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CASE REPORT
Year : 2022  |  Volume : 42  |  Issue : 4  |  Page : 194-196

Successful treatment of early-onset Morganella morganii sepsis in an extremely low birth weight infant


1 Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, 325 Cheng-Kung Road, Section 2, Neihu, Taipei 114, Taiwan
2 Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, 325 Cheng-Kung Road, Section 2, Neihu, Taipei 114; Department of Pediatrics, St Joseph Hospital, Kaohsiung, Taiwan

Date of Submission02-Dec-2021
Date of Decision10-Feb-2022
Date of Acceptance10-Feb-2022
Date of Web Publication21-Apr-2022

Correspondence Address:
Dr. Wen-Tsung Lo
Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, 325, Cheng-Kung Road, Section 2, Neihu, Taipei 114; Department of Pediatrics, St Joseph Hospital, Kaohsiung
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmedsci.jmedsci_353_21

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  Abstract 


Morganella morganii is a rare cause of neonatal infections, and early-onset neonatal sepsis caused by M. morganii is serious and even fatal. We describe an extremely low birth weight female infant with early-onset M. morganii sepsis to highlight the importance of awareness of this potentially fatal organism.

Keywords: Early-onset neonatal sepsis, Morganella morganii, bacteremia


How to cite this article:
Chang CN, Chen SJ, Wang CC, Lo WT. Successful treatment of early-onset Morganella morganii sepsis in an extremely low birth weight infant. J Med Sci 2022;42:194-6

How to cite this URL:
Chang CN, Chen SJ, Wang CC, Lo WT. Successful treatment of early-onset Morganella morganii sepsis in an extremely low birth weight infant. J Med Sci [serial online] 2022 [cited 2022 Aug 16];42:194-6. Available from: https://www.jmedscindmc.com/text.asp?2022/42/4/194/353047




  Introduction Top


Morganella morganii is a Gram-negative bacillus which is commonly found in the gastrointestinal tract as normal flora. In adults, M. morganii bacteremia frequently occurs secondary to urinary tract or hepatobiliary tract infection and was associated with a high mortality rate.[1] Early-onset neonatal infections caused by M. morganii are very rare and it can cause highly fatal illnesses.[2],[3],[4],[5] We describe a case of early-onset M. morganii sepsis in an extremely low birth weight infant. She was successfully treated with a 2-week course of cefotaxime alone and was survived without significant complications.


  Case Report Top


A female neonate (birth weight: 690 g) was delivered at 25-week and 6-day gestation by spontaneous vaginal delivery 1 h after spontaneous rupture of membranes. The mother was 34 years old and healthy. The pregnancy was complicated by preterm contractions and cervical dilatation, first noted 3 weeks before delivery. Cervical incompetence was diagnosed and she underwent emergent cervical cerclage. At 25-week gestation, she experienced lower abdominal pain and was admitted for tocolysis. She received two doses of ampicillin before delivery. No culture had been obtained because there was no maternal fever during labor or delivery. However, she was diagnosed clinically as having chorioamnionitis and urinary tract infection because laboratory investigation yielded the following results: C-reactive protein (CRP), 8.36 mg/dl; white blood cell (WBC) count, 18,800/mm3 with a differential of 88% neutrophils; urine WBC count, 18–20/hpf; and leukocyte esterase, 2+.

The patient was admitted to our neonatal intensive care unit with Apgar scores of 6 and 8 at 1 and 5 min, respectively. Mild peripheral cyanosis and respiratory distress were noted after transfer to our neonatal intensive care unit. As the infant's chest X-ray revealed grade I respiratory distress syndrome, nasal continuous positive airway pressure was applied. An umbilical arterial catheter was inserted immediately after the birth to continuously monitor vital signs. Initial laboratory studies disclosed WBC count was 22,100/mm3, with 10.1% segmented neutrophils, and 9.7% lymphocytes. CRP level was up to 2.18 mg/dl. A combination of ampicillin (25 mg/kg/dose in two divided doses) and gentamicin (2.5 mg/kg/dose once daily) was started empirically, both given intravenously. On the 2nd day of life, an invasive infection was highly suspected because of leukocytosis (WBC count, 75,900/mm3 and with 82% segmented neutrophils) and thrombocytopenia (platelet count, 21,000/mm3), and the antibiotic therapy was changed to cefotaxime (50 mg/kg/dose in two divided doses) because a Gram-negative rod was recovered from the blood culture. A spinal tap was performed and yielded normal findings.

By day 4, cultures from the tip of the umbilical arterial catheter and peripheral blood grew M. morganii, susceptible in vitro to cefotaxime, gentamicin, and amikacin [Table 1]. Consequently, the patient underwent a 2-week course of intravenous cefotaxime, responding well to therapy. Subsequent peripheral blood culture was sterile. The infant made a full recovery and was achieving age-appropriate milestones.
Table 1: Antibiogram results of the Morganella morganii isolate

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  Discussion Top


Early-onset infection with M. morganii was defined as the development of symptoms within 72 h of birth.[6] Based on the definition, early onset of neonatal M. morganii disease is extremely rare, only 12 cases have been reported to date.[2],[3],[4],[5] There is no sex predilection, and the median age of these infants was 1.3 days. Six infants (50%) were delivered by cesarean section. Except for one infant born with term pregnancy, all the other 11 (92%) were preterm infants. Four preterm infants had birth weight under 1000 g, and only two of them survived without complications.[2],[3],[4] Bacteremia was diagnosed in all 12 cases, of whom three (25%) had concomitant pneumonia and two (17%) had meningitis.[3],[5] Eight neonates survived and four died. Therefore, the mortality rate of early-onset M. morganii infection was 33%.

Maternal chorioamnionitis was the most common antenatal risk factor (7 [58%] out of 12 cases),[2],[3],[4] which reinforces the notion that the mode of transmission of early-onset M. morganii disease was thought to be associated with vertical transmission. In the present case, the timing of the infant's illness suggested vertical transmission of the infecting organism. However, the exact mode of transmission was not established because a thorough search was not undertaken. Ranu et al.[2] reported an extremely low birth weight infant with fatal early-onset M. morganii infection born by a mother who had undergone placement of a cervical cerclage at 15 weeks of pregnancy. In our patient, the infant's mother received the procedure of emergent cervical cerclage at 23-week gestation due to suspicion of threatened miscarriage. Based on the laboratory investigation, she was presumed to have chorioamnionitis. Cervical cerclage predisposes to premature rupture of membranes and intrauterine infection.[7],[8],[9] The infection rate was increased in patients undergoing emergent surgery.[8] Although cervical cerclage, under ideal circumstances, can significantly prolong pregnancy and increase the chance of viable pregnancy outcome, however, the risk of chorioamnionitis is also increased.[9]

M. morganii normally has an inducible AmpC beta-lactamase, which confers resistance to those beta-lactam antibiotics such as ampicillin.[3] The optimal regimen and treatment duration for early-onset neonatal infection caused by M. morganii remains uncertain.[4] Sinha et al.[3] suggested that extended-spectrum cephalosporin therapy should be considered when M. morganii with inducible chromosomal AmpC beta-lactamases is identified. Since M. morganii is characteristically resistant to many beta-lactam antibiotics, a third-generation cephalosporin alone or with an aminoglycoside for 10–14 days is effective in treating bacteremia or sepsis in patients without complications.[4] In our patient, she was successfully treated with a 2-week course of cefotaxime alone and achieved complete recovery.


  Conclusion Top


M. morganii is an uncommon cause of early-onset neonatal sepsis, which can lead to high mortality and morbidity. Early recognition and appropriate antibiotic therapy such as third-generation cephalosporin are crucial, especially in smaller birth weight preterm infants. The study was reviewed and approved by the National Defense Medical Center Institutional Review Board (TSGHIRB No.: B202105170).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given her consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee IK, Liu JW. Clinical characteristics and risk factors for mortality in Morganella morganii bacteremia. J Microbiol Immunol Infect 2006;39:328-34.  Back to cited text no. 1
    
2.
Ranu SS, Valencia GB, Piecuch S. Fatal early onset infection in an extremely low birth weight infant due to Morganella morganii. J Perinatol 1999;19:533-5.  Back to cited text no. 2
    
3.
Sinha AK, Kempley ST, Price E, Sharma BK, Livermore DM. Early onset Morganella morganii sepsis in a newborn infant with emergence of cephalosporin resistance caused by depression of AMPC beta-lactamase production. Pediatr Infect Dis J 2006;25:376-7.  Back to cited text no. 3
    
4.
Chang HY, Wang SM, Chiu NC, Chung HY, Wang HK. Neonatal Morganella morganii sepsis: A case report and review of the literature. Pediatr Int 2011;53:121-3.  Back to cited text no. 4
    
5.
Paul SP, Newman LM, Mubashar Y, Turner PC. Morganella morganii: A rare cause of early onset neonatal sepsis and meningitis. Br J Hosp Med (Lond) 2020;81:1-3.  Back to cited text no. 5
    
6.
Simonsen KA, Anderson-Berry AL, Delair SF, Davies HD. Early-onset neonatal sepsis. Clin Microbiol Rev 2014;27:21-47.  Back to cited text no. 6
    
7.
Charles D, Edwards WR. Infectious complications of cervical cerclage. Am J Obstet Gynecol 1981;141:1065-71.  Back to cited text no. 7
    
8.
Treadwell MC, Bronsteen RA, Bottoms SF. Prognostic factors and complication rates for cervical cerclage: A review of 482 cases. Am J Obstet Gynecol 1991;165:555-8.  Back to cited text no. 8
    
9.
Cockwell HA, Smith GN. Cervical incompetence and the role of emergency cerclage. J Obstet Gynaecol Can 2005;27:123-9.  Back to cited text no. 9
    



 
 
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