Full-term newborn (NB), second daughter of a 19-year-old healthy mother with controlled pregnancy.
Spontaneous vaginal delivery, Apgar 9 at 1 minute and 5 minutes, birth weight: 3,370 g.
At 34 hours of life, the patient presented with fever up to 38.8 °C, respiratory distress and abdominal discomfort, so she was admitted to the Neonatology Service of the Hospital Parroquial San Bernardo.
Physical examination revealed hypoactivity, poor peripheral perfusion, moderate mental retardation and mild muscular resistance in the abdomen.
Laboratory tests showed leukocytes of 5,300/mm3 without left shift, CRP: 204 mg/l and blood gases with metabolic acidosis.
Complete urine and chest X-ray were normal.
Lumbar puncture revealed a cloudy CSF.
CSF chemistry: glucose 49 mg/dl, proteins 266 mg/dl and leukocytes: 950/mm3 with 70% PMN, Gram stain: coceased Gram stalks in pairs acquis .
Urine and CSF latex for detection of S. aureus antigen were negative.
Ampicillin and cefoxime were started.
On admission, blood cultures were positive at 7.3 hours after inoculation, revealing Gram-positive cocci in chain.
The newborn remained febrile, hypoactive and hemodynamically stable.
A new CSF obtained at 72 hours was cloudy and had 5,050 leukocytes/mm3 with 100% PMN.
The culture of this sample was negative.
We received a report of hemocultive (2), urocultive and CSF taken to the hospital with development of Streptococcus viridans sensitive to penicillin and cefoxime admission.
The microbiology laboratory united identification as preliminary and subject to confirmation.
On the fourth day of hospitalization and due to the poor evolution, she was evaluated by an infectologist, suspending ampicillin and adding in her replacement penicillin 400,000 IU/kg/day and Streptococcus viridans group 4 mg/kg/day as a
Cefuroxime dose was increased from 100 to 150 mg/kg/day to optimize its concentration in the CNS and for suspected abscess.
Hemocultivations obtained intra-treatment were negative, the ultrasound study of brain and abdomen were normal.
Echocardiography showed a patent foramen ovale, ruling out vegetations.
The patient was managed conservatively.
On the seventh day of life, CSF was monitored, reporting: 38 leukocytes/mm3, 93% PMN, proteins 164 mg/dl and glucose 46 mg/dl, Gram stain without bacteria and negative culture.
No further control of CSF was performed.
Once the final microbiological report of Streptococcus pneumoniae and susceptibility corrected according to the meningitis breakpoints were received at the eighth treatment day, treatment was completed only with cefoxime.
The patient remained stable for improvement receiving cefoxime for 21 days, a duration determined by slow clinical recovery and laboratory parameters.
She was discharged at 22 days of life, in good condition, and it was not possible to perform post-discharge follow-up.
Microbiological report.
Two hemocultives, one urocultive and the CSF obtained at admission were positive for Gram positive cocci in chain and diplo.
Blood cultures were positive at 7.3 hours (BacT/Alert® system, BioMérieux).
A subculture was performed in 5% lamb blood agar and chocolate agar (bioMérieux).
The plates were closed for 24 hours at 35°C in atmosphere with 3 to 5% CO2, obtaining the development of colonies to hemolytic umbilicated.
Since growth of phenotypically similar colonies was obtained in all cultures, identification was performed from growth in hemocultives.
The susceptibility test to optoquine detected resistance to it, so a preliminary report of Streptococcus viridans group was issued.
Susceptibility study for cefoxime and cefoxime was performed by E-test and interpreted using the existing NCCLS/CLSI4 breakpoints for Streptococcus non-susceptible to penicillin μg and cefoxime (ml).
Because the appearance of the colony was suggestive of S. pneumoniae, identification was performed using API 20 Strep (bioMérieux), which did not yield conclusive results (S. oral sanis (20%)).
The strain was sent to the Microbiology Program, I.C.B.M., University of Chile, where one of the authors (MTX) identified the Pneumococcal Pneumococcal Infection (B.M.), antigen detection (positive).
The strain was sent to the Public Health Institute following the current regulations for sending invasive S. pneumoniae to the reference center.
The strain was identified as Streptococcus pneumoniae serotype 5 sensitive to penicillin.
Once the diagnosis was made, the interpretation of susceptibility to cefrigme was corrected according to the cut-off points for S. pneumoniae in meningeal location ceftriaxone a microbiological category susceptible to penicillin.
