A 6-day-old boy is brought to the office for poor feeding. He rejects the breast or bottle whenever his mother tries to feed him. He sleeps all day and is very difficult to rouse. Two days ago, the neonate was discharged from the nursery, where he received phototherapy for jaundice. He was born at 39 weeks gestation by uncomplicated vaginal delivery. The pregnancy was uncomplicated and prenatal laboratory studies were normal. His family history is not significant. The neonate currently takes no medications. He is febrile and tachycardic. Physical examination shows a lethargic infant with mild generalized jaundice. Lungs are clear to auscultation. Laboratory results are as follows: Urinalysis shows positive leukocyte esterase and 15 white blood cells/hpf. Blood, urine, and cerebrospinal fluid cultures are pending. Which of the following treatment regimens is most appropriate for this patient?

Question

A 6-day-old boy is brought to the office for poor feeding.  He rejects the breast or bottle whenever his mother tries to feed him.  He sleeps all day and is very difficult to rouse.  Two days ago, the neonate was discharged from the nursery, where he received phototherapy for jaundice.  He was born at 39 weeks gestation by uncomplicated vaginal delivery.  The pregnancy was uncomplicated and prenatal laboratory studies were normal.  His family history is not significant.  The neonate currently takes no medications.  He is febrile and tachycardic.  Physical examination shows a lethargic infant with mild generalized jaundice.  Lungs are clear to auscultation.  Laboratory results are as follows:  Urinalysis shows positive leukocyte esterase and 15 white blood cells/hpf.  Blood, urine, and cerebrospinal fluid cultures are pending.  Which of the following treatment regimens is most appropriate for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfc0_1625_8f63_738cd33bf62f_MD0005_00 Newborns are prone to overwhelming bacterial infection due to their immature immune systems. Fever can be the first and only sign of a serious bacterial infection in neonates. Symptoms of urinary tract infection, bacteremia, and meningitis are nonspecific and can include the poor appetite and lassitude seen in this patient. Complete blood count may show leukocytosis. Indirect hyperbilirubinemia is usually physiologic in neonates, but sepsis-related hemolysis can cause persistent or worsening jaundice. All febrile neonates should undergo the following diagnostic tests: Complete blood count Blood culture Urinalysis Urine culture Cerebrospinal fluid cell count Cerebrospinal fluid culture The most common causes of serious bacterial infection in children are shown in the table. Escherichia coli urinary tract infection accounts for most bacterial infections in neonates. Listeria monocytogenes is currently rare but is still recognized due to potentially devastating complications. The recommended empiric regimen typically consists of ampicillin plus gentamicin or cefotaxime. Cefotaxime is preferred over gentamicin in areas with high rates of gentamicin resistance and suspected meningitis due to better cerebrospinal fluid penetration. (Choices A and D) Ceftriaxone can displace albumin-bound bilirubin in neonates, thereby increasing the amount of free bilirubin. The resultant hyperbilirubinemia can cross the blood-brain barrier and increase the risk of kernicterus. (Choice C) Broad-spectrum empiric antibiotics should be administered as soon as possible. Delaying therapy by even a few hours in an ill-appearing infant can result in permanent morbidity (eg, brain damage) or death. Antibiotics can eventually be narrowed based on culture growth and sensitivity. (Choice E) Sulfamethoxazole and other sulfonamides can worsen indirect hyperbilirubinemia by displacing bilirubin from albumin, thereby increasing the amount of free bilirubin. Trimethoprim-sulfamethoxazole is also avoided in patients age <6 weeks due to increased risk of methemoglobinemia. Educational objective: The most common causes of serious bacterial infection in neonates include Escherichia coli and Group B streptococcus. Broad-spectrum antibiotic therapy should be administered immediately to decrease potential morbidity and mortality. The preferred regimen for neonates consists of a combination of ampicillin and gentamicin or cefotaxime. Ceftriaxone and sulfonamides should be avoided due to risk of hyperbilirubinemia. References: Empirical treatment of neonatal sepsis: are the current guidelines adequate? (http://www.ncbi.nlm.nih.gov/pubmed/20584804) Fever without source in children 0 to 36 months of age. (http://www.ncbi.nlm.nih.gov/pubmed/16574521) Changing epidemiology of bacteremia in infants aged 1 week to 3 months. (http://www.ncbi.nlm.nih.gov/pubmed/22371459)

A 6-Day-Old Boy Is Brought to the Office for Poor