Successful Treatment of Late-Onset Infection due to Resistant Klebsiella pneumoniae in an Extremely Low Birth Weight Infant Using Ciprofloxacin Munish Khaneja, MD James Naprawa, MD Alok Kumar, MD Steve Piecuch, MD, MPH OBJECTIVE: This paper presents a case in which an extremely low birth weight infant with multidrug-resistant Klebsiella pneumoniae infection was success- fully treated with ciprofloxacin and gentamicin. STUDY DESIGN: A clinical case report of a neonate who received broad spectrum antibiot- ics for possible infection despite negative cultures. The infant developed sepsis and meningitis resulting from multidrug-resistant K. pneu- moniae, which was treated with ciprofloxacin and gentamicin. The literature for the use of ciprofloxacin in pediatric patients was reviewed. RESULTS: The infant responded to the antibiotic regimen with sterilization of blood and cerebrospinal fluid; no adverse effects were attributable to the cipro- floxacin. Although ciprofloxacin has been found to cause irreversible injury to cartilage in juvenile laboratory animals, a review of the litera- ture found that this complication occurs rarely if at all in pediatric pa- tients. Ciprofloxacin has been found to be effective in the treatment of multidrug-resistant Gram-negative infections in pediatric patients, in- cluding premature infants. CONCLUSION: Ciprofloxacin should be considered in the treatment of neonatal infec- tion caused by multidrug-resistant Gram-negative organisms. Although the published experience with this drug suggests that it is effective and that significant toxicity is not common, its use should be restricted to the treatment of serious infections for which an alternative antibiotic is not available. Neonatal infections caused by Gram-negative bacteria are associ- ated with a significant risk of mortality and of long-term neurode- velopmental sequelae, especially when complicated by meningitis. Third-generation cephalosporins have a central role in the manage- ment of Gram-negative infections because of their excellent activity against these organisms and their ability to achieve high levels in the cerebrospinal fluid. However, resistance to cephalosporins has in- creased as their use in the neonatal intensive care unit (NICU) has become more common. Ciprofloxacin, a fluoroquinolone derivative of nalidixic acid that acts by inhibiting bacterial DNA gyrase, 1 is effective against Gram-negative organisms and penetrates the cerebrospinal fluid well, 2 but its use in pediatric patients has been limited because of safety concerns. 3 We recently used ciprofloxacin to successfully treat an extremely low birth weight infant with multidrug-resistant Kleb- siella pneumoniae infection. PATIENT REPORT A 585-gm girl was born by cesarean section at 26 weeks’ gestation to a mother being treated with ampicillin and gentamicin for chorio- amnionitis. The infant received ampicillin and cefotaxime for 2 weeks for presumptive infection. She then developed signs of possible necro- tizing enterocolitis, and the antibiotics were changed to vancomycin, clindamycin, and amikacin, which were administered for 7 days. In both cases, blood cultures were negative but treatment was continued because the infant had signs of infection. In addition, it was felt that the culture results might be unreliable because intrapartum antibiot- ics had been administered and because cultures can be negative in patients with necrotizing enterocolitis. While on antibiotics, the in- fant’s blood culture grew Candida lusitaniae, which was treated with a 4-week course of amphotericin and 5-flucytosine. At 23 days of age the infant developed signs of infection and cultures of blood and cerebrospinal fluid grew K. pneumoniae, which was resistant to third-generation cephalosporins and to amikacin but sensitive to ciprofloxacin and gentamicin. The cerebrospinal fluid was not bloody but only enough specimen was obtained to send for cul- ture. In consultation with the Pediatric Infectious Diseases Service, it was decided that the benefits of treatment with ciprofloxacin out- weighed the potential risks. The infant received intravenous cipro- floxacin, 10 mg/kg per dose every 12 hours, in combination with gentamicin for 25 days. Subsequent blood and cerebrospinal fluid cultures were negative. Our patient did not develop any joint swelling or inflammation while Department of Pediatrics, State University of New York-Health Science Center, Brooklyn, NY. Address correspondence and reprint requests to Steve Piecuch, MD, MPH, Division of Neona- tology, Children’s Medical Center of Brooklyn, 450 Clarkson Ave., Box 49, Brooklyn, NY 11203-2098. Journal of Perinatology (1999) 19(4) 311–314 © 1999 Stockton Press. All rights reserved. 0743– 8346/99 $12 http://www.stockton-press.co.uk 311 Clinical Perinatal/Neonatal Case Presentation              