Congenital Pneumonia Medication: Antibiotics, Antivirals

Medication Summary

The frequency of bacterial infection as the primary cause or as a superimposed complication of pulmonary inflammation in general, and congenital pneumonia in particular, usually mandates antibiotic administration as the cornerstone of therapy.

Agents typically used initially include a combination of ampicillin and either gentamicin or cefotaxime. The selection of cefotaxime or gentamicin must be based on experience and considerations at each center and in each patient. Combination therapy provides reasonable antimicrobial efficacy against the pathogens that typically cause serious infection in the first days of life.

Other agents or combinations may be appropriate for initial empiric therapy if justified by the range of pathogens and susceptibilities encountered in a particular clinical setting.

Consultation of appropriate neonatal references, such as Neofax, is recommended when using antibiotics in these patients. Similarly, an appropriate reference should be used when using adjunctive therapy such as bronchodilators, mucolytics, nitric oxide, or epoprostenol.

Antibiotics

Class Summary

The frequency of bacterial infection as the cause or a major complication of congenital pneumonia usually mandates antibiotics as a cornerstone of therapy.

Ampicillin

This parenteral agent offers antimicrobial efficacy against many pathogens encountered in infections that occur in the first few days of life, including, but not limited to, group B Streptococcus, many types of other streptococci, L monocytogenes, and some strains of E coli, enterococci, and nontypeable H influenzae.

Cefotaxime (Claforan)

Cefotaxime is a third-generation cephalosporin with gram-negative spectrum. Cefotaxime arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth. When administered parenterally, this agent offers antimicrobial efficacy against many gram-negative pathogens that are commonly encountered in the first few days of life, including E coli, nontypeable H influenzae, Klebsiella species, and other enteric organisms. Cefotaxime crosses the blood-brain barrier into the CNS reasonably well and theoretically poses less risk of renal toxicity or ototoxicity than gentamicin and other aminoglycosides, which are the common alternatives. It is less likely than gentamicin to interfere with function of neuromuscular junction in infants born to mothers with myasthenia gravis.

However, compared with gentamicin, cefotaxime is more costly, is associated with much more rapid emergence of resistant organisms in a closed environment (eg, NICU), covers a slightly narrower range of gram-negative organisms, and has not been demonstrated to yield superior outcomes in a randomized controlled trial of neonatal patients.

Gentamicin

Gentamicin is an aminoglycoside antibiotic used for gram-negative coverage. Gentamicin is typically used in combination with agents against gram-positive organisms. When administered parenterally, this agent offers antimicrobial efficacy against many gram-negative pathogens commonly encountered in the first few days of life, including E coli, Klebsiella species, and other enteric organisms, as well as many strains of nontypeable H influenzae. It is also variably effective against some strains of certain gram-positive organisms, including S aureus, enterococci, and L monocytogenes.

Gentamicin crosses the blood-brain barrier into the CNS less well and theoretically poses greater risk of renal toxicity or ototoxicity than cefotaxime and other third-generation cephalosporins, which are the common alternatives. Compared with cefotaxime, gentamicin is less costly, is associated with much less rapid emergence of resistant organisms in a closed environment (eg, NICU), and covers a broader range of gram-negative organisms.

Gentamicin has been reported to offer additive or synergistic activity against enterococci when used with ampicillin.

Azithromycin

Empiric use of azithromycin or other macrolides for presumed Ureaplasma infection is not currently evidence based and should be reserved for infants who have that organism recovered from a normally sterile site or who are critically ill and do not have a more likely cause of infection. Azithromycin acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. It concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.

Erythromycin (Ery-Tab, Erythrocin, EryPed, E.E.S.)

Erythromycin is a macrolide antibiotic with a large spectrum of activity. Erythromycin binds to the 50S ribosomal subunit of the bacteria, which inhibits protein synthesis.

Like azithromycin, the use of erythromycin for presumed Ureaplasma infection is not currently evidence based and should be reserved for infants who have that organism recovered from a normally sterile site or who are critically ill and do not have a more likely cause of infection.

Orally administered erythromycin has been associated with the development of infantile hypertrophic pyloric stenosis in infants younger than 1 month.

Antivirals

Class Summary

Antiviral agents interfere with viral replication and weaken or abolish viral activity. An example of an antiviral agent is acyclovir (Zovirax).

Acyclovir (Zovirax)

Acyclovir treatment should be considered when a diagnosis of herpes simplex virus is suspected and when the infant is not responding to antibiotic therapy.



Muhammad Aslam, MD Associate Professor of Pediatrics, University of California, Irvine, School of Medicine; Neonatologist, Division of Newborn Medicine, Department of Pediatrics, UC Irvine Medical Center

Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics

Coauthor(s)

Mariam L Abdul-Latif, MD Neonatal-Perinatal Medicine Fellow, Department of Pediatrics, University of California, Irvine, School of Medicine

Mariam L Abdul-Latif, MD is a member of the following medical societies: American Academy of Pediatrics, Texas Medical Association, Texas Pediatric Society

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Brian S Carter, MD, FAAP Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Attending Physician, Division of Neonatology, Children's Mercy Hospital and Clinics; Faculty, Children's Mercy Bioethics Center

Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Pediatric Society, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Society for Pediatric Research, National Hospice and Palliative Care Organization

Chief Editor

Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Acknowledgements

Roger G Faix, MD Professor, Department of Pediatrics (Neonatology), University of Utah School of Medicine

Roger G Faix, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American Society for Microbiology, National Perinatal Association, Society for Pediatric Research, and Utah Medical Association

Disclosure: Nothing to disclose.

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Anteroposterior chest radiograph in an infant born at 28 weeks' gestation was performed following apnea and profound birth depression. Subtle reticulogranularity and prominent distal air bronchograms were consistent with respiratory distress syndrome, prompting exogenous surfactant and antimicrobial therapy. Initial smear of endotracheal aspirate revealed few neutrophils but numerous, small, gram-negative coccobacilli. Culture of blood and tracheal aspirate yielded florid growth of nontypeable Haemophilus influenzae.

Full-term infant (note ossified proximal humeral epiphyses, consistent with full term) with progressive respiratory distress from birth following delivery to a febrile mother through thick, particulate, meconium-containing fluid and recovery of copious meconium from the trachea. Right clavicle is fractured without displacement. Note the coarse dense infiltrates obscuring the cardiothymic silhouette bilaterally with superimposed prominent air bronchograms. Listeria monocytogeneswas recovered from the initial blood culture.

Patchy infiltrates most prominent along left cardiothymic margin in a full-term infant (note proximal humeral ossific nuclei) born to an afebrile woman 18 hours after membranes ruptured. The infant was initially vigorous but developed gradual onset of progressive respiratory distress beginning at 2 hours and prompting endotracheal intubation and transfer to a tertiary center at age 10 hours. Note blunting of the right costophrenic angle, a thin radiodense rim along the lateral right hemithorax, and a fluid line in the right major fissure, all consistent with pleural effusion. Gram staining of pleural fluid recovered at thoracentesis indicated occasional gram-negative bacilli. Tracheal aspirate, pleural fluid, and blood all yielded Escherichia coliupon culture. The dense right upper lobe may appear to suggest lobar infiltrate, but upward bowing of the fissure is more suggestive of volume loss, as in atelectasis, than the bulging picture expected with dense pneumonic change. This lobe appeared normal and appropriately inflated on a subsequent film 2 hours later, also suggestive of atelectasis. Umbilical venous catheter and endotracheal tube were positioned properly on the follow-up film.