CONGENITAL PNEUMONIA

BUDHARAPU RAHUL
GROUP 52
5th COURSE
 CLINICAL CASE

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A female infant was delivered by vacuum extraction at 37+4 weeks gestational age to a
multiparous mother after premature rupture of membranes, meconium stained amniotic fluid
and pathological cardiotocogram. Maternal vaginal swabs were tested negative for Group B
Streptococcus. Apgar scores and umbilical artery pH were within the normal range.
About 12 hours after birth the neonate showed signs of respiratory distress with tachypnea,
grunting and an oxygen demand of FiO2 >0,3. He was intubated and transferred to our NICU.
A chest radiograph on admission showed bilateral streaky infiltrates . On day 2 an elevated CRP
of >1.0mg/dL, In the yellowish tracheal aspirates Listeria monocytogenes were detected. The
asymptomatic mother was tested negative for Listeria infection in stool and urine probes.. On
closer questioning the mother remembered having gastrointestinal symptoms with diarrhea
2 weeks prior to birth after having eaten some cheese made from unpasteurized milk from a
local food store.
●
Congenital Pneumonia is lung infection in a neonate. it is already established
at birth. It may become established long before birth or relatively shortly
before birth.
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Pneumonia is the most common invasive bacterial infection after primary sepsis.
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Early-onset pneumonia is part of generalized sepsis that first manifests at or within hours
of birth.
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Late-onset pneumonia usually occurs after 7 days of age,
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Transmission of congenital pneumonia usually occurs via 1 of 3 routes:
1)Hematogenous (mother with accumulation of bacterial , viral or microorganism in blood)
2)Ascending (infection from borth canal)
3)Aspiration (aspiration of infected or inflamed amniotic fluid.)
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Agents of chronic congenital infection, (e. g. TORCH) cause pneumonia in the first 24
hours of life
 ETIOLOGY

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It can be Infectious or Non Infectious.
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INFECTIOUS:
Group B streptococci, E.Coli , Hemophylus Influenza, Listeria Monocytogenes
Enterococci, Staphylococcus aureus.
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Non Infectious:
Any diffuse lung diseases like diffuse alveolar damage,
organising pneumonia, non specific interstitial pneumonia,
desquamative interstitial pneumonia, lymphocytic interstitial pneumonia.
 PRE NATAL RISK FACTORS

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Unexplained preterm labor
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Uterine tenderness
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Rupture of membranes before the onset of labor ●
Foul-smelling amniotic fluid
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Membrane rupture more than 18 hours before ●
Infection of the maternal genitourinary
delivery
tract
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Maternal fever (>38°C/100.4°F)
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Gestational history of illness consistent with an
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Previous infant with neonatal infection
organism known to have transplacental ●
Fetal tachycardia
pathogenic potential
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Maternal obesity
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Breech presentation
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Maternal congenital cardiopulmonary disease ●
Meconium in the amniotic fluid
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Antibiotic use during pregnancy ●
Recurrent maternal urinary tract
infection
 Signs & Symptoms:
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persistent tachypnea (respiratory rate >60/min),
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expiratory grunting,
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accessory respiratory muscle recruitment
(eg, nasal flaring and subcostal, intercostal, or suprasternal retraction).
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Airway secretions :White, yellow, green, or hemorrhagic colors
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Unstable body temperature
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Jaundice at birth & Cyanosis
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Abdominal distension
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Hypoperfusion
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Oliguria
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Hepatospleenomegaly
DIAGNOSIS: (Physical examination)
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Observe for signs of respiratory distress
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Examination of chest may be normal but it may show decreased chest expansion
on affected side.
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Harsh breath sounds can be heard on auscultation
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Crackles (rales) may be heard over affected area during inspiration
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Percussion may be dulled over affected lung.
Laboratory Studies:
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Cultures of Blood , Urine , CSF are gold standard.
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Inflammatory Markers:Inc C-reactive protein, procalcitonin, cytokines
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(eg, interleukin-6), interalpha inhibitor proteins.
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CBC:Increase of white blood cell count ( 5000-25000IU)
 Radiological Examination
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UltraSound (useful for identifying and
localizing fluid in the pleural and pericardial
spaces. )
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X ray of chest(Patchy irregular densities &
persistent infiltrates are seen)
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CT or MRI
Other primary pulmonary anomalies
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Other methods:
Bronchoscopy,
Thoracocentesis
COMPLICATIONS

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Restrictive pleural effusion ●
Airway injury
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Infected pleural effusion ●
Obstructive airway secretions
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Systemic infection with metastatic foci ●
Hypoperfusion
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Persistent pulmonary hypertension of ●
Chronic lung disease
the newborn
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Hypoxic-ischemic and cytokine-
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Air leak syndrome, including
pneumothorax, pneumomediastinum,
mediated end-organ injury
pneumopericardium, ●
Necrotizing enterocolitis
and pulmonary interstitial emphysema ●
Empyema
MANAGEMENT: Respiratory Support
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Adequate has exchange depends not only on alveolar ventilation but also on
perfusion and gas transport capacity of alveolar perfusate
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AIRWAY PETENCY:
Gentle vibration and percussion is used in some centres to mobilise the
sections
Deep suctioning should be avoided because it can cause airway trauma and
swelling, which in turn may cause large airway obstruction
●
VENTILLATORY SUPPORT:
Use of mucolytic agentsMaybe rendered unusually challenging by alveoli with
variable degrees of inflation from the unpredictable distribution of surfactant
inactivation, partial airway obstruction , and fluid exudation.
 OTHER SUPPORTIVE MEASURES:

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Red blood cells should be administered to achieve a hemoglobin concentration
of 13-16 g/dL in the acutely ill infant, to ensure optimal oxygen delivery to the
tissues.
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Delivery of adequate amounts of glucose and maintenance of
thermoregulation, electrolyte balance, and other elements of neonatal
supportive care are also essential.
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Nutrition
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Attempts at enteral feeding often are withheld in favor of parenteral nutritional
support until respiratory and hemodynamic status is sufficiently stable.
 MEDICATIONS

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ANTIBIOTICS & ANTI VIRALS
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Ampicilin 50 mg/kg/dose IV or IM q 12 hours
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Cefotaxime 50 mg/kg/dose IV or IM q 12 hours
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Erythromycin 30-50 mg/kg/dose PO divided q 8hours
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Gentamycin 2.5 mg/kg/dose IV or IM q 24hours
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Acyclovir ( This treatment should be considered when a diagnosis of HSV
is suspected or when infant is not responding to antibiotic therapy.)
PREVENTION:
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Prevention strategies may include antepartum and intrapartum broad-spectrum
antibiotic treatment in mothers with preterm rupture of membranes or in whom
chorioamnionitis is suspected.
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In the presence of particulate amniotic fluid meconium, suction the trachea
immediately after birth if the infant is not vigorous.
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Currently, there is little evidence demonstrating the potential efficacy of the
following interventions in neonates:
Elevating the head
Use of antireflux medications
Differential policies for oral care and changes of suction and ventilator tubing
Other potential interventions