- •Congenital pneumonia: infection established during fetal life may result from an ascending infection across the chorioamniotic membranes or a hematogenous transplacental route.
- •Early-onset pneumonia: develops within the first week of life and results from perinatal pathogen exposure, either intrauterine or during passage through the birth canal.
- •Late-onset pneumonia (including ventilator-associated pneumonia; VAP): develops after the first week of life from environmental, often nosocomial, pathogen exposure.
2. Neonatal pneumonia risk factors
2.1 Immature innate and adaptive immunity increases neonatal susceptibility to pneumonia
- Saini Y.
- Wilkinson K.J.
- Terrell K.A.
- Burns K.A.
- Livraghi-Butrico A.
- Doerschuk C.M.
- et al.
- Saini Y.
- Wilkinson K.J.
- Terrell K.A.
- Burns K.A.
- Livraghi-Butrico A.
- Doerschuk C.M.
- et al.
2.2 Maternal risk factors for congenital pneumonia
2.3 Perinatal risk factors for early-onset bacterial pneumonia
|Prematurity and low birth weight|
|Low socio-economic status|
|Colonization with a known pathogen (e.g. group B streptococcus)|
|Prolonged rupture of membranes >18 h|
|Galactosemia (increased susceptibility to infections with Gram-negative organisms)|
|Premature rupture of membranes|
2.4 Risk factors for late-onset neonatal pneumonia
3.1 Pathogenesis of congenital and early-onset pneumonia
|Herpes simplex virus|
|Early-onset pneumonia (may also present at birth)|
|Group A streptococcus|
3.2 Pathogenesis of late-onset pneumonia and VAP
|Respiratory synctitial virus|
|Influenza A or B|
3.3 Pneumonia pathophysiology
|If there is underlying pulmonary or cardiac disease, two serial X-rays demonstrating at least one of the following:|
|New or progressive infiltrate|
|If there is no underlying pulmonary or cardiac disease, one definitive imaging test result is acceptable|
|(2) Worsening gas exchange|
| Any of the following:|
Increased oxygen requirement
Increased ventilator demand
|(3) Clinical/laboratory evidence|
| Must have at least three of the following:|
Leukopenia (≤4000 WBC/mm3) or leukocytosis (≥15,000 WBC/mm3) and left shift (≥10% band forms);
New onset of purulent sputum or change in character of sputum, or increased respiratory secretions or increased suctioning requirements;
Apnea, tachypnea, nasal flaring with retractions of the chest wall or nasal flaring with grunting;
Wheezing, rales, or rhonchi;
Bradycardia (<100 beats/min) or tachycardia (>170 beats/min).
- Templeton K.E.
- Scheltinga S.A.
- Beersma M.F.C.
- Kroes A.C.M.
- Claas E.C.J.
5.1 Empiric therapy for congenital or early-onset pneumonia
5.2 Empiric therapy for late-onset pneumonia or VAP
|Potential pathogens||Combination antibiotic therapy|
Methicillin-resistant Staphylococcus aureus
|Anti-pseudomonal cephalosporin (cefepime, ceftazidime)|
Anti-pseudomonal carbapenem (imipenem or meropenem)
β-Lactam/β-lactamase inhibitor (piperacillin–tazobactam)
Anti-pseudomonal fluoroquinolone (ciprofloxacin or levofloxacin)
Aminoglycoside (amikacin, gentamicin, or tobramycin)
Linezolid or vancomycin
5.3 Duration of antibiotic therapy
6. Prevention of VAP
|Meticulous hand hygiene before and after patient contact and handling respiratory equipment.|
|Wear gloves when handling ventilator condensate and other respiratory/oral secretions.|
|Use a new, sterile ETT for each intubation attempt.|
|Ensure that the ETT does not contact environmental surfaces before insertion.|
|Use a sterilized laryngoscope.|
|Have at least two NICU staff members present for ETT re-taping or repositioning.|
|Clear secretions from the posterior oropharynx prior to:|
|Prevent gastric distention.|
|Monitor gastric residuals.|
|Adjust feeding to prevent large residuals and/or distention.|
|Use side-lying position as tolerated.|
|Keep the head of bed elevated 15–30° as tolerated.|
|Use left lateral positioning after feedings, as tolerated.|
|Provide oral care:|
|within 24 h after intubation;|
|every 3–4 h;|
|prior to reintubation as time allows;|
|prior to orogastric tube insertion.|
|Use sterile water, mother's milk, or approved pharmaceutical oral care solution|
|Use a separate suction catheter, connection tubing, and canister for oral and tracheal suction.|
|Drain ventilator condensate away from the patient every 2–4 h and before repositioning.|
|Avoid unnecessary disconnection of the ventilator circuit.|
|Change ventilator equipment when visibly soiled or mechanically malfunctioning.|
|Use heated ventilator circuits.|
- •When considering the diagnosis of neonatal pneumonia, age at disease onset and maternal history can provide valuable clues about the potential pathogen.
- •Neonatal pneumonia is diagnosed based on a combination of clinical, radiographic, and laboratory findings.
- •Suctioned samples of tracheal sputum are usually contaminated with commensal organisms, which can prevent definitive microbiological identification of the pathogen(s). Sputum samples with a predominance of a single bacterial morphotype can help guide initial empiric therapy.
- •Congenital pneumonia is frequently a component of certain TORCH infections, which should be considered, especially in the setting of systemic disease.
- •Hand hygiene and VAP “bundles” are evidence-based approaches to limiting occurrence of late-onset pneumonia.
- •Discovery of biomarkers to identify pneumonia, especially in the setting of prematurity or chronic lung disease, which can make pneumonia harder to identify.
- •Establishing the role of the microbiome and dysbiosis in pneumonia pathogenesis.
- •Characterizing the efficacy of different VAP “bundle” elements.
- •Understanding the long-term morbidities of neonatal pneumonia.
Conflict of interest statement
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