Premature Baby Treatment and Patient Education Case Study

Problem Identification

Alexander’s gestational age is 25 4/7 weeks (the period from the first day of the last menstrual cycle to the moment of birth). His postnatal age is 22 days (age counted from the moment of birth). His postmenstrual age is 28 5/7 weeks (the sum of the previous two).

There is an assumption that gestational and postmenstrual ages of an infant are directly related to physical alterations and development of body systems, which means that medication doses must be adjusted accordingly. However, it does not account for the fact that certain conditions and drugs can affect body maturation regardless of the ages. This means that overdosing and underdosing that may bring about undesired outcomes are possible even if these parameters are taken into consideration (Camacho-Gonzalez, Spearman, & Stoll, 2013).

The following factors indicate the presence of infection in Alexander:

• high C-reactive protein;
• fever;
• leukocytosis
• tachycardia
• tachypnea
• apnea
• hypotension.

Although most sepsis symptoms are shared by adults and children, there are still some peculiarities when making the diagnosis (Shah & Padbury, 2014):

• while infants more often have hypothermia, adults usually have a fever;
• infants typically experience leucopenia and adults have leukocytosis;
• infants may suffer from both tachycardia and bradycardia whereas adult patients commonly have tachycardia.

Desired Outcome

The major goals of pharmacotherapy for this infant can be summarized as follows:

• successfully eliminate MRSA and Stenotrophomonas infections;
• prevent morbidity and mortality;
• ensure weight gain and growth to cope with the current conditions;
• normalize all physical indicators;
• prevent adverse effects of medications;
• eliminate associated pain;
• resolve cholestasis;
• successfully deal with apnoea;
• prevent retinopathy of prematurity;
• eliminate dermatitis.

Therapeutic Alternatives

There are some therapeutic alternatives for empiric treatment of neonatal sepsis that occurs within the first week of life (Shah & Padbury, 2014):

• Ampicillin plus gentamicin is the most common combination that helps to deal with the major organisms typically found in neonatal sepsis (Group B streptococcus, Staphylococcus, E. coli, Enterococcus, and Listeria are eliminated by ampicillin whereas streptococci and staphylococci are covered by gentamicin).
• Another combination is ampicillin plus cefotaxime: The latter is used for treating sepsis in infants allowing them to avoid the risk of bilirubin displacement (that ceftriaxone may present) and providing higher penetration in the cerebral spinal fluid (as compared to gentamicin). Yet, the advantage of this alternative has not been proven; on the contrary, it is often associated with higher risks of morbidity and mortality than the first option. Furthermore, it fails to provide coverage against such organisms as Listeria or Enterococcus species.
• Vancomycin plus gentamicin is also rather a common option for neonatal sepsis patients: The former component provides gram-positive coverage of late-onset sepsis caused by S. aureus while the latter can deal with gram-positive streptococci and staphylococci.
• Vancomycin plus antipseudomonal penicillin (which can be substituted for third- or fourth-generation cephalosporin) allows achieving the same effect as the previous combination and also covers such gram-negative agents as Serratia, Enterobacter, and Pseudomonas.
• Any of the combinations may be enriched by adding ampicillin, acyclovir; amphotericin, or antifungals in case of necessity.

The dose of gentamicin (1.8 mg IV every 8 hours) was not appropriate for the patient as it does not take into account age and development peculiarities of renal maturation. For it to be appropriate, it must be 2 mg IV every 36 hours as this regimen would have a higher volume of distribution in neonates and would increase penetration into CNS. Moreover, prolonged intervals would ensure clearance.

Aztreonam is the most suitable option for S. maltophilia treatment as compared to other alternatives. Levofloxacin could be used; however, it does not have the approval to be administered to neonates. Sulfamethoxazole may bring about hyperbilirubinemia and kernicterus, while ceftazidime may fail to act properly due to the sensitivity pattern.

Vancomycin is the best choice for the treatment of MRSA bacteremia due to its low risks: Sulfamethoxazole/trimethoprim presents the risk for hyperbilirubinemia and kernicterus; levofloxacin has no FDA approval for neonates and may cause osteochondrosis and arthropathy, and linezolid is meant for the patient with multidrug-resistant infections.

Optimal Plan

Since the patient suffers from late-onset sepsis, the recommended therapeutic regimen can be:

• vancomycin plus gentamicin;
• vancomycin plus antipseudomonal penicillin;
• vancomycin plus antipseudomonal penicillin plus gentamicin;
• added acyclovir.

Alexander should be treated for MRSA bacteremia and S. maltopilia: The recommended regimen is aztreonam (22 mg IV every 12 hours for 14 days) combined with vancomycin (7.3 mg IV every 12 hours for 14 days).

Outcome Evaluation

The following clinical and laboratory parameters should be monitored to evaluate the efficacy of the proposed regimen (Shane & Stoll, 2014):

• blood culture;
• blood cell count;
• temperature;
• CRP;
• respiratory rate;
• heart rate;
• blood pressure;
• renal function;
• urine output;
• liver function;
• gastrointestinal functions;
• the concentration of vancomycin.

Patient Education

The patient’s mother must be made aware of the fact that neonates not only feel pain but also have increased sensitivities to its variations as compared to adults, which means that their feelings are more acute. Since Alexander needs prolonged hospitalization and intensive care, he will inevitably have to suffer pain. Thus, unless adequate pain control is ensured, the infant may develop hyperalgesia, allodynia, and cognitive deficits (Camacho-Gonzalez et al., 2013).

References

Camacho-Gonzalez, A., Spearman, P. W., & Stoll, B. J. (2013). Neonatal infectious diseases: Evaluation of neonatal sepsis. Pediatric Clinics of North America, 60(2), 367-389.

Shah, B. A., & Padbury, J. F. (2014). Neonatal sepsis: An old problem with new insights. Virulence, 5(1), 170-178.

Shane, A. L., & Stoll, B. J. (2014). Neonatal sepsis: Progress towards improved outcomes. Journal of Infection, 68(1), S24-S32.