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Life threatening Branhamella catarrhalis pneumonia in young infants
Journal of Infection (199o)
2I, 305-307
CASE REPORTS Life threatening
Branhamella catarrhalis pneumonia young infants
in
C h r i s t o p h e r Dyson,* H e m a n t e e D. P o o n y t h , t M i c h a e l Watkinson, t a n d S t e p h e n J. R o s e t
* Departments of Microbiology and t Child Health, East Birmingham Hospital, Bordesley Green East, Bordesley Green, Birmingham B9 5ST, U.K. Accepted for publication 3 June 199o Summary
Branhamella catarrhalis is a common nasopharyngeal commensal organism but is also a recognised pathogen. Lower respiratory tract infections caused by this organism have been reported in adults but not, to our knowledge, in otherwise healthy infants. Two infants, born prematurely, suffered near fatal pneumonia. Branhamella catarrhalis was the only microbial pathogen isolated in each case. We suggest that initial antibiotic therapy for severe pneumonia in young infants should be tailored to cover B. catarrhalis infection.
Introduction
Branhamella catarrhalis is k n o w n to cause otitis media and sinusitis in children. 1 W e n o w report two cases of near fatal B. catarrhalis p n e u m o n i a in p r e t e r m infants. Both presented with coryzal s y m p t o m s , b u t then had s u d d e n respiratory arrests.
Case I A 7 - w e e k - o l d p r e t e r m b a b y was admitted in N o v e m b e r I989 with a 3 days' history of c o u g h and coryza. H e was born weighing 1"39 kg at 31 weeks gestation, to a m o t h e r who smoked 2o cigarettes a day. H e had not been ventilated and had n e e d e d s u p p l e m e n t a r y oxygen for only 24 h after birth. O n admission he was afebrile, pink in air with slight intercostal recession, had a respiratory rate of 3 5 / m i n and thick nasal secretions. T w o days later he suddenly b e c a m e cyanosed and h y p o t h e r m i c (rectal t e m p e r a t u r e 34"3 °C) with slow shallow respirations and crepitations in both lungs. After obtaining specimens o f blood, urine, C S F and nose and throat swabs for culture, he was started on IV ceftazidime at 25 m g / k g 12 hourly. Chest X - r a y showed right u p p e r lobe consolidation/collapse. H e then became apnoeic and was resuscitated and ventilated. Branhamella catarrhalis from the endotracheal secretions was the only pathogen isolated. T h i s isolate was resistant to ampicillin and was a beta lactamase producer. It was sensitive to erythromycin, cotrimoxazole (and tetracycline). Direct immunofluorescence and cell culture for respiratory viruses were negative. T h e child required ventilation for 5 days, initially in IOO % oxygen, falling to 4o % oxygen or less after 1o h. H e became hyponatraemic (serum sodium o163-4453/9o/o6o3o5+o3$02.00/0
© I99O T h e British Society for the Study of Infection 12-2
306
c. D Y S O N E T A L .
I I7 mmol/1) because of inappropriate antidiuretic hormone secretion. After extubation he progressed uneventfully, and was ready for discharge 48 h later. 4 weeks later, he had no further respiratory problems and his chest X-ray was clear. Case z
In December I989, a 4-week-old preterm baby was brought to hospital by his parents with a 2o h history of poor feeding, coryza and cough. He had been born at 35 weeks gestation, with a birthweight of 2"3 kg, to a mother who smoked eight cigarettes/day. He had been discharge 6 days after feeding had been established. On admission he was cyanosed, hypothermic (rectal temperature 34"6 °C) and had a respiratory arrest within minutes of arrival. He was resuscitated and ventilated in i o o % oxygen. After microbiological cultures had been taken IV ampicillin (4o m g / k g 6 hourly) and gentamicin (2"5 m g / k g 8 hourly) were started. Widespread crepitations were heard and chest X-ray showed right middle and lower lobe consolidation. Copious endotracheal secretions were aspirated, from which there was a pure growth of B. catarrhalis, sensitive to penicillin, ampicillin, erythromycin, cefotaxime and gentamicin. No other viral or bacterial pathogens were isolated. He was ventilated for 24 h then nursed in headbox oxygen. T h e r e was no hyponatraemia. He was discharged 6 days later and has remained well since. Discussion
Branhamella catarrhalis is a recognised cause of pneumonia in adultsfl Pneumonia caused by this organism has been reported in children undergoing intensive care s and in infants with underlying lung disease. ~ These two case reports describe life threatening pneumonia in otherwise healthy infants who had been born prematurely. Several features were common to both case histories. T h e r e was sudden collapse and hypothermia following an initially mild respiratory illness, a requirement for intubation and subsequent production of copious secretions. In both cases, B. catarrhalis was the only pathogen isolated. T h e rate of isolation of B. catarrhalis from patients with bronchopulmonary infection seems to be increasing. This trend is partly due to an increased awareness by microbiologists of its pathogenicity but selective antibiotic pressure, resulting from the extensive use of ampicillin and trimethoprim to which B. catarrhalis is frequently resistant, may have contributed to a genuine increase in its prevalence) T h e opportunistic nature of some B. catarrhalis infections is well recognised. 6 Neither of these preterm infants had reached his expected data of delivery and in such babies immunoglobulin levels are known to be lower than in term babies. An association between B. catarrhalis and immunoglobulin deficiency has been reported. 7 About 7o % of strains of B. catarrhalis produce beta lactamase and this proportion is increasing. Selective antibiotic pressure associated with extensive use of ampicillin may be the cause of this t r e n d ) T h e organism remains sensitive to erythromycin, angmentin and second- and third-generation
B. C a t a r r h a l i s p n e u m o n i a in infants
307
c e p h a l o s p o r i n s . T h e i m p o r t a n t t h e r a p e u t i c i m p l i c a t i o n is t h a t the initial a n t i b i o t i c t r e a t m e n t u s e d in cases o f severe p n e u m o n i a in y o u n g i n f a n t s s h o u l d i n c l u d e an a g e n t active a g a i n s t B . catarrhalis.
References I. Bluestone CD. Otitis media and sinusitis in children : role ofBranhamella catarrhalis. Drugs 3I: Suppl. 3: 132-141. 2. Capewell S, McLeod DT, Croughan MJ, Ahmad F, Calder MA, Seaton A. Pneumonia due to Branhamella catarrhalis. Thorax 1988; 43: 929-93o. 3- Cook PP, Hecht DW, Snydman DR. Nosocomial Branhamella catarrhalis in a paediatric intensive care unit: risk factors for disease. J Hosp Infect 1989; 13: 299-3o8. 4. Berg RA, Bartley DL. Pneumonia associated with Branhamella eatarrhalis in infants. Pediatr Infect Dis J 1987; 6: 569-573. 5. McLeod DT, Ahmad F, Capewell S, Croughan MJ, Calder MA, Seaton A. Increase in bronchopulmonary infection due to Branhamella catarrhalis. Br Med J 1986; 292: I I 0 3 - - I IO 5.
6. Leading Article. Branhamella catarrhalis: pathogen or opportunist? Lancet 1982; i: IO56. 7. Diamond LA, Lorber B. Branhamella catarrhalis pneumonia and immunoglobutin abnormalities: a new association. Am Rev Respir Dis 1984; 129: 876-878.
2I, 305-307
CASE REPORTS Life threatening
Branhamella catarrhalis pneumonia young infants
in
C h r i s t o p h e r Dyson,* H e m a n t e e D. P o o n y t h , t M i c h a e l Watkinson, t a n d S t e p h e n J. R o s e t
* Departments of Microbiology and t Child Health, East Birmingham Hospital, Bordesley Green East, Bordesley Green, Birmingham B9 5ST, U.K. Accepted for publication 3 June 199o Summary
Branhamella catarrhalis is a common nasopharyngeal commensal organism but is also a recognised pathogen. Lower respiratory tract infections caused by this organism have been reported in adults but not, to our knowledge, in otherwise healthy infants. Two infants, born prematurely, suffered near fatal pneumonia. Branhamella catarrhalis was the only microbial pathogen isolated in each case. We suggest that initial antibiotic therapy for severe pneumonia in young infants should be tailored to cover B. catarrhalis infection.
Introduction
Branhamella catarrhalis is k n o w n to cause otitis media and sinusitis in children. 1 W e n o w report two cases of near fatal B. catarrhalis p n e u m o n i a in p r e t e r m infants. Both presented with coryzal s y m p t o m s , b u t then had s u d d e n respiratory arrests.
Case I A 7 - w e e k - o l d p r e t e r m b a b y was admitted in N o v e m b e r I989 with a 3 days' history of c o u g h and coryza. H e was born weighing 1"39 kg at 31 weeks gestation, to a m o t h e r who smoked 2o cigarettes a day. H e had not been ventilated and had n e e d e d s u p p l e m e n t a r y oxygen for only 24 h after birth. O n admission he was afebrile, pink in air with slight intercostal recession, had a respiratory rate of 3 5 / m i n and thick nasal secretions. T w o days later he suddenly b e c a m e cyanosed and h y p o t h e r m i c (rectal t e m p e r a t u r e 34"3 °C) with slow shallow respirations and crepitations in both lungs. After obtaining specimens o f blood, urine, C S F and nose and throat swabs for culture, he was started on IV ceftazidime at 25 m g / k g 12 hourly. Chest X - r a y showed right u p p e r lobe consolidation/collapse. H e then became apnoeic and was resuscitated and ventilated. Branhamella catarrhalis from the endotracheal secretions was the only pathogen isolated. T h i s isolate was resistant to ampicillin and was a beta lactamase producer. It was sensitive to erythromycin, cotrimoxazole (and tetracycline). Direct immunofluorescence and cell culture for respiratory viruses were negative. T h e child required ventilation for 5 days, initially in IOO % oxygen, falling to 4o % oxygen or less after 1o h. H e became hyponatraemic (serum sodium o163-4453/9o/o6o3o5+o3$02.00/0
© I99O T h e British Society for the Study of Infection 12-2
306
c. D Y S O N E T A L .
I I7 mmol/1) because of inappropriate antidiuretic hormone secretion. After extubation he progressed uneventfully, and was ready for discharge 48 h later. 4 weeks later, he had no further respiratory problems and his chest X-ray was clear. Case z
In December I989, a 4-week-old preterm baby was brought to hospital by his parents with a 2o h history of poor feeding, coryza and cough. He had been born at 35 weeks gestation, with a birthweight of 2"3 kg, to a mother who smoked eight cigarettes/day. He had been discharge 6 days after feeding had been established. On admission he was cyanosed, hypothermic (rectal temperature 34"6 °C) and had a respiratory arrest within minutes of arrival. He was resuscitated and ventilated in i o o % oxygen. After microbiological cultures had been taken IV ampicillin (4o m g / k g 6 hourly) and gentamicin (2"5 m g / k g 8 hourly) were started. Widespread crepitations were heard and chest X-ray showed right middle and lower lobe consolidation. Copious endotracheal secretions were aspirated, from which there was a pure growth of B. catarrhalis, sensitive to penicillin, ampicillin, erythromycin, cefotaxime and gentamicin. No other viral or bacterial pathogens were isolated. He was ventilated for 24 h then nursed in headbox oxygen. T h e r e was no hyponatraemia. He was discharged 6 days later and has remained well since. Discussion
Branhamella catarrhalis is a recognised cause of pneumonia in adultsfl Pneumonia caused by this organism has been reported in children undergoing intensive care s and in infants with underlying lung disease. ~ These two case reports describe life threatening pneumonia in otherwise healthy infants who had been born prematurely. Several features were common to both case histories. T h e r e was sudden collapse and hypothermia following an initially mild respiratory illness, a requirement for intubation and subsequent production of copious secretions. In both cases, B. catarrhalis was the only pathogen isolated. T h e rate of isolation of B. catarrhalis from patients with bronchopulmonary infection seems to be increasing. This trend is partly due to an increased awareness by microbiologists of its pathogenicity but selective antibiotic pressure, resulting from the extensive use of ampicillin and trimethoprim to which B. catarrhalis is frequently resistant, may have contributed to a genuine increase in its prevalence) T h e opportunistic nature of some B. catarrhalis infections is well recognised. 6 Neither of these preterm infants had reached his expected data of delivery and in such babies immunoglobulin levels are known to be lower than in term babies. An association between B. catarrhalis and immunoglobulin deficiency has been reported. 7 About 7o % of strains of B. catarrhalis produce beta lactamase and this proportion is increasing. Selective antibiotic pressure associated with extensive use of ampicillin may be the cause of this t r e n d ) T h e organism remains sensitive to erythromycin, angmentin and second- and third-generation
B. C a t a r r h a l i s p n e u m o n i a in infants
307
c e p h a l o s p o r i n s . T h e i m p o r t a n t t h e r a p e u t i c i m p l i c a t i o n is t h a t the initial a n t i b i o t i c t r e a t m e n t u s e d in cases o f severe p n e u m o n i a in y o u n g i n f a n t s s h o u l d i n c l u d e an a g e n t active a g a i n s t B . catarrhalis.
References I. Bluestone CD. Otitis media and sinusitis in children : role ofBranhamella catarrhalis. Drugs 3I: Suppl. 3: 132-141. 2. Capewell S, McLeod DT, Croughan MJ, Ahmad F, Calder MA, Seaton A. Pneumonia due to Branhamella catarrhalis. Thorax 1988; 43: 929-93o. 3- Cook PP, Hecht DW, Snydman DR. Nosocomial Branhamella catarrhalis in a paediatric intensive care unit: risk factors for disease. J Hosp Infect 1989; 13: 299-3o8. 4. Berg RA, Bartley DL. Pneumonia associated with Branhamella eatarrhalis in infants. Pediatr Infect Dis J 1987; 6: 569-573. 5. McLeod DT, Ahmad F, Capewell S, Croughan MJ, Calder MA, Seaton A. Increase in bronchopulmonary infection due to Branhamella catarrhalis. Br Med J 1986; 292: I I 0 3 - - I IO 5.
6. Leading Article. Branhamella catarrhalis: pathogen or opportunist? Lancet 1982; i: IO56. 7. Diamond LA, Lorber B. Branhamella catarrhalis pneumonia and immunoglobutin abnormalities: a new association. Am Rev Respir Dis 1984; 129: 876-878.