Scand J Infect Dis 22: 493-497, 1990
CASE REPORT
Neonatal Sepsis due to Streptococcus pneumoniae JAN JACOBS,' KRISTIEN GARMYN,' JAN VERHAEGEN,' HUGO DEVLIEGER' and EPHREM EGGERMONT2 From the Departments of 'Bacteriology, University Hospital St Rafael and 'Pediatrics,
Scand J Infect Dis Downloaded from informahealthcare.com by UB der LMU Muenchen on 03/08/13 For personal use only.
University Hospital Gasthuisberg. Leuven, Belgium
A 20-year-old primigravida in the 33rd week of gestation was delivered of a girl weighing 1790 g 23 h after spontaneous rupture of the membranes. 13 h after birth, the child showed signs of shock. Cultures of blood, conjunctiva and nasopharyngeal aspirate grew Streptococcus pneumoniae of serotype 11. Cultures from the mother's cervix and from the placenta and membranes also grew S. pneumoniae of the same serotype. The infant responded well to ampicillin and netilmicin. The early-onset pneumococcal septicemic cases reported over the last 20 years are reviewed. J. Verhaegen, M D , Dept. of Bacteriology, Vniv. Hospital St Rafael, 8-3000 Leuven, Belgium
INTRODUCTION Streptococcus pneumoniae is an important pathogen; it is the most frequently isolated organism in bacteremia in children (1). However, neonatal infections due to this organism are rare (2). We report on an early-onset pneumococcal septicemia with documented carriage of S. pneumoniae in the genital tract of the mother. This case as well as those previously reported show the similarity of symptoms and outcome with group B streptococcal septicemia.
CASE REPORT A 20-year-old primigravida presented at 33 weeks gestation with spontaneous rupture of membranes. Pregnancy had been uneventful. A female infant weighing I790 g was born vaginally, 23 h after rupture of the membranes. Cultures of placenta and membranes were taken immediately after birth, according to the protocol for cases of prolonged rupture of membranes. At birth, the infant was in good condition, with Apgar scores of 9 and 10 after I and 5 min respectively. She received routine prophylaxis (neomycin and virginiamycin drops, Spitalenm) to the eyes. 13 h after birth, the infant suddenly developed apneic spells, became cyanotic and showed signs of shock. At physical examination a purulent conjunctivitis of the left eye was noted. Crepitations were heard over the left lung basis. Laboratory examination showed a ~ WBCII), an absolute neutropenia ( 1 .OX 10' polymorphonuclear cellsil with 10% leukopenia ( 2 . 8 lo9 bands) and a thrombocyte count of 4OOx 109/1. Cultures were taken from the conjunctiva, blood, nasopharyngeal aspirate and CSF. Ampicillin and netilmicin intravenously were given according to the standard procedure for suspected neonatal septicemia. After 24 h the blood cultures (Bactec NR-730, Becton Dickinson, Towson, USA) grew large gram-positive elongated cocci in pairs and short chains. A commercial latex agglutination procedure (Slidex pneumo-Kit, BioMerieux, France) done on the blood culture supernatant, indicated that the organism was S. pneumoniae. At the same time, cultures of the conjuctiva, nasopharyngeal aspirate, placenta and membranes also grew large, alpha-hemolytic colonies in pure culture on horse blood agar, which were identified as S. pneumoniae by their sensitivity to optochin. The CSF culture remained sterile. The latex agglutination procedure performed on the CSF was negative. The infant responded well to therapy, and was discharged in good condition on day 30. A swab, taken from the cervix of the mother, 5 days after delivery, yielded abundant growth of S. pneumoniae. All isolates showed the same sensitivity pattern, with sensitivity to penicillin, erythromycin, doxycycline and chloramphenicol. They all possessed the capsular polysaccharide antigen 1 I . 32 -908554
494
J. Jacobs et al.
Scand J Infect Dis 22 (1990)
Scand J Infect Dis Downloaded from informahealthcare.com by UB der LMU Muenchen on 03/08/13 For personal use only.
DISCUSSION In the last 20 years, there are only a few reports on early-onset neonatal septicemia due to S. pneumoniae. Over a period of 2.5 years, S. pneumoniae was isolated in 5/73 (5.5%) of the neonatal septicemic cases reported to the National Institute of Hygiene and Epidemiology in Belgium (3). Clusters of neonatal pneumococcal sepsis are reported sporadically (4-7). Its incidence accounts for up to 9 %of early-onset neonatal sepsis in one series (7). The previously reported cases over the past 20 years and the cases which occurred in our hospital are tabulated in Table I. The clinical features of early-onset pneumococcal sepsis have striking similarities with early-onset group B streptococcal (GBS) sepsis, including the early onset of circulatory failure and of severe respiratory distress with radiological and histological evidence of hyaline membrane disease (4, 5 , 8 ) . The resulting mortality rate (43 Yo of the reported cases) approaches that of GBS sepsis (40-80%) (9). On the other hand, milder forms exist, as is illustrated by Bergqvist and Trovik (8) and the present case.
Table I. Culture-proven early-onset
(i 72
h) pneumococcal sepsis
RDS = respiratory distress syndrome, HMD = hyaline membrane disease, D = died, S = survived ~~~~~~
~
Sex
F M F F F
M F F M M F F F M -
-
F M M M F F M F
-
F M F F a
Weight (g)
1600 1 300 1 500 2 680 2 780 2 401 2 680 2 950 3 095 2 840 3 300 I588 2 400 2 730 2 760 3 780 I 840 2 100 2 140
-
1750 1200
-
2 300 2 740 1 790 2 600 2 750 2 870
~
Gestational age (weeks)
40 31 32 28 31
36 38 36 38 41 38 40 32 33 36 38 40 34 33 35 35 30 28 37 35 40 33 37 38 36
Time from rupture of membranes to delivery, Age when symptoms started.
Prom" (h)
48 37 72 18 16 11 24 48 14 12 15 10 31
42 6 35 48 17 53 21 39 6 10 4 23 8
-
< 24
Onsetb (h)
72 24 6 < 10 min L
< 10 min 37.5"C) (26).The newborn infant at high risk of early-onset pneumococcal sepsis shares at least the first and the second risk factor: 54% of the infants had a gestational age < 37 weeks and in 58 O/o of the cases a prolonged rupture of fetal membranes was noted. S . pneumoniae fits in the spectrum of the antibiotic regimen for empiric treatment of neonatal septicemia. Once identified as the responsible organism, therapy should be switched to benzylpenicillin.
CONCLUSION This case illustrates the continued sporadic occurrence of pneumococcal early-onset neonatal sepsis. Together with previously reported cases, it strenghtens the observation that colonization of the maternal genital tract by S. pneumoniae may lead to septicemia of the newborn infant. A review of the reported cases reveals striking similarities with the symptoms and prognosis of early-onset group B streptococcal sepsis. Further investigation is required to understand the epidemiology of pneumococcal infections in newborns and to identify those women whose babies are at high risk of early-onset pneumococcal sepsis.
REFERENCES I . Klein JO. The epidemiology of pneumococcal disease in infants and children. Rev Infect Dis 3: 246-253, 1981. 2. Adhami Z, Stack TA. Pneumococcal septicaemia in newly born babies. J Hosp Infect 4: 301-303, 1983. 3. Anonymous. Etudes des septickmies et meningites neonatales (1/9/1986-26/02/1989). National Institute of Hygiene and Epidemiology, Brussels, 1989. 4. Bortolussi R, Thompson TR, Ferrieri P. Early-onset pneumococcal sepsis in newborn infants. Pediatrics 60: 352-355, 1977. 5. Rhodes PG, Burry VF, Hall RT, Cox R. Pneumococcal septicemia and meningitis in the neonate. J Pediatr 86: 593-595, 1975. 6. Moriartey RR, Finer NN. Pneumococcal sepsis and pneumonia in the neonate. Am J Dis Child 133: 601-602, 1979. 7. Lopez de Heredia J, Cotero A, Castro C, Jaquotot R, Gutierrez C. lnfeccion neonatal precoz por pneumococo. An Esp Pediatr 14: 41 6-420, 198 1. 8. Bergqvist G, Trovik M. Neonatal infections with Streptococcus pneumoniae. Scand J Infect Dis 17: 33-35, 1985. 9. Franciosi RA. Knostman JD, Zimmerman RA. Group B streptococcal neonatal and infant infections. J Pediatr 82: 707-718, 1973. 10. Dillon HC, Gray E, Pass MA. Anorectal and vaginal carriage of group B streptococci during pregnancy. J Infect Dis 145: 794-799, 1982. 11. McCarthy VP, Cho CT. Endometritis and neonatal sepsis due to Streptococcus pneumoniae. Obstet Gynecol 53, Suppl: S47-S49, 1979. 12. Peter G, Singer DB. Respiratory distress and shock in a term neonate. J Pediatr 96: 946-949, 1980. 13. Hayes A, OBrien NG. Pneumococcal infection in the newborn-2 case reports. Ir Med J 73: 168-169, 1980. 14. Tarpay MM, Turbeville DF, Kraus HF. Streptococcus pneumoniae type 111 sepsis in mother and infant. Am J Obstet Gynecol 136: 257, 1980. 15. Hutchinson CPT, Kenney A, Eykyn S. Maternal and neonatal death due to pneumococcal infection. Obstet Gynecol 63: 130-131, 1984.
Scand J Infect Dis Downloaded from informahealthcare.com by UB der LMU Muenchen on 03/08/13 For personal use only.
Scand J Infect Dis 22 (1990)
Pneumococcal sepsis in neonates
16. Wilkins EGL, Manning G. Pneumococcal septicaemia in newly born babies. J Hosp Infect 5: 334-335, 1984. 17. Naylor JC, Wagner KR. Neonatal sepsis due to Streptococcus pneumoniae. Can Med Assoc J 133: 1019-1 020, 1985. 18. Weintraub MI, Otto RN. Pneumococcal meningitis and endophthalmitis in a newborn. JAMA 219: 1763-1 764, 1972. 19. Tempest B. Pneumococcal meningitis in mother and neonate. Pediatrics 53: 759-760, 1974. 20. Scanlon JW. Fatal pneumonia presenting as transient neonatal tachypnea. Clin Pediatr 13: 73-74, 1974. 21. Guzzardo MB, Marye E, Hacher BM, Walker G. Neonatal pneumococcal pneumonia. J Med Assoc Ga 77: 313-315, 1988. 22. Harrison GA. Pneumococcal infection in the newborn. J Hosp Infect 7: 98-99, 1986. 23. Mehtar S, Drabu YJ, Vijeratnam S, Mayet F. Cross infection with Streptococcus pneumoniae through a Resuscitaire. Br Med J 292: 25-26, 1986. 24. Beargie R, Priscilla L, Ticker E, Duhring J. Perinatal infection and vaginal flora. Am J Obstet Gynecol 122: 31-38, 1975. 25. Duff P, Gibbs RS. Acute intraamniotic infection due to Streptococcus pneumoniae. Obstet Gynecol61, SUPPI:25S-27S, 1983. 26. Boyer KM, Gadzalo CA, Burd LI, Fisher DE, Paton JB. Selective intrapartum chemoprophylaxis of neonatal group B streptococcal early-onset disease. I . Epidemiologic rationale. J Infect Dis 148: 795-801, 1983. 27. Handdrick W, Spencher FB, Vogtmann C , Gotze J. Perinatale Infektionen durch seltene Erreger. 4. Pneumokokken. Padiatr Grenzgeb 21: 141-144, 1982. 28. Shanks G, Turnige J, Marshall P, McDonald P. Pneumococcal sepsis in a neonate. Aust NZ J Med 12: 185-186. 1982.
497
CASE REPORT
Neonatal Sepsis due to Streptococcus pneumoniae JAN JACOBS,' KRISTIEN GARMYN,' JAN VERHAEGEN,' HUGO DEVLIEGER' and EPHREM EGGERMONT2 From the Departments of 'Bacteriology, University Hospital St Rafael and 'Pediatrics,
Scand J Infect Dis Downloaded from informahealthcare.com by UB der LMU Muenchen on 03/08/13 For personal use only.
University Hospital Gasthuisberg. Leuven, Belgium
A 20-year-old primigravida in the 33rd week of gestation was delivered of a girl weighing 1790 g 23 h after spontaneous rupture of the membranes. 13 h after birth, the child showed signs of shock. Cultures of blood, conjunctiva and nasopharyngeal aspirate grew Streptococcus pneumoniae of serotype 11. Cultures from the mother's cervix and from the placenta and membranes also grew S. pneumoniae of the same serotype. The infant responded well to ampicillin and netilmicin. The early-onset pneumococcal septicemic cases reported over the last 20 years are reviewed. J. Verhaegen, M D , Dept. of Bacteriology, Vniv. Hospital St Rafael, 8-3000 Leuven, Belgium
INTRODUCTION Streptococcus pneumoniae is an important pathogen; it is the most frequently isolated organism in bacteremia in children (1). However, neonatal infections due to this organism are rare (2). We report on an early-onset pneumococcal septicemia with documented carriage of S. pneumoniae in the genital tract of the mother. This case as well as those previously reported show the similarity of symptoms and outcome with group B streptococcal septicemia.
CASE REPORT A 20-year-old primigravida presented at 33 weeks gestation with spontaneous rupture of membranes. Pregnancy had been uneventful. A female infant weighing I790 g was born vaginally, 23 h after rupture of the membranes. Cultures of placenta and membranes were taken immediately after birth, according to the protocol for cases of prolonged rupture of membranes. At birth, the infant was in good condition, with Apgar scores of 9 and 10 after I and 5 min respectively. She received routine prophylaxis (neomycin and virginiamycin drops, Spitalenm) to the eyes. 13 h after birth, the infant suddenly developed apneic spells, became cyanotic and showed signs of shock. At physical examination a purulent conjunctivitis of the left eye was noted. Crepitations were heard over the left lung basis. Laboratory examination showed a ~ WBCII), an absolute neutropenia ( 1 .OX 10' polymorphonuclear cellsil with 10% leukopenia ( 2 . 8 lo9 bands) and a thrombocyte count of 4OOx 109/1. Cultures were taken from the conjunctiva, blood, nasopharyngeal aspirate and CSF. Ampicillin and netilmicin intravenously were given according to the standard procedure for suspected neonatal septicemia. After 24 h the blood cultures (Bactec NR-730, Becton Dickinson, Towson, USA) grew large gram-positive elongated cocci in pairs and short chains. A commercial latex agglutination procedure (Slidex pneumo-Kit, BioMerieux, France) done on the blood culture supernatant, indicated that the organism was S. pneumoniae. At the same time, cultures of the conjuctiva, nasopharyngeal aspirate, placenta and membranes also grew large, alpha-hemolytic colonies in pure culture on horse blood agar, which were identified as S. pneumoniae by their sensitivity to optochin. The CSF culture remained sterile. The latex agglutination procedure performed on the CSF was negative. The infant responded well to therapy, and was discharged in good condition on day 30. A swab, taken from the cervix of the mother, 5 days after delivery, yielded abundant growth of S. pneumoniae. All isolates showed the same sensitivity pattern, with sensitivity to penicillin, erythromycin, doxycycline and chloramphenicol. They all possessed the capsular polysaccharide antigen 1 I . 32 -908554
494
J. Jacobs et al.
Scand J Infect Dis 22 (1990)
Scand J Infect Dis Downloaded from informahealthcare.com by UB der LMU Muenchen on 03/08/13 For personal use only.
DISCUSSION In the last 20 years, there are only a few reports on early-onset neonatal septicemia due to S. pneumoniae. Over a period of 2.5 years, S. pneumoniae was isolated in 5/73 (5.5%) of the neonatal septicemic cases reported to the National Institute of Hygiene and Epidemiology in Belgium (3). Clusters of neonatal pneumococcal sepsis are reported sporadically (4-7). Its incidence accounts for up to 9 %of early-onset neonatal sepsis in one series (7). The previously reported cases over the past 20 years and the cases which occurred in our hospital are tabulated in Table I. The clinical features of early-onset pneumococcal sepsis have striking similarities with early-onset group B streptococcal (GBS) sepsis, including the early onset of circulatory failure and of severe respiratory distress with radiological and histological evidence of hyaline membrane disease (4, 5 , 8 ) . The resulting mortality rate (43 Yo of the reported cases) approaches that of GBS sepsis (40-80%) (9). On the other hand, milder forms exist, as is illustrated by Bergqvist and Trovik (8) and the present case.
Table I. Culture-proven early-onset
(i 72
h) pneumococcal sepsis
RDS = respiratory distress syndrome, HMD = hyaline membrane disease, D = died, S = survived ~~~~~~
~
Sex
F M F F F
M F F M M F F F M -
-
F M M M F F M F
-
F M F F a
Weight (g)
1600 1 300 1 500 2 680 2 780 2 401 2 680 2 950 3 095 2 840 3 300 I588 2 400 2 730 2 760 3 780 I 840 2 100 2 140
-
1750 1200
-
2 300 2 740 1 790 2 600 2 750 2 870
~
Gestational age (weeks)
40 31 32 28 31
36 38 36 38 41 38 40 32 33 36 38 40 34 33 35 35 30 28 37 35 40 33 37 38 36
Time from rupture of membranes to delivery, Age when symptoms started.
Prom" (h)
48 37 72 18 16 11 24 48 14 12 15 10 31
42 6 35 48 17 53 21 39 6 10 4 23 8
-
< 24
Onsetb (h)
72 24 6 < 10 min L
< 10 min 37.5"C) (26).The newborn infant at high risk of early-onset pneumococcal sepsis shares at least the first and the second risk factor: 54% of the infants had a gestational age < 37 weeks and in 58 O/o of the cases a prolonged rupture of fetal membranes was noted. S . pneumoniae fits in the spectrum of the antibiotic regimen for empiric treatment of neonatal septicemia. Once identified as the responsible organism, therapy should be switched to benzylpenicillin.
CONCLUSION This case illustrates the continued sporadic occurrence of pneumococcal early-onset neonatal sepsis. Together with previously reported cases, it strenghtens the observation that colonization of the maternal genital tract by S. pneumoniae may lead to septicemia of the newborn infant. A review of the reported cases reveals striking similarities with the symptoms and prognosis of early-onset group B streptococcal sepsis. Further investigation is required to understand the epidemiology of pneumococcal infections in newborns and to identify those women whose babies are at high risk of early-onset pneumococcal sepsis.
REFERENCES I . Klein JO. The epidemiology of pneumococcal disease in infants and children. Rev Infect Dis 3: 246-253, 1981. 2. Adhami Z, Stack TA. Pneumococcal septicaemia in newly born babies. J Hosp Infect 4: 301-303, 1983. 3. Anonymous. Etudes des septickmies et meningites neonatales (1/9/1986-26/02/1989). National Institute of Hygiene and Epidemiology, Brussels, 1989. 4. Bortolussi R, Thompson TR, Ferrieri P. Early-onset pneumococcal sepsis in newborn infants. Pediatrics 60: 352-355, 1977. 5. Rhodes PG, Burry VF, Hall RT, Cox R. Pneumococcal septicemia and meningitis in the neonate. J Pediatr 86: 593-595, 1975. 6. Moriartey RR, Finer NN. Pneumococcal sepsis and pneumonia in the neonate. Am J Dis Child 133: 601-602, 1979. 7. Lopez de Heredia J, Cotero A, Castro C, Jaquotot R, Gutierrez C. lnfeccion neonatal precoz por pneumococo. An Esp Pediatr 14: 41 6-420, 198 1. 8. Bergqvist G, Trovik M. Neonatal infections with Streptococcus pneumoniae. Scand J Infect Dis 17: 33-35, 1985. 9. Franciosi RA. Knostman JD, Zimmerman RA. Group B streptococcal neonatal and infant infections. J Pediatr 82: 707-718, 1973. 10. Dillon HC, Gray E, Pass MA. Anorectal and vaginal carriage of group B streptococci during pregnancy. J Infect Dis 145: 794-799, 1982. 11. McCarthy VP, Cho CT. Endometritis and neonatal sepsis due to Streptococcus pneumoniae. Obstet Gynecol 53, Suppl: S47-S49, 1979. 12. Peter G, Singer DB. Respiratory distress and shock in a term neonate. J Pediatr 96: 946-949, 1980. 13. Hayes A, OBrien NG. Pneumococcal infection in the newborn-2 case reports. Ir Med J 73: 168-169, 1980. 14. Tarpay MM, Turbeville DF, Kraus HF. Streptococcus pneumoniae type 111 sepsis in mother and infant. Am J Obstet Gynecol 136: 257, 1980. 15. Hutchinson CPT, Kenney A, Eykyn S. Maternal and neonatal death due to pneumococcal infection. Obstet Gynecol 63: 130-131, 1984.
Scand J Infect Dis Downloaded from informahealthcare.com by UB der LMU Muenchen on 03/08/13 For personal use only.
Scand J Infect Dis 22 (1990)
Pneumococcal sepsis in neonates
16. Wilkins EGL, Manning G. Pneumococcal septicaemia in newly born babies. J Hosp Infect 5: 334-335, 1984. 17. Naylor JC, Wagner KR. Neonatal sepsis due to Streptococcus pneumoniae. Can Med Assoc J 133: 1019-1 020, 1985. 18. Weintraub MI, Otto RN. Pneumococcal meningitis and endophthalmitis in a newborn. JAMA 219: 1763-1 764, 1972. 19. Tempest B. Pneumococcal meningitis in mother and neonate. Pediatrics 53: 759-760, 1974. 20. Scanlon JW. Fatal pneumonia presenting as transient neonatal tachypnea. Clin Pediatr 13: 73-74, 1974. 21. Guzzardo MB, Marye E, Hacher BM, Walker G. Neonatal pneumococcal pneumonia. J Med Assoc Ga 77: 313-315, 1988. 22. Harrison GA. Pneumococcal infection in the newborn. J Hosp Infect 7: 98-99, 1986. 23. Mehtar S, Drabu YJ, Vijeratnam S, Mayet F. Cross infection with Streptococcus pneumoniae through a Resuscitaire. Br Med J 292: 25-26, 1986. 24. Beargie R, Priscilla L, Ticker E, Duhring J. Perinatal infection and vaginal flora. Am J Obstet Gynecol 122: 31-38, 1975. 25. Duff P, Gibbs RS. Acute intraamniotic infection due to Streptococcus pneumoniae. Obstet Gynecol61, SUPPI:25S-27S, 1983. 26. Boyer KM, Gadzalo CA, Burd LI, Fisher DE, Paton JB. Selective intrapartum chemoprophylaxis of neonatal group B streptococcal early-onset disease. I . Epidemiologic rationale. J Infect Dis 148: 795-801, 1983. 27. Handdrick W, Spencher FB, Vogtmann C , Gotze J. Perinatale Infektionen durch seltene Erreger. 4. Pneumokokken. Padiatr Grenzgeb 21: 141-144, 1982. 28. Shanks G, Turnige J, Marshall P, McDonald P. Pneumococcal sepsis in a neonate. Aust NZ J Med 12: 185-186. 1982.
497
