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Vertical transmission of Citrobacter freundii
  1. T J Malpas1,
  2. J J Munoz1,
  3. I Muscat2
  1. 1Department of Paediatrics, The General Hospital, Jersey JE1 3QS, Channel Islands; t.malpasgov.je
  2. 2Department of Pathology, The General Hospital, Jersey

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    An infant developed early respiratory distress after delivery at 34 weeks gestation after prolonged rupture of membranes. Citrobacter freundii was cultured from a maternal midstream urine sample at delivery. C freundii, resistant to ampicillin but sensitive to gentamicin, cephalosporins, and ciprofloxacin, was isolated from neonatal blood cultures taken on admission. Gram negative rods were seen on microscopy of cerebrospinal fluid (CSF), with no white cells and 730 red cells per high power field. CSF protein was 1.26 g/l and glucose 3.0 mmol/l, with blood glucose of 4.9 mmol/l. No organisms grew on CSF culture. Ampicillin and gentamicin were discontinued, and ciprofloxacin and cefotaxime started for a three week course. Serial cranial ultrasound and computed tomography scans showed no evidence of intracranial abscess or ventriculitis. At 1 year of age the infant is neurodevelopmentally normal.

    Neonatal infection with Citrobacter species is usually acquired in a nosocomial fashion, and causes septicaemia, meningitis, and brain abscesses associated with a high morbidity and mortality. Eleven cases of vertically acquired Citrobacter koseri infection have been reported.1 However, the only previous report of vertical transmission of C freundii describes a 32 week infant in whom the organism was identified from maternal high vaginal swab and infant gastric aspirate, but not from blood cultures.2 Neonatal septicaemia with meningitis, as in our patient, has not been previously described.

    C freundii differs from other organisms causing neonatal meningitis by being able to replicate within brain capillary epithelium, perhaps accounting for the propensity of this organism for causing cerebral abscesses.3 However, including this case, this complication appears to be confined to late onset disease, with possible explanations being the early use of antibiotics, and absence of a putative virulence factor.1

    The combination of cefotaxime and an aminoglycoside is recommended for neonatal Gram negative meningitis, but CSF concentrations of gentamicin may only be marginally above the minimum bactericidal concentration of Gram negative organisms.4 Ciprofloxacin has been shown to be effective in Gram negative meningitis, and should be considered in the treatment of this condition.5

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