The lungs are the most common site of infection in neonates. Group B streptococcus is the most common cause of lower respiratory infection in newborns. The infection is most likely acquired in utero from a contaminated amniotic environment. Affected infants frequently develop fulminant illness within hours of birth. Other common bacterial pathogens in newborns and infants include Streptococcus pneumoniae and Haemophilus influenzae serotype B. Chlamydial pneumonia usually occurs after 3 weeks of age and is accompanied by conjunctivitis in 50 percent of cases. Infants with bacterial as well as viral pneumonia may present with fussiness, stuffy nose, decreased appetite, abrupt onset of high fever (<39°C), nasal flaring, grunting, retraction, tachypnea, and tachycardia.

Patients with chlamydial pneumonia are usually afebrile and tachypenic and have a prominent cough. Respiratory syncytial virus (RSV), adenovirus, and parainfluenzavirus can also cause pneumonia in otherwise well infants. In addition, infections with Bordetella pertussis may cause paroxysms of cough in an otherwise well-appearing infant. The cough may not be accompanied by characteristic whoop. Pertussis always must be considered in infants who have severe, paroxysmal cough and posttussive vomiting. Because many adults are susceptible to infection with pertussis, such an infection should be ruled out if the caretaker has a persistent cough.

The approach to febrile infants with suspected bacterial pneumonia should include a full evaluation for potential sepsis (blood and urine cultures, chest radiographs, and complete blood count). The blood culture results are typically negative, but obtaining two culture samples instead of one during the initial evaluation may increase the diagnostic yield fourfold. A lumbar puncture should be done if there are no contraindications.

Infants who have fever and pneumonia should be hospitalized and receive parenteral antibiotics against staphylococci and potential gram-negative pathogens. Infants suspected of having chlamydial or B. pertussis pneumonia should receive erythromycin or sulfamethoxazole. Infants who are afebrile with pneumonia may be treated as outpatients when a viral pathogen is suspected. Inability to eat, respiratory distress, and hypoxemia are criteria for hospitalization. Patients observed on an outpatient basis should be seen daily until symptoms are resolving. 2 29

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