Early onset Morganella morganii sepsis in
newborn babies is a rarity. We encountered two cases of early onset
Morganella morganii sepsis within days of each other. In this
article we report these two cases and review the literature.
Case Reports
Case 1
This 1470 g male infant was delivered at 32 weeks
gestation. The antenatal period was uncomplicated. The mother was immuno-competent,
had no infections during pregnancy and was not exposed to prolonged
antibiotics. Her membranes ruptured spontaneously at 32 weeks and labour
pains started an hour later. She received a dose of dexamethasone and
ampicillin and delivered vaginally after 8 hours of rupture of
membranes. There was no perinatal asphyxia. The gastric aspirate was
full of neutrophils. He developed respiratory distress and was
administered early rescue surfactant. The chest X-ray showed
evidence of pneumonia and the sepsis screen was suggestive of sepsis.
The serum C-Reactive Protein (CRP) was elevated and there was
leucocytosis (39,000/cu mm) and neutrophilia (13,065/cu mm). The blood
culture drawn soon after birth grew Morganella morganii,
sensitive to third generation Cefalosporins, Aminoglycosides and
Ciprofloxacin and resistant to Ampicillin. The cerebrospinal fluid (CSF)
examination was normal. Maternal amniotic membrane culture was
non-contributory. He was started on intravenous Cefotaxime and Amikacin
soon after birth. He was administered inotropes for the management of
shock and CPAP for respiratory distress. The mother had no signs of
infection. Her blood culture, high vaginal swab culture and urine
culture, sent immediately after the baby’s culture report, were sterile.
Case 2
This baby was delivered by emergency LSCS for
uncontrolled hypertension and spontaneous premature rupture of membranes
at 32 weeks gestation, just one day after the above case was delivered.
She weighed 1100 g and was disproportionately small for gestational age.
The mother was immuno-competent and had not received any antibiotics
during pregnancy. She received one dose of antenatal dexamethasone and
ampicillin before delivery. She developed respiratory distress soon
after birth, and the chest X-ray showed pneumonia. The sepsis
screen showed a positive CRP, TLC 21,300 and ANC 10,500. The blood
culture drawn soon after birth grew Morganella morganii, which
showed an identical antibiogram. The CSF analysis showed no abnormal
findings. She was started on Cefotaxime and Amikacin. On day 2 she
developed shock, metabolic acidosis and thrombocytopenia. Antibiotics
were emperically changed to Ciprofloxacin and Netilmycin, but she
continued to deteriorate and died on day 8. The mother had no signs of
infection. Maternal cultures had not been sent.
Discussion
Morganella morganii is a gram-negative enteric
bacterium, within the Entero-bacteriaceae family. It has most commonly
been described as a nosocomial pathogen in immunocompromised adults or
those with chronic urinary catheterization. M. morganii typically
has an inducible beta-lactamase and is resistant to multiple
antibiotics.
Our index cases developed early onset Morganella
morganii sepsis within a day of each other, but we were not able to
establish a common source. Given the rarity of the infection, the
probability of the 2 cases occurring concurrently as a chance phenomenon
is remote and colonization after admission to our unit seems more
likely.
The mothers of the 2 babies were unrelated and had
not visited a common health facility prior to their coming to our
hospital. Here, they were looked after by the same set of physicians and
nurses in the delivery rooms complex. No baby had grown Morganella
morganii in our unit for a period of two years before the birth of
these two infants and none has been isolated for over 12 months after
their birth. Environmental cultures were taken from the labour room area
and from the neonatal unit and from the personnel working there, but
these did not grow Morganella morganii. We had managed another
case of early onset Morganella morganii sepsis two years
prior(1). This baby was born to an immuno-competent primigravida mother
by sponta-neous vaginal delivery at 34 weeks. The membrane culture and
the baby’s blood culture both grew Morganella morganii.
Our cases were all premature, had congenital
pneumonia, and blood cultures drawn soon after birth were positive.
Apart from spontaneous premature onset of labour in 2 cases, none of the
other recognized risk factors of early onset sepsis were present. Sepsis
screens consistently showed leuco-cytosis and neutrophilia. The
antibiograms of the 3 isolates were identical, with resistance to
Ampicillin. In none of the cases was there a risk for colonization with
an unusual organism. There was no prolonged hospitalization, prolonged
administration of broad-spectrum antibiotics or clinical evidence of
immunodeficiency. However, a single dose of Ampicillin and Dexamethasone
had been given in all instances. In our perinatal unit, there is a
common practice to administer Ampicillin to mothers with threatened
premature delivery, because we deal with a large population of unbooked
and in-adequately supervised mothers who arrive late in pregnancy. This
practice may lead to the emergence of unusual Ampicillin-resistant
organisms.
Early onset Morganella morganii neonatal
sepsis has been an infrequently reported infection in literature(2-7).
Most cases were associated with evidence of maternal
chorioamnionitis(2-4,6,7). All reported cases were premature, with
antenatal exposure to Ampicillin being reported in several cases(2-7).
Resistance to Ampicillin, though common, was not universal. There is an
unusual case of a one-day-old neonate presenting with necrotizing
fasciitis caused by Morganella morganii acquired post-natally
following a fall into the toilet bowl during a domestic delivery(5).
We conclude that Morganella morganii is an
unusual cause of early-onset neonatal sepsis. Affected babies are
usually delivered premature, with no consistent history of risk factors.
The use of prophylactic antibiotics in pregnancy (particularly
Ampicillin) may play a role in vaginal colonization with such unusual
organisms.
Contributors: SD, AN worked up cases and prepared
the manuscript.
Funding: None.
Competing interests: None stated.
