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, 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, MD, Dept. of Bacteriology, Vniv. Hospital St Rafael, 8-3000 Leuven, Belgium

INTRODUCTION

Streptococcus pneumoniae is an important pathogen; it is the most frequently isolated organ- ism 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 leukopenia ( 2 . 8 ~ lo9 WBCII), an absolute neutropenia ( 1 .OX 10' polymorphonuclear cellsil with 10% bands) and a thrombocyte count of 4OOx 109/1. Cultures were taken from the conjunctiva, blood, nasopha- ryngeal 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. pneumo- niae. 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 chloram- phenicol. They all possessed the capsular polysaccharide antigen 1 I .

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494 J. Jacobs et al. Scand J Infect Dis 22 (1990)

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 evi- dence 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 ~~~~~~ ~ ~

Weight Gestational age Prom" Onsetb Sex (g) (weeks) (h) (h) Symptoms/signs

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

- -

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

-

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

- -

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

-

-

-

72 24 6

< 10 min L

< 10 min < 2 30 48

4 18 72

< 1 Soon

1 1

48 8

Immediate

Soon -

L

- Soon Immediate 24

2 2

13 7

0.5 48-72

RDS RDS Apnea, pneumonia HMD, hypotension, cyanosis HMD Apnea, HMD Cyanosis, grunting Apnea, cyanosis Apnea, RDS RDS RDS Pneumonia RDS RDS RDS RDS Apnea, convulsions RDS Apnea RDS RDS RDS RDS RDS RDS RDS RDS RDS, convulsions RDS RDS RDS RDS

a Time from rupture of membranes to delivery, Age when symptoms started.

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Scand J Infect Dis 22 (1990) Pnmumococcal semis in neonates 495

What group B streptococcus concerns, the mother’s anorectal region and vagina have been identified as the reservoir from where colonization of the neonate occurs (10). In our case, several observations point to the possibility of an infection acquired by this route. As in previously described cases, prolonged rupture of membranes and early onset of the symptoms in the newborn infant strongly suggest an ascending infection. The isolation from the placenta, membranes and cervix of the mother of a S. pneumoniae strain belonging to the same (rather uncommon) serotype as the strain isolated from the blood and conjunctiva of the newborn infant confirms this hypothesis. In neonatal pneumococcal sepsis (5, 8, 11-17) and other neonatal pneumococcal infections (5, 8, 18-23), S. pneumoniae has been isolated from the female genital tract. S. pneumoniae, however, is not a common inhabitant of the vaginal flora of pregnant women (24). The possibility of colonization of the genital tract by orogenital sex (20) or by respiratory droplet spread after admission to the labour ward (2,24) has been raised. In addition to this route, 2 other routes of transmission are attributed to the pneumococcus: hematogenous transplacental transmission from the mother and nosocomial transmission.

Other cultures positive Outcome Ref.

CSF, nose Noselcervix mother Trachea, gastric aspirate Urine, tracheahagha mother Gastric aspirate, ear Ear, throathagha mother Stool, throatlvagina mother

Tracheal aspirate

Gastric aspiratelvagina mother CSFlvagina mother CSFhagina mother Mother: Blood, CSF, vagina Gastric aspirate, meconium, ear CSF, ear, gastric aspirate, meconium CSF CSF CSF, nose, conjunctiva CSF Gastric aspirate, skin

Cord, throat, nose Ear, blood, CSFlvagina and uterus mother Vagina mother Vagina and cervix mother

Nasopharynx, umbilical areakervix mother Conjunctivae, nasopharynx/cervix mother, placenta CSF, skin, nasopharynxhagina mother CSF CSF

D D S D D D S S S S D D S D D S S D D S S S S D S S D S S S S S

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496 J. Jacobs et al. Scand J Infect Dis 22 (1990)

The latter route has been described by Mehtar et al. (23), who identified a Resuscitaire as the responsible source of cross-infection between 2 newborn infants resuscitated consecutively. The route of transplacental transmission is illustrated by a case of pneumococcal meningitis in a mother and her newborn infant (1 9). Three other cases are reported, where both mother and infant had simultaneous culture-proven pneumococcal infection (1 1, 14, 15).

The risk factors for early-onset GBS sepsis have been identified as spontaneous preterm onset of labour (<37 weeks), prolonged rupture of membranes (> 18 h), and maternal intrapartum fever (> 37.5"C) (26) . The newborn infant at high risk of early-onset pneumococ- cal 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 coloniza- tion 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.

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