Congenital Pneumonia, please share your experience

[Aymen Eshene]

Hello dear 

where i work, i have seen a lot of babies admitted and treated for pneumonia and a significant number of  them have had no maternal risk factors for infection.

this point is making a lot of of argument and discussion between us and the obs-gyn team.

usually we look for PROM, UTI, Meconium, GBS, prematurity, Chorio. Also we take into consideration other risks like the need for resuscitation and apgar score.

Recently , i red an article about  the role of multiple vaginal examination as a risk for infection and in another article they were discussing the possibility of vernix as a  main factor leading to pneumonia .

Now i will formulate my questions

What are the unusual risk factor for infection ?  

Do you do a tracheal aspirate or gastric aspirate as a part of your workup ?

In which cases you add antiviral or antifungal to the treatment plane?

 

[Hamed]

Hi Ayman,     

Dividing your question to EOS and LOS

EOS:

-Concerning your first question please visit the Management of term infants at increased risk for early onset bacterial sepsishttps://www.cps.ca/en/documents/position/management-infant-sepsis  

-Concerning your second question: In our practice, we would NOT include tracheal aspirate to routine septic workup.

- Antifungal for prophylaxis in ELBWI (in Japan 3 times/week) unless we have a positive culture or suspected skin rash we switch to a therapeutic regimen. 

- Antiviral eg HSV (acyclovir) given in the following scenarios:

The CPS statement on prevention and management of HSV infection in this link: https://www.cps.ca/en/documents/position/prevention-management-neonatal-herpes-simplex-virus-infections

1- If symptomatic for signs and symptoms of neonatal HSV regardless and/or without knowing maternal history. (symptoms eg:  vesicular skin lesion, seizures, DIC, unexplained thrombocytopenia, elevates liver enzymes with or without resp. distress)  

2- If asymptomatic newborn  plus    

   (A) +ve maternal history WITH active genital herpes lesion and delivered by CS (in primary genital herpes)  or CS/VD (in recurrent genital herpes) --> collect surface swabs within 24hrs of age for HSV PCR (eye, throat, umbilicus) if PCR results are +ve or neonate become unwell take CSF sample via lumbar puncture (LP) for HSV PCR and start acyclovir.

   (B) +ve maternal history of primary genital herpes WITH active genital herpes lesion and delivered by VD  --> take swabs + LP + start acyclovir.

  (C)  +ve maternal history primary or recurrent genital herpes  WITHOUT active genital herpes lesion--> Observation  If develops any symptoms of neonatal HSV as above --> take swabs + LP + start acyclovir.

LOS: once clinical suspected we take cultures (Bl, urine and CSF) start antibiotics (the type of antibiotics depends on your units policy eg in Japan: mostly Gentamycine and ampicillin, in Canada: Vancomycin and tobramycin).  Results in 48hr If cultures + , take another culture and switch antibiotics according to sensitivity if not sensitive to the initially given. Duration of treatment after obtaining a -ve culture depends on the organisms type and whether or not CSF sample was +ve.  We use meningitic dose from the start if suspected meningitis (eg seizure). until CSF results. Antifungal if cultures are +ve for fungus.           Rarely would we take a tracheal aspirate, however, if there is a lot of secretions in an intubated infant and received a septic workup and bl cultures are -ve after 48hrs and still secretions are a lot, then we may consider taking a tubal aspirate for culture.

Edited May 14, 2018 by Hamed
addition

[bimalc]

I'm going to look at this from a different perspective than Hamed (who makes many good points, as usual): How sure are you that you are actually treating congenital pneumonia and not 'sick baby'?

[M.abdelwahab]

Hello dear

It is a clinical dilema to have such adiagnosis specially if no risk factors  we're not mention.Good history taking and looking to the previous antnatal history, sometimes socioeconomic status can guide u specially in developing countries.if u in dought

 do two serial CRP if raise that mean sepsis and complete sepsis workup.tqs

[Aymen Eshene]

On 5/15/2018 at 12:53 AM, bimalc said:

I'm going to look at this from a different perspective than Hamed (who makes many good points, as usual): How sure are you that you are actually treating congenital pneumonia and not 'sick baby'?

 Hello, Thank you for your reply. 

Its mainly based on two thing 

1- Clinical condition and respiratory distress which need M.v as Respiratory support ( Spo2,Co2). 

2- Radiological finding of infiltrates that is  more localized and doesn't fit a classical TTN.

 

I appreciate any input regarding the above mentioned point of veiw.

[tarek]

Thanks a lot @Aymen Eshene

Really i appreciate your effort and your good questions but let me add another dilemma:

if you started antibiotics for suspecting congenital pneumonia and blood culture result showed no growth after 72 hours what you will do ??

Regarding tracheal cs we are taking it if we are thinking in VAP( although i read one article that normally the ETT will colonize with gram positive bacteria after 6 hours from intubation and will colonize with gram _ve bacteria after 48 hours)

The 3rd question @Hamed antifungal prophylaxis fluconazole( 3- 6 mg/kg) iv 72 hourly if less than 1 kg in nursuries with high rates of invasive candidiasis > 10 % for 6 weeks can i use it even the rate is not that much

For babies 1 - 1.5 kg oral nystatin 100000 units 8 hourly is used( week recommendation)

[Hamed]

On 5/26/2018 at 1:33 PM, tarek said:

Thanks a lot @Aymen Eshene

Really i appreciate your effort and your good questions but let me add another dilemma:

if you started antibiotics for suspecting congenital pneumonia and blood culture result showed no growth after 72 hours what you will do ??

Regarding tracheal cs we are taking it if we are thinking in VAP( although i read one article that normally the ETT will colonize with gram positive bacteria after 6 hours from intubation and will colonize with gram _ve bacteria after 48 hours)

The 3rd question @Hamed antifungal prophylaxis fluconazole( 3- 6 mg/kg) iv 72 hourly if less than 1 kg in nursuries with high rates of invasive candidiasis > 10 % for 6 weeks can i use it even the rate is not that much

For babies 1 - 1.5 kg oral nystatin 100000 units 8 hourly is used( week recommendation)

@tarek yes you are correct the use of systemic prophylaxis anti-fungal therapy (IV fluconazole) varies from one unit to another, according to their experiences with unit`s fungal infection rate. A units with a fungal infection rate less than 5~10% would most probably preserve its use of systemic prophylaxis anti-fungal therapy for only suspected cases with possible risks of fungal infection, according to the AAP`s recommendations. https://www.ncbi.nlm.nih.gov/pubmed?otool=ijpsamulib&term=26679628

In our unit in Japan for example, we wouldn't use systemic prophylaxis anti-fungal therapy in VLBWI . Meanwhile, in Canada we didn't use in ELBWI nor in VLBWI unless suspected cases with possible risk to avoid promoting resistant candida species within the unit.

As for oral Nystatin, it is not well absorbed  from the gut.  In both of my experiences in Japan and Canada we didn't use as prophylaxis, but only as therapeutic for oral candidiasis. Although using for prophylaxis was shown to reduced the incidence of invasive fungal infection in VLBWI in a meta-analysis, in both units we found the cons to overweight the pros.

[selvanr4]

Hello,

Here is our observation we made in our nicu about congenital pneumonia. Please go through and if you need any clarification will be happy to give

The retrospective study was an unpublished one

Neonatal Pneumonia, A major cause of respiratory distress.doc