Gardnerella Vaginalis Bacteremia in a Premature Neonate

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Perinatal/Neonatal Casebook &&&&&&&&&&&&&& Gardnerella Vaginalis Bacteremia in a Premature Neonate

Rene A. Amaya, MD blood culture were obtained and intravenous ampicillin and Fahad Al-Dossary, MD gentamicin were administered empirically for 72 hours. Gail J. Demmler, MD Shortly after delivery, the infant’s mother developed fever and abdominal pain and was diagnosed as having endometritis. A blood culture was obtained and this remained sterile. She received intravenous ampicillin-sulbactam, gentamicin, and metronidazole Gardnerella vaginalis is a normal component of the human vaginal flora and her symptoms resolved within 4 days. and commonly associated with bacterial vaginosis. Invasive infection in The infant remained clinically stable; however, on the fourth day obstetrical patients due to G. vaginalis has also been reported. In the of life the initial blood and tracheal aspirate cultures yielded pure pediatric age range, infection due to G. vaginalis is extremely rare and growth of a Gram-negative bacillus identified as G. vaginalis. limited to neonates. We describe a 23-week premature infant with Repeat blood and tracheal aspirate cultures were obtained and G. vaginalis bacteremia and review the characteristics of neonatal cerebrospinal fluid (CSF) examination was performed. The CSF was 3 G. vaginalis infection reported in the literature. Antibiotic susceptibility benign; however, the white blood cell count was 24,200/mm testing of G. vaginalis isolates has shown that penicillin, ampicillin, (66% neutrophils, 5% bands forms, and 29% lymphocytes). erthromycin, clindamycin, and vancomycin are effective in vitro. Kirby-Bauer antibiotic susceptibilities on the isolates were not Journal of Perinatology (2002) 22, 585 – 587 doi:10.1038/sj.jp.7210757 performed because standards for interpretation are unavailable, and an attempt to perform macrobroth dilution susceptibilities was unsuccessful due to poor growth. On day of life 5, intravenous metronidazole (7.5 mg/kg) was administered every 48 hours for Gardnerella vaginalis is a normal constituent of the vaginal flora 10 doses. No additional problems associated with G. vaginalis 1,2 and is one of the organisms associated with bacterial vaginosis. were identified. In the pediatric age range, infection due to G. vaginalis is extremely uncommon, and invasive infections have been reported only during the neonatal period.3–11 In this report, we describe a DISCUSSION 23-week premature infant with G. vaginalis bacteremia and present a review of the reported infections due to G. vaginalis in G. vaginalis was first described by Leopold in 1953 and was termed 12 newborn infants. Haemophilus vaginalis. The name was later changed to Corynebacterium vaginale and to Gardnerella vaginalis in 1980 in honor of Dr. Herman Gardner.13 G. vaginalis is a Gram-negative CASE REPORT or variable bacillus that is characterized by its slow growth on A 560-g female infant was born prematurely at 23 weeks’ gestation ordinary media on which it is difficult to differentiate from other to a 17-year-old primigravida. The pregnancy was uncomplicated vaginal bacteria. On sheep blood agar G. vaginalis grows as pinpoint until the infant’s mother presented in active labor with abdominal colonies anaerobically or in 5% carbon dioxide. The medium of choice for its isolation is Columbia agar with human blood, on cramping and bloody vaginal discharge. The infant was delivered 14 vaginally without complications and the Apgar scores were 5 and 8 at which it causes hemolysis. 1 and 5 minutes, respectively. Physical examination at birth revealed G. vaginalis is a normal component of the human vaginal flora an extremely premature infant in respiratory distress, prompting and primarily is a pathogen of the female genitourinary tract. intubation and assisted ventilation. A tracheal aspirate culture and Bacterial vaginosis is the most common condition associated with this organism.1,2 In obstetrical patients, G. vaginalis is a recognized though uncommon cause of more serious infection. Reports have identified G. vaginalis as an etiologic agent in puerperal Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, sepsis,3,4,15–18 endometritis,15,16,19 and septic abortion.4,16 The TX, USA. pathogenesis of these infections is considered to represent Address correspondence and reprint requests to Gail J. Demmler, MD, Section of Infectious opportunistic spread of the organism from the vagina to the uterus Diseases, Department of Pediatrics, Baylor College of Medicine, Room 302A, One Baylor Plaza, Houston, TX 77030, USA. and urogenital tract as a result of mucosal injury during delivery.

Table 1 Newborn Cases of G. Vaginalis Infection Reference no. Gestational age (wk) Diagnosis Source of isolate Treatment Outcome (year of publication)

Present report 23 Bacteremia Blood Ampilicillin and gentamicin; Resolved metronidazole Tracheal Aspirate 9 (1988) Term Meningitis CSF Ampicillin, cefotaxime, and netilmicin Resolved 10 (1988) Term Respiratory distress Tracheal aspirate Ampicillin and gentamicin Resolved 11 (1988) 34 Scalp abscess Abscess aspirate Topical bacitracin Resolved 8 (1986) Term Cephalohematoma/ Abscess Aspirate Ampicillin, gentamicin, and clindamicin Resolved parietal osteomyelitis 7 (1985) Term Conjunctivitis Conjunctival swab Topical chloramphenicol Resolved 6 (1982) Term Facial cellulitis/abscess Abscess Aspirate Cloxacilin Resolved 4 (1976) Premature Bacteremia Blood Penicillin Died Premature Bacteremia Blood Penicillin and kanamycin Died Premature Bacteremia Blood Penicillin and kanamycin Resolved Term Bacteremia Blood None Resolved 3 (1973) Term Bacteremia Blood Penicillin and kanamycin Resolved 5 (1971) Stillborn Pneumonia Fetal cord blood – – Stillborn No data Fetal cord blood – – Term Sepsis/shock Blood None Died Term Scalp abscess Blood Ampicillin and kanamycin Resolved

A review of the English-language literature revealed nine Our patient received ampicillin and gentamicin as empiric publications of neonatal infection with G. vaginalis 3–11 (Table 1). treatment for possible sepsis after the initial blood and tracheal Our patient represents the most premature infant infected with G. aspirate cultures were obtained. It may be reasonable to assume that vaginalis reported to date. Most of the infections in these infants were the repeat cultures were sterile due to the efficacy of ampicillin considered to arise due to exposure to maternal vaginal flora during against G. vaginalis. Eight of the previously reported 15 infants childbirth. These infants received various antibiotics and the majority received empiric penicillin or ampicillin which may have contributed of them recovered without serious sequelae. Among the 15 infants to the resolution of their infection. described, only three infants died. These deaths were attributed to Our patient’s presentation illustrates the unusual occurrence of prematurity and severity of illness in the era before modern neonatal G. vaginalis bacteremia in a premature neonate. The positive supportive care. tracheal aspirate culture suggests that aspiration of contaminated Treatment for G. vaginalis infection has focused primarily on maternal amniotic fluid may have provided the portal of entry for recommendations for adults with genital tract infections. Metroni- the infection. The delayed growth on culture media is dazole and clindamycin are recognized as effective treatment of characteristic for this fastidious organism and the mother’s illness bacterial vaginosis.20 However, because extravaginal invasive shortly following delivery suggests she may also have been infected infections from G. vaginalis occur, antibiotic susceptibility testing with G. vaginalis. This patient serves as a reminder that vaginal has been performed to screen for emergence of resistance and to delivery exposes infants to a myriad of potential bacterial identify other therapeutic options.21 These studies have shown that pathogens. Gram-variable or Gram-negative bacilli seen on gram other antibiotics are effective in vitro for treatment. Kharsany et al.21 stain that are slow to grow in culture media should raise the tested 93 isolates of G. vaginalis for their susceptibilities to 25 suspicion for G. vaginalis infection. antibiotics. Minimal inhibitory concentrations (MICs) were determined by the agar dilution method. All strains were susceptible to penicillin (MIC ,0.5g/ml), ampicillin (MIC ,0.5g/ml), 90 90 References erythromycin (MIC , 0.06 g/ml), clindamycin (MIC , 90 90 1. Gardner HL, Dukes CD. Haemophilus vaginalis vaginitis. Am J Obstet 0.03 g/ml) and vancomycin (MIC ,0.5g/ml). Most of the 90 Gynecol 1955;69(5):962–76. strains were susceptible to metronidazole (MIC90,16g/ml) 2. Chattopadhyay B. The role of Gardnerella vaginalis in ‘‘non-specific’’ although the hydroxy metabolite of metronidazole showed greater vaginitis. J Infect 1984;9:113–25. activity than the parent compound (MIC90,4g/ml). Marked 3. Carney FE. Hemophilus vaginalis septicemia. Obstet Gynecol 1973;41(1): resistance to amikacin (MIC90, 128 g/ml) and sulfamethoxazole 78–9. (MIC90, >128 g/ml) was observed. 4. Venkataramani TK, Rathbun HK. Corynebacterium vaginalis (Hemophilus

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vaginalis) bacteremia: clinical study of 28 cases. Johns Hopkins Med J 13. Greenwood JR, Pickett MJ. Transfer of Haemophilus vaginalis Gardner and 1976;139:93–7. Dukes to new genus Gardnerella: G. vaginalis (Gardner and Dukes). Int J 5. Platt MS. Neonatal Hemophilus vaginalis (Corynebacterium vaginalis) Syst Bacteriol 1980;30:170–8. infection. Clin Pediatr (Philadelphia) 1971;10:513–6. 14. Catlin BW. Gardnerella vaginalis: characteristics, clinical considerations 6. Leighton PM, Bulleid B, Taylor R. Neonatal cellulitis due to Gardnerella and controversies. Clin Microbiol Rev 1992;5:213–37. vaginalis. Pediatr Infect Dis J 1982;1:339–40. 15. Regamey C, Schoenknecht FD. Puerperal fever with Haemophilus vaginalis 7. Chowdhury MNH, Kambal AM. A case of conjunctivitis in a neonate due to septicemia. JAMA 1973;225(13):1621–3. Gardnerella vaginalis. Trop Geogr Med 1985;37:365–6. 16. Monif GRG, Baer H. Haemophilus (Corynebacterium) vaginalis 8. Nightingale LM, Eaton CB, Fruehan AE, Waldman JB, Clark WB, Lepow ML. septicemia. Am J Obstet Gynecol 1974;120(8):1041–5. Cephalohematoma complicated by osteomyelitis presumed due to Gardner- 17. Adeniyi-Jones C, Groves DJ, Mannethu A, Righter J. Haemophilus vaginalis ella vaginalis. JAMA 1986;256(14):1936–7. bacteremia. Can Med Assoc J 1980;122:424–6. 9. Berardi-Grassias L, Roy O, Berardi JC, Furioli J. Neonatal meningitis due to 18. Reimer LG, Reller LB. Gardnerella vaginalis bacteremia: a review of thirty Gardnerella vaginalis. Eur J Clin Micro Infect Dis 1988;7(3):406–7. cases. Obstet Gynecol 1984;64:170–2. 10. Furman LM. Neonatal Gardnerella vaginalis infection. Pediatr Infect Dis J 19. Johnson AP, Boustouller YL. Extra-vaginal infection caused by Gardnerella 1988;7:890. vaginalis. Epidemiol Infect 1987;98:131–7. 11. McGregor JA, French JI. Are neonatal scalp abscesses another complication of 20. Legder WJ. Historical review of the treatment of bacterial vaginosis. Am J bacterial vaginosis? Pediatr Infect Dis J 1988;7:437–8. Obstet Gynecol 1993;169(2 pt 2):474–8. 12. Leopold S. Heretofore undescribed organism isolated from genitourinary 21. Kharsany AB, Hoosen AA, Van Den Ende J. Antimicrobial susceptibilities of system. US Armed Forces Med J 1953;4:263–6. Gardnerella vaginalis. Antimicrob Agents Chemother 1993;37(12): 2733–5.

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