neonatal pneumonia s.ghaemi. md pneumonia is the most common form of neonatal infection and one of...
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Neonatal pneumonia
S.Ghaemi. MD
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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%
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Etiology:
Pneumonia may be acquired:
1. Tranplacental or congenital
2. Perinatal
3. Postnatal
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Riskfactors:
I. Neonatal riskfactors:
A. Prematurity (immaturity of
mucociliary clearance, small size of
the conducting airway)
B. Lowered host defenses
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Riskfactors: (cont’)
C. Invasive procedures (tracheal
intubation, barotrauma, hyperoxic
damage to the respiratory tract)
D. Asphyxia
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II. Environmental riskfactors:
nosocomial flora of the hospital
nursery (nursery equipment or
unwashed hands of caregivers).
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III. Maternal riskfactors:
a) PROM > 18 hr
b) Maternal fever and other bacterial
infection
c) Prolonged labor.
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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.
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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.
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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.
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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.
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Respiratory symptoms are often present at
delivery or in the first few days of
life. Infants may have systemic signs:
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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.
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III) Postnatal pneumonia:
Newborns exposed to respiratory
equipment or humidified incubators are at
risk for respiratory infection by
pseudomonas species, flavobacterium,
kelebsiella, or serratia.
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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.
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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
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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.
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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.
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UTI in newborns
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UTI in newborns frequently is associated
with bactermia and may result in long-
term complications.
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Newborn with UTI should be evaluated for
associated systemic infection and
anatomic or functional
abnormalities of the urinary tract.
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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%.
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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.
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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.
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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.
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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.
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Approximately 30%-50% of newborns
with UTI have urinary tract abnormalities,
VUR is most common.
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Clinical features
The signs and symptoms of neonatal UTI
are nonspecific most of the times resemble
neonatal sepsis, preterm infants
frequently present with apnea.
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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%)
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Diagnosis
Urine collection:
A – Suprapubic aspiration is the most
reliable technique to identify bacteriuria.
Any growth of urinary pathogens is
significant.
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Bladder catheterization:
This technique less reliable than suprapubic
aspiration.
Catheterization culture more than 1000
CFU (colony forming units) ∕ CC pathogens
is significant.
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Urinalysis:
WBC ≥ 5 per hpf
Sepsis evaluation:
Blood culture/CSF culture, should be
obtained in infants in whom UTI is
suspected.
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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.
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Sterilization of the urine must be
documented by repeat culture after 48h/ of
therapy.
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Treatment duration:
Is usually 10-14 days, but may be longer
in complication such as:
1. Persistent bacteriuria
2. Anatomic obstruction
3. Perinephric abscess.
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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.
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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.
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Radiographic Evaluation:
Radiographic evaluation should be
performed in all newborn with UTI.
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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).
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Earlier examination may be indication in
infants with abnormalities detected on
antenatal utrasound examination.
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C. DMSA scintigraphy
To identify renal scarring and
pyelonephritis.
It may be considered if renal damage
is suggested by ulterasonography.
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Outcome:
Many newborns with UTI develop renal
scarring
Renal scarring may result in hypertension
and chronic renal disease.
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