Atlas of Pediatric Infectious Diseases A Parthasarathy, Rohit C Agrawal, Ritabrata Kundu, Vijay N Yewale, Jaydeep Choudhury, Abhay K Shah, Digant D Shastri, Dhanya Dharmapalan
INDEX
×
Chapter Notes

Save Clear


Infections in NeonatesSection 1

Section Editors
Rhishikesh Thakre,
Sandeep Kadam,
Contributors
Naveen Bajaj,
Ramesh S Bajaj,
Rajeeb S Chatterjee,
Sandeep S Kadam,
Pradeep Suryawanshi,
Snehal Thakre,
Rhishikesh Thakre
  • 1.1 Superficial Infections
  • 1.2 Systemic Infections
  • 1.3 Congenital Infections
  • 1.4 Miscellaneous
Section Outline
  • 1.1 Superficial Infections
    • • Acute Otitis Media
    • • Bacille Calmette-Guérin Abscess
    • • Breast Abscess
    • • Cellulitis
    • • Conjunctivitis
    • • Gangrene
    • • Impetigo
    • • Neonatal Scabies
    • • Oral Thrush
    • • Pustules
    • • Umbilical Sepsis
  • 1.2 Systemic Infections
    • • Brain Abscess
    • • Necrotizing Enterocolitis
    • • Neonatal Candidiasis
    • • Neonatal Osteomyelitis
    • • Neonatal Meningitis
    • • Pneumonia with Pneumatoceles
    • • Sclerema Neonatorum
    • • Septic Shock
    • • Staphylococcal Scalded Skin Syndrome
  • 1.3 Congenital Infections
    • • Congenital Cytomegalovirus
    • • Congenital HIV
    • • Congenital Rubella Syndrome
    • • Congenital Syphilis
    • • Congenital Toxoplasmosis
    • • Congenital Tuberculosis
    • • Neonatal Chickenpox
    • • Neonatal Tetanus
  • 1.4 Miscellaneous
    • • Hand Washing
    • • Sepsis Screen
Picture
Note
Management
 
1.1 SUPERFICIAL INFECTIONS
3
 
Acute Otitis Media
zoom view
Figure 1.1.1: Acute otitis mediaPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the purulent discharge in the external ear. It may be isolated or part of sepsis syndrome. Irritability, incessant crying, and feeding difficulty may be the only manifestations. Fever may or may not be there (Fig. 1.1.1).
  • Otoscopy is diagnostic. Sepsis workup is required.
  • Analgesics, antipyretics and parenteral antibiotics with hospitalization is necessary.
  • Decongestants and antihistamines do not appear to have efficacy. Instillation of eardrops or oil drops is not required.
 
Bacille Calmette-Guérin Abscess
zoom view
Figure 1.1.2: BCG abscessPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the pus formation at Bacille Calmette-Guérin (BCG) site. There is no er ythema, discharge or local warmth. The newborn is otherwise well and manifests 1–5 months post vaccination (Fig. 1.1.2). At times there may be ulceration and lymphadenopathy.
  • Localized complications—hypersensitivity reactions, abscesses at the injection site, and localized lymphadenopathy are usually self limiting post BCG vaccination.
  • There is no role of drainage, needle aspiration, topical or systemic isoniazid, or systemic erythromycin therapy.
  • Early accelerated and exaggerated BCG response may indicate immune compromised state.
 
Breast Abscess
zoom view
Figure 1.1.3: Breast abscessPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the redness and fullness of the left breast (Fig. 1.1.3). This is usually associated with warmth, local tenderness and fluctuation with no discharge. History of squeezing milk from the nipple is often present.
Incision and drainage, analgesics and antibiotic therapy is required.
4
 
Cellulitis
zoom view
Figure 1.1.4: CellulitisPhoto Courtesy: Ramesh S Bajaj, Aurangabad
Note the bluish blackish discoloration of skin over the back with adjoining erythema, edema and skin induration extending on to neck with patchy areas of ulceration and necrosis (Fig. 1.1.4). Signs of worsening such as increasing redness or swelling or foul-smelling drainage from the affected area warrant surgical consult.
  • Workup should include sepsis screen and blood culture.
  • Broad spectrum antibiotics may be started empirically pending culture reports. Antibiotic should cover streptococci and staphylococci.
 
Conjunctivitis
zoom view
Figure 1.1.5: ConjuncitivisPhoto Courtesy: Sandeep Kadam, Pune
Note the bilateral pur ulent eye discharge with partial ability to open the eyes. This is usually associated with conjunctival congestion. Watery discharge with no conjunctival congestions is seen in dacrocystitis.
Gonococcal conjunctivitis tends to be more severe than any other causes of ophthalmia neonatorum (Fig. 1.1.5).
  • To define the exact etiology, conjunctival scraping for Gram stain, Giemsa stain, culture on chocolate agar and/or Thayer-Martin for N. gonorrhea and culture on blood agar for other bacteria is required.
  • Pending lab results, topical erythromycin ointment and IV or IM third-generation cephalosporin (if gonococcal infection suspected) should be initiated. Treatment may be modified later as per culture results.
  • Thorough eye cleaning with sterile saline swab, each separate for each eye is most important. Eye should be cleaned from medial to lateral side.
 
Gangrene
zoom view
Figure 1.1.6: GangrenePhoto Courtesy: Sandeep Kadam, Pune
Note bluish blackish discoloration of fingers, palms, hands extending up to the elbow. There is overlying induration, hardening and necrosis with clear line of demarcation with healthy skin (Fig. 1.1.6). With underlying severe sepsis embolus, thrombosis and/or coagulopathy predispose to gangrene formation. Arterial thrombosis, emboli, trauma, congenital heart disease, coagulopathy, polycythemia, congenital bands, and birth trauma are some of the causes which should be considered.
  • Sepsis workup, early prompt surgical reference along with prompt IV antibiotics, flow enhancers, (heparin, vasodilators, lomodex, hyper baric oxygen, etc.) blood transfusions, wound cleansing (hydrogen peroxide), local ointments (betadine, soframicin), slough removal (eusol, salutyl ointment) and regular dressings are required.
  • Dry dressing is applied over gangrenous area. Appearance of line of demarcation needs amputation.
5
 
Impetigo
zoom view
Figure 1.1.7: ImpetigoPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note multiple superficial lesions over the chin with adjoining erythema and crust formation (Fig. 1.1.7). It is highly contagious and is primarily caused by Staphylococcus aureus.
  • Treatment involves washing with soap and water and letting the impetigo dry in the air.
  • Mild cases may be treated with bactericidal ointment, such as mupirocin.
  • More severe cases require oral antibiotics, such as amoxicillin or first generation cephalosporin.
 
Neonatal Scabies
zoom view
Figure 1.1.8: Neonatal scabiesPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the macules, papules and vesicles over the foot and the web spaces (Fig. 1.1.8). There is a tendency to form pustules early in the course of illness. Such lesions are also seen over the face, neck, scalp, and palms. Eczematization and impetiginization are common. History of scabies in one of the family member or care taker is often present.
  • Examination of close contacts and a careful history should lead to the correct diagnosis. Microscopic examination of scrapings of the vesicles reveals mites, eggs, and feces.
  • Treatment of the infant and family members with 5% permethrin cream successfully eradicates the infestation.
 
Oral Thrush
zoom view
Figure 1.1.9: Oral thrushPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the whitish, curdy plaques over the tongue, buccal mucosa and the soft palate (Fig. 1.1.9). These lesions bleed on scrapping and cannot be removed easily. The newborn presents with feeding difficulty.
  • Oral thrush is a common fungal infection caused by Candida albicans. The diagnosis is clinical.
  • Oral nystatin suspension is used. Simultaneous treatment of the mother's nipple is must.
  • Recurrent oral thr ush is an indicator of immunocompromised state like HIV
6
 
Pustules
zoom view
Figure 1.1.10: PustulesPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note multiple pustules in the periumbilical area. There is surrounding erythema (Fig. 1.1.10). They may also be present over the trunk, axilla, and g roins. At times, there may be induration, hardening of the adjoining skin with pus discharge. Many a times the newborn is asymptomatic.
  • Few lesions in a healthy term infant may be treated with topical antibiotic and oral therapy.
  • More extensive lesions, systemic illness, or pustulosis occurring in the premature infant requires IV therapy.
  • Most common causative organism is Staphylococcus aureus.
 
Umbilical Sepsis
zoom view
Figure 1.1.11: Umbilical sepsisPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the visible periumbilical erythema and induration. These are suggestive of umbilical sepsis. This is usually associated with local warmth, pus discharge and foul smell (Fig. 1.1.11). There may be nonspecific signs such as fever, irritability, feeding difficulty or respiratory distress. It may remain localized or can quickly progress to sepsis and present as a potentially life threatening condition. Underlying umbilical polyp should be looked for.
  • Diagnosis is made clinically with supportive history and physical examination.
  • Treatment consists of antibiotic therapy (penicillin + aminoglycoside) in addition to supportive care for any complications which might result from the infection itself.
 
1.2 SYSTEMIC INFECTIONS
 
Brain Abscess
zoom view
Figure 1.2.1: Brain abscessPhoto Courtesy: Pradeep Suryawanshi, Pune
Note a single, large space occupying lesion in frontal lobe with surrounding edema with minimal shift of midline with no dilatation of ventricles (Fig. 1.2.1). These arise as a complication of septicemia, meningitis or underlying systemic cause for thrombosis or embolism. Presence of unexplained high fever, lethargy, seizures, focal deficit, worsening sensorium should raise suspicion of brain abscess. Any new born baby with acute pyogenic meningitis who is not responding to routine treatment should be screened for complication like subdural empyema, brain abscess, etc.
  • Sepsis screen, cerebrospinal fluid (CSF) study including culture, blood culture, CT brain or MRI confirm brain abscess.
  • USG/CT guided aspiration, antibiotics (4–8 weeks) and if nonresponsive, surgery may be needed.
  • Abscesses larger than 2.5 cm are excised or aspirated, while those smaller than 2.5 cm or which are at the cerebritis stage are aspirated for diagnostic purposes only.
7
 
Necrotizing Enterocolitis
zoom view
Figure 1.2.2: Necrotizing enterocolitisPhoto Courtesy: Naveen Bajaj, Ludhiana
Note the preterm baby has abdominal distension which is tense with overlying shiny abdominal skin. There are yellowish brown gastrointestinal (GI) aspirates (Fig. 1.2.2). These features suggest necrotizing enterocolitis (NEC). The NEC is primarily a disease process of the GI tract of preterm that results in inflammation and bacterial invasion of the bowel wall.
  • Management includes f luid restriction, gastric decompression, nil by mouth, antibiotics, inotropic support, correction of anemia, thrombocytopenia and acidosis as required.
  • Surgery may be required in some patients.
 
Neonatal Candidiasis
zoom view
Figure 1.2.3: Neonatal candidiasisPhoto Courtesy: Sandeep Kadam, Pune
Note the ashen gray complexion in a sick, preterm baby. A slow evolving infection with risk factors like prolonged antibiotics, ventilation, prolonged ICU stay, total parenteral nutrition (TPN), invasive lines and procedures predispose to Candida infection (Fig. 1.2.3).
Unexplained thrombocytopenia, cholestasis, oliguria, nonresponsive to antibiotics warrants screening for Candida.
  • Fungal infections should be suspected whenever, in the presence of a predisposing host conditions, despite seemingly appropriate antibacterial therapy, the illness continues to have a smoldering and persistent course.
  • Blood culture is diagnostic. Screening for end organ damage is recommended (USG liver, kidney, brain, 2D echo, fundus) once candidiasis is diagnosed.
  • Amphotericin B (4–6 weeks) is drug of choice.
  • Removal of catheter is justified in case of catheter related blood stream infection.
 
Neonatal Osteomyelitis
zoom view
Figure 1.2.4: Neonatal osteomyelitisPhoto Courtesy: Sandeep Kadam, Pune
Note the metaphyseal irregularity, radiolucency, periosteal reaction of proximal end of femur. There is also soft tissue swelling. There may be associated widening of the joint space, subluxation or dislocation (Fig. 1.2.4). Clinical symptoms include poor feeding and/or irritability. There may be a history of swelling or failure to move the affected limb (pseudoparalysis).
  • A high index of suspicion, coupled with careful physical examination, is important for early identification and treatment.
  • Ultrasound allows the detection of subperiosteal collections and joint effusions. Note that a normal ultrasound scan does not exclude osteomyelitis.
  • Surgical debridement or drainage, as required, and antibiotic therapy (4–8 weeks) are the pillars of therapy. Antistaphylococcal coverage is needed.
8
 
Neonatal Meningitis
zoom view
Figure 1.2.5: Neonatal meningitisPhoto Courtesy: Rajeeb Chatterjee, Loni
Note the extensor posturing with retraction of neck. Accompanying features include seizures, temperature instability, episodes of apnea or bradycardia, hypotension, feeding difficulty, tense fontanelle and irritability alternating with lethargy (Fig. 1.2.5). Constellation of these signs should raise suspicion of meningitis.
  • The diagnosis is confirmed on CSF examination (microscopy, chemistry and culture) obtained by lumbar puncture.
  • Management includes appropriate antibiotics (14–21 days), meticulous fluid therapy, supportive care and use of anticonvulsants for seizures. There is no role of steroids or mannitol.
 
Pneumonia with Pneumatoceles
zoom view
Figure 1.2.6: Pneumonia with pneumatocelesPhoto Courtesy: Naveen Bajaj, Ludhiana
Radiograph shows bilateral patchy infiltration of both lung fields more so in the right lung. Multiple air filled cavities of different sizes are seen in the left lower lobe suggestive of pneumatoceles (Fig. 1.2.6). Pneumonia complicated by pneumatocele formation is commonly due to staphylococci, Klebsiella and E. coli.
  • Ensuring adequacy of oxygen, aggressive supportive care, antibiotics (usually cloxacillin, oxacillin or vancomycin with a aminoglycoside) and meticulous clinical monitoring is the key.
  • Respiratory support needs to be anticipated.
  • Rarely surgical intervention is required.
 
Sclerema Neonatorum
zoom view
Figures 1.2.7A and B: Sclerema neonatorumPhoto Courtesy: Rajeeb Chatterjee, Loni
Note the newborn is sick, ventilated with ET in situ, with signs of poor perfusion. The skin appears shiny, taut with fullness of extremities (Fig. 1.2.7A). On pinching the skin there is hardness with inability to lift the skin between fingers due to edema and thickening of subcutaneous tissue suggestive of sclerema (Fig. 1.2.7B). The signs initially appear over the thigh and may progress to mask like facies, diffuse woody to stony hard induration of extremities, with restricted joint mobility, temperature instability and poor respiratory efforts. Onset of sclerema heralds poor prognosis.
  • Aggressive management with resuscitation, strict attention to fluid, electrolyte and acid-base balance, ventilatory support, inotropes and broad spectrum antibiotics is needed.
  • Steroid and exchange transfusion are reserved for refractory cases.
  • The prognosis is guarded.
9
 
Septic Shock
zoom view
Figure 1.2.8: Septic shockPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the dusky palms and soles, with patchy bluish discoloration of both hands and legs. There is associated tachycardia, drowsiness, prolonged capillary refill time (CRT), cold extremities with warm trunk, oliguria and hypotension suggestive of septic shock on clinical examination (Fig. 1.2.8).
  • History and clinical course is suggestive. Confirmation is by blood culture and sepsis screen.
  • Aggressive fluid resuscitation, inotropes, meticulous monitoring of vitals, fluids, electrolytes and sugars is the mainstay of management.
 
Staphylococcal Scalded Skin Syndrome
zoom view
Figure 1.2.9: Staphylococcal scalded skin syndrome (SSSS)Photo Courtesy: Sandeep Kadam, Pune
Note the generalized exfoliation of skin. Manifestations include erythematous, bullous skin lesions over face, back and extremities with peeling of skin on contact (Nikolsky sign) (Fig. 1.2.9). Desquamation subsides by 48 hours of appropriate therapy. Skin lesions heal without scarring. Such exfoliation is most commonly seen due to staphylococcal infection.
  • Diagnosis is clinical with isolation of staphylococci in blood culture or pharyngeal swab or gastric aspirate.
  • Skin culture and skin biopsy is useful.
  • The complications include fluid loss, septic arthritis, cellulitis, pneumonia, sepsis, and osteomyelitis.
  • Adequate hydration, meticulous skin care with antistaphylococcal antibiotics are the main stay of therapy.
 
1.3 CONGENITAL INFECTIONS
 
Congenital Cytomegalovirus
zoom view
Figure 1.3.1: Congenital cytomegalovirusPhoto Courtesy: Sandeep Kadam, Pune
Note the CT brain shows calcification which are along the subependymal ventricular region (Fig. 1.3.1).
Periventricular calcifications with small head are a clinical clue to cytomegalovirus (CMV) infection.
Clinical features include growth retardation, thrombocytopenia, anemia, hepatosplenomegaly, neurological problems such as poor tone and seizures.
  • Diagnosis is confirmed by presence of IgM antibody, IgG with fourfold rising antibody titers, PCR or viral cultures.
  • Maternal testing for CMV is required.
  • Ganciclovir is indicated if there is life threatening or sight threatening CMV infection.
10
 
Congenital HIV
zoom view
Figure 1.3.2: Congenital HIVPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the CT brain study shows discrete calcifications in the basal ganglia. There is no evidence of loss of gray-white matter differentiation or ventricular dilatation. Progressive leukoencephalopathy with atrophy of brain is characteristic of congenital HIV infection (Fig. 1.3.2).
Clinical manifestation includes failure to thrive, hepatosplenomegaly, chronic diarrhea, thrush and recurrent bacterial infections.
  • Confirmation is done by HIV PCR or using two different sets of enzyme-linked immunosorbent assay (ELISA) and/or western blot.
  • Anti-retroviral dr ugs are the mainstay of treatment.
 
Congenital Rubella Syndrome
zoom view
Figure 1.3.3: Congenital rubella syndromePhoto Courtesy: Snehal Thakre, Aurangabad
Note that both eyes are hazy with enlarged cornea. Intraocular pressure is increased suggesting buphthalmos. Presence of microcephaly, congenital heart defect such as PDA, growth retardation, sensorineural hearing loss is hallmark of rubella infection (Fig. 1.3.3).
  • Fourfold rise in IgG antibody titers or positive IgM antibody or isolation of rubella virus is diagnostic.
  • There is no specific treatment.
 
Congenital Syphilis
zoom view
Figure 1.3.4: Congenital SyphilisPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the right upper limb in extended posture with paucity of spontaneous movement suggestive of pseudoparalysis (Fig. 1.3.4). Associated hepatosplenomegaly, epitrochlear lymph node and irritability should raise suspicion of congenital syphilis. Clavicle fracture (swelling or palpable break) or brachial plexus injury (absent grasp) also present with monoparesis.
  • Maternal venereal disease research laboratory (VDRL) status, newborn VDRL testing or specific antitreponemal antibody is diagnostic. X-ray changes are suggestive.
  • Treatment involves penicillin with simultaneous screening/treatment of parents.
  • Long-term follow-up is mandatory.
11
 
Congenital Toxoplasmosis
zoom view
Figure 1.3.5: Congenital toxoplasmosisPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the CT brain showing evidence of diffuse calcification in the periventricular region and adjacent brain parenchyma (Fig. 1.3.5). Congenital toxoplasmosis is more likely with diffuse calcification and large head. Associated features include hydrocephalus, chorioretinitis, convulsions, hepatosplenomegaly, anemia and rash.
  • A double sandwich IgM EIA and IgM immunosorbent would help in diagnosis.
  • Agglutination assay (ISAGA) is more specific than commercial IgM EIAs.
  • IgG avidity is now the standard “confirmatory” test.
  • Treatment includes pyrimethamine (1 mg/kg orally daily), sulphadiazine (50 mg/kg orally, twice daily) and folinic acid (1 ml/kg, orally twice weekly).
 
Congenital Tuberculosis
zoom view
Figure 1.3.6: Congenital tuberculosisPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the chest X-ray shows diffuse miliary shadows all over the lung fields (Fig. 1.3.6). Clinically respiratory distress with hepatosplenomegaly should raise suspicion of congenital tuberculosis.
  • History of contact, documentation of primary lesion in the placenta or liver confirms the diagnosis.
  • Anti-tubercular treatment is the main stay of treatment. Immunocompromised state should be ruled out.
 
Neonatal Chickenpox
zoom view
Figure 1.3.7: Neonatal chickenpoxPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Note the erythematous rash on face and trunk. The rash assumes vesicular form on red base and spread over trunk and limbs. There is evidence of cr usting in some lesions with pleomorphism which is diagnostic of chickenpox (Fig. 1.3.7).
  • Treatment with varicella zoster immunoglobulin (VZIg) is indicated prophylactically in preterm, newborn born to mother with chickenpox 5 days before or 2 days after delivery.
  • If VZIg not available or affordable IV Ig can be used.
  • Acyclovir is indicated with clinical manifestation.
12
 
Neonatal Tetanus
zoom view
Figure 1.3.8: Neonatal tetanusPhoto Courtesy: Sandeep Kadam, Pune
Note the neonate has retracted neck (retrocollis) and complete arching of the back (opisthotonus). There is associated mask like facies with inability to open mouth (trismus). Opisthotonus and stimulus induced spasms with intact sensorium is hallmark of tetanus (Fig. 1.3.8).
Treatment is essentially supportive, minimal stimulation, sedatives, muscle relaxants, anticonvulsants, penicillin and tetanus immunoglobulin.
 
1.4 MISCELLANEOUS
 
Hand Washing
zoom view
Figure 1.4.1: Hand washingPhoto Courtesy: Rhishikesh Thakre, Aurangabad
The picture depicts cleaning of the hands with the use of water and soap under an elbow operated tap. Hand washing involves systematic hand motions in six steps to done before entering the nursery (2 min) and after each contact with the patient (Fig. 1.4.1). The purpose is to remove soil, dirt, and/or microorganisms from hand surfaces. Center for Disease Control (CDC) recommends it as one of the most important measures for preventing the spread of pathogens.
  • Use of alcohol based hand rub is not a substitute for hand washing.
  • Medicated hand rubs are indicated only in epidemic situations.
  • Hand drying may be done by sterile cloth or hand dryers.
 
Sepsis Screen
zoom view
Figure 1.4.2: Sepsis screenPhoto Courtesy: Rhishikesh Thakre, Aurangabad
Picture depicts commonly used kits for screening for neonatal infection– EDTA (For CBC, ANC, I:T ratio, platelet count), micro tubes (uESR), plain bulb (CRP) or qualitative CRP kit and blood culture broth (Fig. 1.4.2).
  • The utility of sepsis screen is more in “ruling out” sepsis than “ruling in” sepsis.
  • Blood culture is considered to be the gold standard for confirming the diagnosis of sepsis.
  • For maximum utility, interpret taking into consideration the clinical course, risk factors and results of sepsis screen.
  • Adequate blood volume, proper storage and transport of the sample will improve the yield of blood culture.