offsprings, is being explored. 3~

Prognosis

The mortality rate has gradually fallen over the years with the advent of newer antibiotics but still the case fatality rate may be as high as 60 percent especially in low birth weight babies. 2 The outcome depends upon the maturity and weight of the baby ~md promptness and adequacy of the therapy. Generally the prognosis is poorer in Gram-negative infections as compared to Gram-positive infections except GBS pnemnonia which is ominous. Prognosis is extremely bad in infection,~, caused by Pseudomonas aeruginosa. Bad prognostic signs include onset of symptoms within 48 hours of age, association with congenital anomalies, recurrent episodes of apnea, cardiovascular collapse or shock, profound hypoxemia, persistent transitional circula-

tory pattern, DIC, severe metabolic acidosis and a low polymorphonuclear leukocyte count.

R ~ N C ~

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A N E V A L U A T I O N OF I N F A N T G R O W T H : THE USE AND

I N T E R P R E T A T I O N OF A N T H R O P O M E T R Y

In reviewing the growth of infants who live under favourable conditions and are fed according to WHO feeding recommendations, .the Working Group found significant differences between the growth patterns of these infants and the patterns reflected in the NCHS-WHO international reference. Given the short and long term on sequences of growth failure, and the dangers of both the premature introduction of complementary foods and their undue delay -- described as the "weanling's dilemma", the Working Group concluded that use of the current N C H A W H O reference appears to 'accentuate the difficulty of avoiding these extremes rather than to help ensure optimal infant nutritional management.

The Working Group identified the following requirements : (a) a new reference which will enhance the nutritional management of infants; (b) the reference population should reflect current health recommendations because of the.frequent use of such reference data as standards; (c) evaluation, in a broad range of settings, of the practical utility of using reference data based on infants for whom the WHO feeding recommendations are being followed; (d) close investigation of the effects of different complementary foods on the growth of infants who are being fed according to the WHO recommendations; (e) criteria for evaluating abnormal growth patterns; (/3 research for identifying proxy measures for length; and (g) evaluation of reference data based on other anthropometric measurements, such as skinfold thickness and arm and head circumferences.

Abstracted from : WHO Bulletin 1995; Volume 73(2) pp : 135-136.

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Pneumonias in newborn babies