This is a clinical case with Rh incompatibility. A 10 days baby diagnosed with Rh incompatibility and also having Bacteremia and Klebsiella pneumoniae is causing nosocomial infection in NICU

1. Arpita Chandra

2. Patient ID
 ADMISSION DATE- 07/11/22
 AGE/GENDER – 10 day/Male
 WARD- NICU
 REG NO- 1677467
 PATHO NO- 70
 SAMPLE-Blood (for Microbiological Investigation)
– On 08/11/22

3. History of patient
Chief Complaints
 Baby of Roli
 Delivered by NVD (Weight- 3.720 Kg)
 Maternal blood group- A-ve
 Baby’s blood group- B +ve
Diagnosis - Rh In-compatibilty

4. Physical Examination
 GC- good
 Pulse- 130bmp
 Temp-Afebrile
 R/R- 49/min
 SO2- 99%MPA
 Pallor- Neg
 Icterus- Neg
 Cyanosis- Neg

5. Cardiovascular System
H/R- 130bpm
Apex beat- (+)
S1 S2- (+)
Any Murmur- (-)
Peripheral pulses- Palpable

6. Respiratory system-
Lungs clear
Crepts
Ronchi
Wheezing sound
Pleural fluid
------Negative

7. CNS
 Concious- yes
 Altered sensorium-Neg
 Pupils
 Reflex Planter- Neg

8. Abdomen
Liver and Spleen- NAD
Distension
Presence of free fluid
Ascits
-----Negative

9. 2nd DAY - On 08 Nov 2022
GC- Poor
Yellowish discoloration of face
Phototherapy started- 8 Nov
Stopped on – 12 Nov
Suggestive for Investigations of
CBC, CRP
Blood culture and sensitivity
Direct Coombs Test (DCT)

10. 4th DAY – On 10 Nov 2022
 Icterus – Positive
 Blood culture – Reported Klebsiella pneumoniae
Treatment
Rx-
IV Ceftriaxone-200mg BD
IV Amikacin – 28 mg BD

11. BABY DIAGNOSED WITH
Rh-INCOMPATIBILITY

12. Rh factor
 In 1940 discovered by Landsteiner and Wiener from
the blood of rhesus monkey.

13.  Blood group positive = Rhesus factor present
 Blood group negative = Rhesus factor absent
The worldwide frequency of Rh- positive – 94%
Rh- negative -6%

14. Rh disease
 Rh disease is a condition where antibodies in a
pregnant women’s blood destroy her baby’s blood
cells. It’s also known as Hemolytic disease of the
fetus and new born (HDFN)

16. Sign and Symptoms
Jaundice- Yellow discoloration of skin
Because of much more destruction of RBCs in liver
Which produces excess Bilirubin
- Fast heart rate (Tachycardia)
- Fast breathing (tachypnea)
- Weakness
- Enlargement of liver or spleen
- Severe swelling of the body

17. Blood Specimen collection
Preparation of the site –
Require proper disinfection of the vein from which the
blood is to be drawn
If a patient has an existing IV line
Blood should be drawn below the existing line
Blood drawn above the line
It will be diluted with fluid being infused

18. Antisepsis
Once a vein is selected
Site is defatted with 70% alcohol
To kill surface and subsurface bacteria
Because blood culture medium enhance the growth of
any stray contaminating bacterium
Such as- normal flora of skin

19. Specimen Volume
Adults- For many years, it has been recognized that
most bacterimias in adults have a low number of colony
forming units (CFU) / mL of blood.
Fewer than 30 CFU/mL of blood were commonly found
in patients with clinically significant bacteremia .
10-20 mL blood – For Adults
Media volume- 70 ml

21. Children
- Not safe to take large sample of blood from children,
particularly infants.
- Infants with more serious disease usually yield more 10
CFU of bacteria/ mL of blood.
1 to 5 mL blood- For infants and small children
Media Volume- 20mL

23. Number of Blood Culture
Because periodicity of microorganisms in the blood
stream may be characteristics for some diseases,
continuous for some, and random in others
In patients with endocarditis
who have not received antibiotics
Single blood culture is positive (90-95% cases)

24. Who have received prior antibiotic therapy
3 separate blood collections of 10-20 mL each
Detects most etiologic agents of endocarditis
Without endocarditis – 80% to 92% (detected by first
blood culture)
90-99% - First two cultures
99.6% - At least one of the first three cultures

25. BloodCulture media- composition
 Trypticase soy broth
 Brain heart infusion broth
 Supplemented peptone or thioglycolate broth
 Most specialized broth base include Columbia or
Brucella broth.

26. Blood drawn for culture can be inoculated directly into
blood culture broth media
If Culture media bottle
NOT AVAILABLE

27. Anticoagulant
Blood drawn into a blood collection tube
Containing an anticoagulant for transport to lab
Use Sodium polyanethol sulfonate (SPS, Liqoid) –
0.025% to 0.03% (Best anticoagulant)
Today- 0.03% to 0.05% SPS
Heparin,
Ethylenediaminet
etraacetic acid
(EDTA), Citrate
inhibits numerous
org.

28. Properties of SPS
 Anti-complementary
 Anti-phagocytic
 Interferes with the activity of some Antibiotics
 EX- Aminoglycosides
 It inhibits the growth- Neisseria spp. Gardnerella
vaginalis, Streptobacillus moniliforms and all strains
of Peptostreptococcus anaerobius.
 Addition of 1.2% gelatin – Counteract this inhibitory
action of SPS

29. Conventional Blood Cultures
In blood culture bottles
Low oxidation reduction potential
Permitting the growth of (Facultative aerobic and Some
anaerobic org.)
For encouragement of growth of obligate (strict) aerobes
Such as- yeast & Pseudomonas aeruginosa, transient
venting of the bottles with a sterile, cotton plugged
needle may be necessary.

30. ON CULTURE PLATE (Aerobic)
Take a few drops of well mixed medium
Spreading this inoculum onto
- Mac-Conkey agar
- Blood agar
- Chocolate agar
Incubate it at 35°C for 48 hours

31. ON CULTURE MEDIABOTTLE (Anaerobic)
Stationary bottles by visual inspection
– RBCs Hemolysis,
- Gas bubbles,
- Turbidity,
- Small aggregates of bacterial and fungal growth
Incubated culture bottles for – 7 days

32. If growth is detected in the anaerobic bottles
Subcultures are made
Incubated
Both anaerobically and aerobically
After 48 hours of incubation
A second blind subculture or acridine orange stain may
be performed.

33. Automated system
 BD Septi Chek system,
 Becton Drickson Microbiology System,
 BacT/Alert Microbial detection system
 Lysis Centrifugation
 VITAL

34. Probable contaminant
 Growth of Bacillus spp, Corynebacterium spp,
Propionibacterium acnes or CONS
 Polymicrobial bacteremia is uncommon
 Organism causing primary site of infection is not same
as that isolated from the blood culture

35. Probable pathogen
 Same organism=Repeated cultures= at different times
 Endocarditis suspected patients= Enterococcus
 Gram negative rods = Gram negative sepsis
 Enterobacteriaceae, Streptococcus pneumoniae &
pyogens
 Isolation of commensal microbial flora = Immuno-
suppressed patients

36. Processing in Microbiology Lab
Sample came to the lab
After incubation of 24 hours
First subculture on cled agar
Also can be streak on – Mac-Conkey agar, Blood agar
and Chocolate agar

37. (After 24 hrs of incubation at 37°C Observe Colony
Morphology From Culture plate (CLED Agar)
( Lactose Fermenting, Mucoid pink colour colonies )

38. Marked isolated colonies for smear
Smear preparation & Gram stain
Examine under oil immersion (100X)
GNB (Short thick bacilli)
Catalase (+ve) Oxidase (-ve)
Enterobacteriaceae

39. Hanging drop
Non Motile
Lactose fermenting bacteria (suspected)
- Klebsiella spp. (Gram neg. Bacteria)
GNB process with All biochemical and AST

40. AFTER 24 HRS OF INCUBATION
( OBSERVE ALL BIOCHEMICALS AND AST)
Indole test (-ve) Urease test(+ve) Mannitol- NM/F

41. Citrate test(+ve) TSI (Triple sugar iron)
A/A with gas

42. ANTIBIOTIC SENSITIVITY TEST
 Sensitive to- CPM, C, CFS, CX, MRP, IPM, PIT, TGC,
OF, CL, PB, LE, AK, CPT
 Resistance to- TOB, A/S, GEN, PI, AT, CIP, COT, CTX,
NET, CTR
 Inrinsic Resistance to- Ampicillin, Ticarcillin
 Organism Isolated- Klebsiella pneumoniae

43. CRITICAL ALERT
IMMEDIATELY WE INFORMED TO CLINICIAN

44. RECENT RESISTANCE PATTERN IN K. PNEUMONIAE (2017)
- From a cross sectional study observed a significant
increase in antibiotic resistance (>40%) to the following
antibiotics: cefazolin, amoxicillin-clavulanic acid,
cefuroxime, cefepime, ceftriaxone, and ceftazidime
- The rate of bacterial ESBL production has been
steadily increasing about 39.66% ± 12.46%
>30% resistance to ciprofloxacin
- The rates of resistance to Imipenem and
Meropenem were 5.1% and 3.4%, respectively[3]

45. Klebsiella pneumoniae
An opportunistic Pathogen is a leading cause of neonatal
sepsis
It causes nosocomial infection or Hospital aquired
infection and also causes pneumonia in intensive care
units (ICUs)
Other infections
- Severe bronchopneumoniae
- UTI
- Wound infections
- Septicaemia
- Meningitis and rarely Diarrhoea

46. Nosocomial infection in neonatal intensive care unit
(NICU)
Risk of nosocomial infection in neonates is very
higher due to severity in their prematurity, illness,
systemic infection, congenital defects, invasive
monitoring, no judiciary use of antibiotics and no
proper use of disinfections
Nurses are the primary caregivers for infants in the
NICU and their hands (without proper disinfection)
also one of the common source of infection [2].

47. ON 14th NOV 2022
PATIENT DISCHARGED
WITH GOOD HEALTH

48. REFERENCES
 C. P. BAVEJA (Textbook of Microbiology)
 BAILEY & SCOTT’S (Diagnostic Microbiology)
[2]- Kahraman EP, Çiftcia IH (2017) The Antibiotic
Resistance Patterns of Klebsiella pneumoniae Clinic
Isolates: A Comprehensive Meta-Analysis. Open J Bac
1(1): 021-026.
[3] https://www.jehp.net//text.asp?2022/11/1/158/347162

49. THANKS A LOT