Caliwan, Nicole B.

BSN 2Y2-3

Group 3A Case Analysis: Neonatal Pneumonia

Neonatal pneumonia is lung infection in a neonate. Onset may be within hours of birth and part
of a generalized sepsis syndrome or after 7 days and confined to the lungs. Signs may be limited
to respiratory distress or progress to shock and death. Diagnosis is by clinical and laboratory
evaluation for sepsis. Treatment is initial broad-spectrum antibiotics changed to organism-
specific drugs as soon as possible.

Pneumonia is the most common invasive bacterial infection after primary sepsis. Early-onset
pneumonia is part of generalized sepsis that first manifests at or within hours of birth. Late-onset
pneumonia usually occurs after 7 days of age, most commonly in neonatal ICUs among infants
who require prolonged endotracheal intubation because of lung disease (called healthcare-
associated pneumonia)

Etiology

Organisms are acquired from the maternal genital tract or the nursery. These organisms include
gram-positive cocci (eg, groups A and B streptococci, both methicillin-sensitive and methicillin-
resistant Staphylococcus aureus) and gram-negative bacilli (eg, Escherichia coli,
Klebsiella sp, Proteus sp). In infants who have received broad-spectrum antibiotics, many other
pathogens may be found, including Pseudomonas, Citrobacter, Bacillus, and Serratia. Viruses or
fungi cause some cases.

Predisposing Factors

maternal systemic infection

maternal chorioamnioniti
prolonged rupture of the chorioamniotic membranes
premature rupture of the chorioamniotic membrane
lower socioeconomic status
aspiration or ingestion of organisms in the amniotic fluid during the intrapartum period
was the most common mechanism of acquisition of congenital pneumonia in extremely
low birthweight infants

Significant predictors of mortality in ventilated patients include the following [22] :

Weight below 2500 g

Gestational age less than 34 weeks
Initial arterial pH less than 7.1
Shock
Pulmonary hemorrhage
 Apnea
Hypoglycemia
Neutropenia
Thrombocytopenia

Signs and Symptoms

Late-onset health-care associated pneumonia manifests with unexplained worsening of the

patient's respiratory status and increased quantities and a change in the quality of the respiratory
secretions (eg, thick and brown). Infants may be acutely ill, with temperature instability and
neutropenia.

Diagnostic Test

Evaluation includes chest x-ray, pulse oximetry, blood cultures, and Gram stain and culture of
tracheal aspirate.

New, persistent infiltrates should be visible on chest x-ray but may be difficult to recognize if the
infant has severe bronchopulmonary dysplasia.

If Gram stain shows a significant number of polymorphonuclear leukocytes and a single

organism that is consistent with the one that grows from culture of the tracheal aspirate, the
likelihood increases that this organism is the cause of the pneumonia. Because bacterial
pneumonia in neonates may disseminate, a full evaluation for sepsis, including a lumbar
puncture, should also be done. However, blood cultures are positive in only 2 to 5% of cases of
healthcare-associated pneumonia.

Treatment

Usually vancomycin and a broad-spectrum -lactam drug

Antimicrobial therapy in early-onset disease is similar to that for neonatal

sepsis. Vancomycin and a broad-spectrum -lactam drug such as meropenem,
piperacillin/tazobactam, or cefepime (see Table: Recommended Dosages of Selected Parenteral
Antibiotics for Neonates), are the initial treatment of choice for most late-onset healthcare-
associated pneumonia. This regimen treats sepsis as well as pneumonia with typical hospital-
acquired pathogens including P. aeruginosa. Local patterns of infection and bacterial resistance
should always be used to help guide empiric choices of antimicrobials. More specific antibiotics
are substituted after sensitivity results are available. General treatment is the same as that
for neonatal sepsis.