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|Year : 2013 | Volume
| Issue : 2 | Page : 187--189
Neonatal listeriosis followed by nosocomial infection
M Dinic1, S Stankovic2,
1 Institute for Public Health Nis, Bul dr Zorana Djindjica 50, Nis, Serbia
2 Intensive Care Unit, Clinic of Children's Internal Disease, Clinical Center of Nis, Bul dr Zorana Djindjica 48, Nis, Serbia
Institute for Public Health Nis, Bul dr Zorana Djindjica 50, Nis
Neonatal listeriosis is widely reported, but this is the first case reported in Serbia. A newborn developed respiratory distress syndrome 2 hours after delivery and was admitted to the neonatal intensive care unit. Initial empirical therapy was inappropriate. Consequently, on the second day, the patient developed meningitis. Listeria monocytogenes was isolated from the tracheal aspirate, blood, periumbilical swab, and cerebrospinal fluid. After bacteriology results, the therapy was changed to ampicillin and meropenem. On day 11 of hospitalization, the patient developed nosocomial infection due to multidrug-resistant Stenotrophomonas maltophilia. Since therapeutic options were limited, the patient was treated with ciprofloxacin. After 26 days of hospitalization the patient showed complete recovery and was discharged with no apparent sequelae. This case showed the importance of bacteriological examination in cases of infections caused by uncommon organisms. Pediatricians should be aware of the neonatal infection caused by Stenotrophomonas maltophilia.
|How to cite this article:|
Dinic M, Stankovic S. Neonatal listeriosis followed by nosocomial infection.Indian J Med Microbiol 2013;31:187-189
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Dinic M, Stankovic S. Neonatal listeriosis followed by nosocomial infection. Indian J Med Microbiol [serial online] 2013 [cited 2020 Sep 27 ];31:187-189
Available from: http://www.ijmm.org/text.asp?2013/31/2/187/115229
Neonatal listeriosis is an uncommon infection, nevertheless reported in Western countries. The disease manifests in one of two forms: Early-onset form, usually acquired in utero; and late-onset form, occurring 1-3 weeks after birth.  Inappropriate initial therapy can lead to severe illness and could be associated with the development of nosocomial infection. Listeriosis in Serbia is under-reported. To our knowledge, this was the first report of early-onset neonatal listeriosis in Serbia, followed by nosocomial infection caused by multidrug-resistant Gram-negative bacilli.
A 2.35-kg female baby was vaginally delivered at the gestational age of 36 weeks. The amniotic fluid was meconium stained and Apgar score was 8 at the first minute. Her mother did not report any symptoms of infection during pregnancy. Within the first 2 hours after birth, the newborn developed respiratory distress and was immediately admitted to the neonatal intensive care unit (NICU). On admission, she was pale, hypotonic with poor activity, afebrile, with respiratory and heart rate 68 and 200/minute, respectively. The initial laboratory study revealed white blood cell (WBC) count 118000/mm 3 (38% polymorphonuclear leukocytes, 54% lymphocytes), C-reactive protein (CRP) 86.9 mg/dl, whereas serum electrolytes and liver function tests were normal. Blood-gas analysis revealed mild acidosis. Tracheal secretion, blood and periumbilical swab were taken for culture. Nasal continuous positive airway pressure (CPAP) was started. The patient was empirically treated with ceftriaxone (50 mg/kg/day) and amikacin (15 mg/kg/day). On the second day of life she developed generalized cutaneous rash and fever (rectal temperature of 38.7°C). Neurological examination revealed hypertonicity and convulsions. On the same day laboratory studies showed a WBC count 9100/mm 3 with 85.3% polymorphonuclear leukocytes, 59000/mm 3 platelets, CRP 179 mg/dl, procalcitonin level >100 ng/ml, hypocalcemia, and hypomagnesemia. A very small quantity of cerebrospinal fluid (CSF) was obtained via lumbar puncture and, consequently, sent only to the laboratory for microbiological investigation. The Gram-stained smear of the CSF and bacterial latex agglutination antigen test for antigens of most common bacterial meningitis agents were negative. On the fourth day, cultures from CSF, blood, tracheal secretion, and periumbilical swab were positive for Gram-positive bacilli identified as Listeria monocytogenes (L. monocytogenes) by Vitek 2 System (BioMerieux, France). The isolate was susceptible to penicillin (MIC = 0.38 mg/l), ampicillin (MIC = 0.75 mg/l), gentamicin (MIC = 0.19 mg/l), and meropenem (MIC = 0.064 mg/l). Based on culture result, the antibiotic treatment was changed to ampicillin (150 mg/kg/day). Cervical and high vaginal swabs from the mother were taken for culture, but L. monocytogenes was not isolated. In the next 2 days clinical improvement was observed, and CPAP was discontinued. However, platelet count was still low (24000/mm 3 ) and based on this result, on the seventh day, meropenem (3 × 40 mg/kg/day) was added. On the ninth day, ampicillin was temporarily unavailable in our hospital and therapy continued with meropenem. On the 11 th day her clinical condition deteriorated. She developed mild respiratory distress and laboratory studies showed severe trombocytopenia (6.000/mm 3 ), anemia, and CRP 201 mg/dl. Platelets and erythrocytes were transfused and the antibiotic treatment was empirically changed to a chloramphenicol (2 × 25 mg/kg/day). Blood, CSF, and tracheal aspirate were obtained for culture. Gram stain from aspirate revealed polymorphonuclear leucocytes and Gram-negative bacilli. Over the next few days she was clinically stable but without significant improvement. On the 16 th day, laboratory studies revealed CRP 92.37 mg/dl, platelet count increased to 142000 mm 3 . CSF culture was sterile. Cultures from tracheal aspirate and blood yielded Stenotrophomonas maltophilia (S. maltophilia) and Klebsiella pneumoniae (K. pneumoniae) ESBL-positive, respectively, and both strains were susceptible to ciprofloxacin. Antibiotic treatment was changed again to i.v. ciprofloxacin (2 × 10 mg/kg/day). She responded well to the therapy and showed clinical and laboratory improvement. Neurological examination, cranial ultrasonography brain echogram, and electroencephalogram were normal. She showed complete recovery and was discharged after 26 days of hospitalization.
Listeriosis is an uncommon infection among neonates, but still reported in Western countries. Smith et al., reported 21 cases of neonatal listeriosis in Denmark for the period of 11 years. Maternal illness is usually mild, while newborns develop a severe infection (e.g., pneumonia, septicemia, and meningitis) with high case fatality rate.  Mokta et al., reported case of neonatal listeriosis with fatal outcome. The authors suggested that listeriosis in neonates should be suspected and that prompt appropriate therapy could reduce mortality rate.  In Serbia, listeriosis is not a reportable disease, so that its incidence is underestimated. To our knowledge, there are no published data of neonatal listeriosis in Serbia. In our experience of over 20 years, this was the first case of culture-confirmed neonatal L. monocytogenes infection. Our patient developed respiratory distress syndrome shortly after delivery, suggesting that infection was probably acquired via inhalation of amniotic fluid. Although most common manifestations of the maternal infection are fever and flu-like syndrome, an asymptomatic infection has been reported.  In this case, based on anamnestic data collected from the mother, there were no symptoms of infection during pregnancy. Meconium staining of the amniotic fluid (MASF) in preterm infants could be associated with listeriosis, but Tybulewicz et al., demonstrated that none of the preterm infants with MASF had listeriosis. Authors concluded that meconium stained liquor cannot alone be a marker of significance for listerial infection.  Clinical manifestations of neonatal listeriosis are similar to that caused by group B streptococci and enterobacteria, the most common bacteria causing neonatal infection.  Enterobacteria are the bacteria most commonly recognized as etiologic agents of infection in our clinical ward, which were often resistant to ampicillin and gentamicin. Thus, listeriosis was not suspected. Consequently, in our case initial empirical treatment was inappropriate since L. monocytogenes was resistant to cephalosporins. On the second day, our patient developed signs of meningitis. The diagnosis of listerial infection required isolation of L. monocytogenes and it took some time for organism to be cultured. According to this, the appropriate antibiotic treatment with ampicillin started on the fourth day of hospitalization. Based on the laboratory data obtained in the next few days, meropenem was added. Unfortunately, the treatment with ampicillin was discontinued after the course of 6 days. The patient responded well to therapy, until the 11 th day when her clinical condition deteriorated. We could not distinguish whether the clinical deterioration occurred because of the therapy failure or the nosocomial infection. Although our isolate was susceptible to meropenem, ampicillin was the preferred antimicrobial agent for the treatment of listerial meningitis, with the duration of therapy of 2-3 weeks.  Meropenem is an effective alternative in the cases of L. monocytogenes meningitis. Although some good clinical outcomes in patients treated with meropenem have been reported, meropenem therapy failures were documented. , Another reason for deterioration could have been nosocomial infection. The patients hospitalized in NICUs are at high risk of nosocomial infection. Risk factors that associated with neonatal nosocomial infection are low birth weight, mechanical ventilation, prolonged hospital stay, exposure to antimicrobial agents, and use of intravenous catheters. In neonates receiving broad-spectrum antibiotics, mucous membranes and skin are often colonized by multidrug-resistant organisms. Colonization is often associated with invasive disease, most commonly sepsis and pneumonia, and carbapenems remain the therapy of choice.  Considering that our patient deteriorated during the therapy with meropenem, it was difficult to determine the appropriate empirical antibiotic therapy. We decided to change antibiotic treatment to an old broad-spectrum antibiotic, chloramphenicol, until culture results were available. Gram stain parameters of the tracheal aspirate were suggestive of infection and based on culture results, therapy was changed again, this time to ciprofloxacin. S. maltophilia is a low-virulence organism, intrisically resistant to carbapenems and often mutidrug-resistant that causes nosocomial infections in immunocompromised patients. S. maltophilia infections are usually associated with surgical intervention and administration of long-term broad-spectrum antibiotics, especially carbapenems. To our knowledge, only few cases of S. maltophilia infection in neonates have been reported. , Because of its multiple-resistance, the therapeutic options are limited. Ciprofloxacin is not a recommended treatment in pediatrics patients, but it is often the case that there is no other effective agent available. Nevertheless, the good clinical outcome has been reported in S. maltophilia infected neonates receiving ciprofloxacin. Van den Over et al., reported that therapy with ciprofloxacin was effective in neonates infected with multi-drug resistant Gram-negative bacteria, and severe side effects were not identified during the observation period of 3 years.  Blood culture result yielded a growth of K. pneumoniae that was susceptible to meropenem and become positive after 6 days of incubation. According to this result, the isolate was interpreted as sample contamination.
This case is unusual because of insufficient empirical therapy of infections caused by uncommon and multidrug-resistant organisms. A timely and effective communication between the microbiologist and clinicians should improve clinical outcome of patients in intensive care units and could reduce the development of nosocomial infections.
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