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Neonatal Pneumonia

By Mary T. Caserta, MD, Professor of Pediatrics, Division of Infectious Diseases; Attending Physician, University of Rochester School of Medicine and Dentistry; Golisano Children’s Hospital at Strong, University of Rochester Medical Center

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Neonatal pneumonia is lung infection in a neonate. Onset may be within hours of birth and part of a generalized sepsis syndrome or after 7 days and confined to the lungs. Signs may be limited to respiratory distress or progress to shock and death. Diagnosis is by clinical and laboratory evaluation for sepsis. Treatment is initial broad-spectrum antibiotics changed to organism-specific drugs as soon as possible.

Pneumonia is the most common invasive bacterial infection after primary sepsis. Early-onset pneumonia is part of generalized sepsis that first manifests at or within hours of birth (see Neonatal Sepsis). Late-onset pneumonia usually occurs after 7 days of age, most commonly in neonatal ICUs among infants who require prolonged endotracheal intubation because of lung disease (called healthcare-associated pneumonia).


Organisms are acquired from the maternal genital tract or the nursery. These organisms include gram-positive cocci (eg, groups A and B streptococci, both methicillin-sensitive and methicillin-resistant Staphylococcus aureus) and gram-negative bacilli (eg, Escherichia coli,Klebsiella sp, Proteus sp). In infants who have received broad-spectrum antibiotics, many other pathogens may be found, including Pseudomonas, Citrobacter,Bacillus, and Serratia. Viruses or fungi cause some cases.

Symptoms and Signs

Late-onset health-care associated pneumonia manifests with unexplained worsening of the patient's respiratory status and increased quantities and a change in the quality of the respiratory secretions (eg, thick and brown). Infants may be acutely ill, with temperature instability and neutropenia.


  • Chest x-ray

Evaluation includes chest x-ray, pulse oximetry, blood cultures, and Gram stain and culture of tracheal aspirate.

New, persistent infiltrates should be visible on chest x-ray but may be difficult to recognize if the infant has severe bronchopulmonary dysplasia.

If Gram stain shows a significant number of polymorphonuclear leukocytes and a single organism that is consistent with the one that grows from culture of the tracheal aspirate, the likelihood increases that this organism is the cause of the pneumonia. Because bacterial pneumonia in neonates may disseminate, a full evaluation for sepsis, including a lumbar puncture, should also be done. However, blood cultures are positive in only 2 to 5% of cases of healthcare-associated pneumonia.


  • Usually vancomycin and a broad-spectrum β-lactam drug

Antimicrobial therapy in early-onset disease is similar to that for neonatal sepsis. Vancomycin and a broad-spectrum β-lactam drug such as meropenem, piperacillin/tazobactam, or cefepime (see Table: Recommended Dosages of Selected Parenteral Antibiotics for Neonates), are the initial treatment of choice for most late-onset healthcare-associated pneumonia. This regimen treats sepsis as well as pneumonia with typical hospital-acquired pathogens including P. aeruginosa. Local patterns of infection and bacterial resistance should always be used to help guide empiric choices of antimicrobials. More specific antibiotics are substituted after sensitivity results are available. General treatment is the same as that for neonatal sepsis.

Chlamydial Pneumonia

Exposure to chlamydial organisms during delivery may result in development of chlamydial pneumonia at 2 to 18 wk. Infants are tachypneic but usually not critically ill and may also have a history of conjunctivitis caused by the same organism. Eosinophilia may be present, and x-rays show bilateral interstitial infiltrates with hyperinflation.


  • Erythromycin

Treatment with erythromycin leads to rapid resolution (see Table: Recommended Dosages of Selected Oral Antibiotics for Neonates*). Because erythromycin in neonates may cause hypertrophic pyloric stenosis (HPS), all neonates treated with erythromycin should be monitored for symptoms and signs of HPS and their parents counseled regarding potential risks. Azithromycin 20 mg/kg po once/day for 3 days may also be effective. The diagnosis of pneumonia secondary to Chlamydia trachomatis should prompt an evaluation of the mother and her partner because untreated maternal chlamydial infection may have complications such as pelvic inflammatory disease and sterility.