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Pneumococcal septicaemia in newly born babies
Journal of Hospital Infection (1983) 4, 301-303
SHORT
Pneumococcal
REPORT
septicaemia Zubaida
Adhami
in newly
born
babies
and T. A. Stack
Department of Microbiology and Department of Paediatrics, Dudley Road Hospital, Birmingham B18 7&H
Introduction Infection due to Streptococcus pneumoniae is an important cause of mortality and morbidity, mainly in children and the elderly. The incidence of pneumococcal bacteraemia in children is of increasing concern (McIntyre, Kennedy and Harris, 1983). However, neonatal infection due to this organism is rare. A review over a period of five years has shown that only 13 cases of pneumococcal septicaemia were reported in infants under one month of age 1982). We report the occurrence of (Communicable Disease Report, septicaemia in two newly born babies which occurred here recently, and the possible source of infection. Case 1 The first case was a baby boy born on 4 October 1982 following a normal vaginal delivery at 36.5 weeks, and 17 h after spontaneous rupture of membranes. The baby was in a good condition at birth, and the Apgar score was nine at 1 min and nine at 5 min, but respiratory grunting was noted. He became progressively worse and was transferred to the special care baby unit 2 h after delivery. There he was noted to have central cyanosis, marked respiratory grunting and subcostal and intercostal recession and tachypnoea. Chest X-ray on admission to the unit showed patchy shadowing. He had a white cell count of 4.9 x 109/1 with only 2 per cent polymorphonuclear leucocytes and a low platelet count. Penicillin and gentamicin were given after blood cultures had been taken. Streptococcus pneumoniae sensitive to penicillin, tetracycline and erythromycin and capsular antigen type 39 was isolated from his blood cultures after 48 h incubation. The baby made a good recovery after ten days of intravenous penicillin and seven days of gentamicin. The mother of the baby had no problems during pregnancy other than a mild anaemia. She was apyrexial during labour. Genital swabs taken after 01954701/83/040301+03
C 1983 The Hospital
803.00
301
Infection
Soc~ry
302
2. Adhami
and T. A. Stack
admission, before delivery and three days post partum showed no increase in pus cells on microscopy or Str. pneumoniae on culture. Case 2
A baby girl was born on 9 December 1982, after a normal vaginal delivery at 35 weeks gestation. The mother of the baby had an uneventful pregnancy until her admission. She had a normal delivery following antepartum haemorrhage; and 53.5 h after spontaneous rupture of membranes. She was pyrexial during labour and her white cell count was 20 x lO’/l. The liquor at this time was noted to be offensive but was not cultured. The baby suffered mild birth asphyxia and required intubation and intermittent positive pressure ventilation for 4 min. Her Apgar score was 4 at 1 min and 9 at 5 min. Blood cultures and swabs from nose, throat and cord were taken before starting on intravenous penicillin and gentamicin. All swabs yielded a heavy growth of Str. pneumoniae. Blood cultures grew Str. pneumoniae after 24 h incubation, which subsequently typed as type 39. The strain was sensitive to penicillin, tetracycline and erythromycin. Genital swabs taken from the mother after admission, before delivery and two days post partum while on ampicillin, failed to yield Str. pneumoniae and showed no increase in pus cells on microscopy. The baby made a full recovery and was discharged home five days after delivery. Discussion
Streptococcus pneumoniae is an uncommon cause of infection in newly born babies. The early onset of infection is strongly in favour of intrauterine infection in both cases. The absence of clinical signs and symptoms in the mother of the first baby possibly points to an ascending infection rather than transplacental infection. In the second baby it is possible that the infection was acquired by either route. Neither of the mothers was suffering from of two strains of Str. respiratory infection at the time. The isolation pneumoniae of the same but rather uncommon serotype, within a short period of time suggested a possible connection between the strains. Str. pneumoniae is not part of the normal vaginal flora of pregnant women. In a large study of 1083 high vaginal swabs taken from mothers after admission to hospital prior to delivery, Str. pneumoniae was isolated on only two occasions (Beargic et al., 1975). The failure to isolate the organism from the vagina of both of our mothers does not exclude its presence in small numbers, i.e. less than lo3 colony forming units/ml (cfu). However, there is a possibility that pneumococci were introduced into the vagina after admission to the labour ward. Two other incidents occurred recently that drew our attention to the possible role of upper respiratory flora in the causation of neonatal infection. Streptococcus salivarius was isolated from blood cultures of a newly born baby with congenital pneumonia, shortly after the first case of pneumococcal
Pneumococcal
septicaemia
in newborns
303
septicaemia, and a new policy was adopted in which face masks were no longer used when attending patients in labour ward. However, we did not find it justifiable to screen the labour ward staff, since the carriage of pneumococci in the upper respiratory tract is very common (S-70 per cent of the population) (Mandell, Douglas and Bennett, 1979), and the isolation of pneumococci of similar serotype from other sources would still not establish a causal association. It is difficult to demonstrate outbreaks due to pneumococci, although cross-infection has been reported in South Africa with antibiotic-resistant strains (Appelbaum et al., 1977). The recent increase in orogenital sex may result in changes in the ecology of microbial flora of the lower genital tract and may result in colonization of the vagina with micro-organisms such as SW. pneumoniae and Huemophilus spp. This may subsequently alter the microbial aetiology of neonatal infection. It is only after thorough investigation of suspected patients together with the application of an enrichment technique to detect pneumococci, and the development of a typing system that discriminates between strains of similar capsular type, that a better understanding of the epidemiology of pneumococcal infection will be developed. We would like to thank Mr Paul Cooper, for serotyping the pneumococci.
Cross-Infection
Reference
Laboratory,
Colindale,
References Appelbaum,
P. C., Scragg, J. N., Bowen,
A. J., Bhamjee, A., Hallett, A. F. & Cooper, R. C. to penicillin and chloramphenicol. Lancet 2,
(1977). Streptococcus pneumoniue resistant 995-997. Beargie, R., Lynd,
P., Tucker,
E. & Duhring,
J. (1975).
Perinatal
American Journal of Obstetrics and Gynecology 122, 3 l-33. Communicable Disease Report (1982). Review of Streptococcus
infection
and vaginal
flora.
pneumonia bacteraemia 1975-1979. 4 (13 March). Mandell, G. L., Douglas, R. G. & Bennett, J. E. (1979). Principle and Practice of Infectious Diseases, Vol. 2, 1589. New York: Wiley Medical. McIntyre, P., Kennedy, R. &Harris, F. (1983). Occult pneumococcal bacteraemia and febrile convulsion. British Medical Journal 286, 203-206.
SHORT
Pneumococcal
REPORT
septicaemia Zubaida
Adhami
in newly
born
babies
and T. A. Stack
Department of Microbiology and Department of Paediatrics, Dudley Road Hospital, Birmingham B18 7&H
Introduction Infection due to Streptococcus pneumoniae is an important cause of mortality and morbidity, mainly in children and the elderly. The incidence of pneumococcal bacteraemia in children is of increasing concern (McIntyre, Kennedy and Harris, 1983). However, neonatal infection due to this organism is rare. A review over a period of five years has shown that only 13 cases of pneumococcal septicaemia were reported in infants under one month of age 1982). We report the occurrence of (Communicable Disease Report, septicaemia in two newly born babies which occurred here recently, and the possible source of infection. Case 1 The first case was a baby boy born on 4 October 1982 following a normal vaginal delivery at 36.5 weeks, and 17 h after spontaneous rupture of membranes. The baby was in a good condition at birth, and the Apgar score was nine at 1 min and nine at 5 min, but respiratory grunting was noted. He became progressively worse and was transferred to the special care baby unit 2 h after delivery. There he was noted to have central cyanosis, marked respiratory grunting and subcostal and intercostal recession and tachypnoea. Chest X-ray on admission to the unit showed patchy shadowing. He had a white cell count of 4.9 x 109/1 with only 2 per cent polymorphonuclear leucocytes and a low platelet count. Penicillin and gentamicin were given after blood cultures had been taken. Streptococcus pneumoniae sensitive to penicillin, tetracycline and erythromycin and capsular antigen type 39 was isolated from his blood cultures after 48 h incubation. The baby made a good recovery after ten days of intravenous penicillin and seven days of gentamicin. The mother of the baby had no problems during pregnancy other than a mild anaemia. She was apyrexial during labour. Genital swabs taken after 01954701/83/040301+03
C 1983 The Hospital
803.00
301
Infection
Soc~ry
302
2. Adhami
and T. A. Stack
admission, before delivery and three days post partum showed no increase in pus cells on microscopy or Str. pneumoniae on culture. Case 2
A baby girl was born on 9 December 1982, after a normal vaginal delivery at 35 weeks gestation. The mother of the baby had an uneventful pregnancy until her admission. She had a normal delivery following antepartum haemorrhage; and 53.5 h after spontaneous rupture of membranes. She was pyrexial during labour and her white cell count was 20 x lO’/l. The liquor at this time was noted to be offensive but was not cultured. The baby suffered mild birth asphyxia and required intubation and intermittent positive pressure ventilation for 4 min. Her Apgar score was 4 at 1 min and 9 at 5 min. Blood cultures and swabs from nose, throat and cord were taken before starting on intravenous penicillin and gentamicin. All swabs yielded a heavy growth of Str. pneumoniae. Blood cultures grew Str. pneumoniae after 24 h incubation, which subsequently typed as type 39. The strain was sensitive to penicillin, tetracycline and erythromycin. Genital swabs taken from the mother after admission, before delivery and two days post partum while on ampicillin, failed to yield Str. pneumoniae and showed no increase in pus cells on microscopy. The baby made a full recovery and was discharged home five days after delivery. Discussion
Streptococcus pneumoniae is an uncommon cause of infection in newly born babies. The early onset of infection is strongly in favour of intrauterine infection in both cases. The absence of clinical signs and symptoms in the mother of the first baby possibly points to an ascending infection rather than transplacental infection. In the second baby it is possible that the infection was acquired by either route. Neither of the mothers was suffering from of two strains of Str. respiratory infection at the time. The isolation pneumoniae of the same but rather uncommon serotype, within a short period of time suggested a possible connection between the strains. Str. pneumoniae is not part of the normal vaginal flora of pregnant women. In a large study of 1083 high vaginal swabs taken from mothers after admission to hospital prior to delivery, Str. pneumoniae was isolated on only two occasions (Beargic et al., 1975). The failure to isolate the organism from the vagina of both of our mothers does not exclude its presence in small numbers, i.e. less than lo3 colony forming units/ml (cfu). However, there is a possibility that pneumococci were introduced into the vagina after admission to the labour ward. Two other incidents occurred recently that drew our attention to the possible role of upper respiratory flora in the causation of neonatal infection. Streptococcus salivarius was isolated from blood cultures of a newly born baby with congenital pneumonia, shortly after the first case of pneumococcal
Pneumococcal
septicaemia
in newborns
303
septicaemia, and a new policy was adopted in which face masks were no longer used when attending patients in labour ward. However, we did not find it justifiable to screen the labour ward staff, since the carriage of pneumococci in the upper respiratory tract is very common (S-70 per cent of the population) (Mandell, Douglas and Bennett, 1979), and the isolation of pneumococci of similar serotype from other sources would still not establish a causal association. It is difficult to demonstrate outbreaks due to pneumococci, although cross-infection has been reported in South Africa with antibiotic-resistant strains (Appelbaum et al., 1977). The recent increase in orogenital sex may result in changes in the ecology of microbial flora of the lower genital tract and may result in colonization of the vagina with micro-organisms such as SW. pneumoniae and Huemophilus spp. This may subsequently alter the microbial aetiology of neonatal infection. It is only after thorough investigation of suspected patients together with the application of an enrichment technique to detect pneumococci, and the development of a typing system that discriminates between strains of similar capsular type, that a better understanding of the epidemiology of pneumococcal infection will be developed. We would like to thank Mr Paul Cooper, for serotyping the pneumococci.
Cross-Infection
Reference
Laboratory,
Colindale,
References Appelbaum,
P. C., Scragg, J. N., Bowen,
A. J., Bhamjee, A., Hallett, A. F. & Cooper, R. C. to penicillin and chloramphenicol. Lancet 2,
(1977). Streptococcus pneumoniue resistant 995-997. Beargie, R., Lynd,
P., Tucker,
E. & Duhring,
J. (1975).
Perinatal
American Journal of Obstetrics and Gynecology 122, 3 l-33. Communicable Disease Report (1982). Review of Streptococcus
infection
and vaginal
flora.
pneumonia bacteraemia 1975-1979. 4 (13 March). Mandell, G. L., Douglas, R. G. & Bennett, J. E. (1979). Principle and Practice of Infectious Diseases, Vol. 2, 1589. New York: Wiley Medical. McIntyre, P., Kennedy, R. &Harris, F. (1983). Occult pneumococcal bacteraemia and febrile convulsion. British Medical Journal 286, 203-206.