Time for a neonatal-specific consensus definition for sepsis

Could P2X7 receptor be a potencial target in neonatal sepsis?

The United Nations Inter-Agency Group for Child Mortality Estimation (UNIGME) estimates that every year 2.5 million neonates die in their first month of life, accounting for nearly one-half of deaths in children under 5 years of age. Neonatal sepsis is the third leading cause of neonatal mortality. The worldwide burden of bacterial sepsis is expected to increase in the next decades due to the lack of effective molecular therapies to replace the administration of antibiotics whose efficacy is compromised by the emergence of resistant strains. In addition, prolonged exposure to antibiotics can have negative effects by increasing the risk of infection by other organisms. With the global burden of sepsis increasing and no vaccine nor other therapeutic approaches proved efficient, the World Health Organization (WHO) stresses the need for new therapeutic targets for sepsis treatment and infection prevention (WHO, A73/32). In response to this unresolved clinical issue, the P2X7 receptor (P2X7R), a key component of the inflammatory cascade, has emerged as a potential target for treating inflammatory/infection diseases. Indeed numerous studies have demonstrated the relevance of the purinergic system as a pharmacological target in addressing immune-mediated inflammatory diseases by regulating immunity, inflammation, and organ function. In this review, we analyze key features of sepsis immunopathophysiology focusing in neonatal sepsis and on how the immunomodulatory role of P2X7R could be a potential pharmacological target for reducing the burden of neonatal sepsis.

Utility of doppler ultrasound in early-onset neonatal sepsis: A case-control study

BACKGROUND

Early-onset sepsis is one of the leading causes of neonatal morbidity and mortality worldwide and timely diagnosis is, therefore, of paramount importance. As there is a lack of literature regarding early alteration of the cerebral blood flow (CBF) in neonatal sepsis, our study aimed to appraise changes in the CBF velocities and Doppler indices in neonates with early-onset neonatal sepsis (EONS) and to assess its diagnostic accuracy.

METHODS

A total of 99 neonates were recruited in the study; 56 neonates with EONS, and the age-matched 43 neonates without any manifestations of sepsis. A Transcranial Doppler examination and cerebral hemodynamics were assessed in neonates during the first seventy-two hours of life. Doppler indices and CBFV were measured in the anterior cerebral artery (ACA), and middle cerebral artery (MCA), of either side. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated.

RESULTS

A significantly lower resistance in Resistivity (RI) and Pulsatility (PI) indices, a significant high end-diastolic velocity (EDV), and relatively higher peak systolic velocity (PSV) in both ACA and MCA have been documented within 72 hours of birth in neonates with EONS compared to the control group of neonates without sepsis.

CONCLUSION

Our Study revealed that assessment of CBF at early hours of birth by Transcranial Doppler examination showed alteration in cerebral hemodynamics in neonates with EONS with an increase in the CBF and a decrease in the resistance. It can be adopted as a bedside, noninvasive tool with immediate diagnostic value.

Early postnatal immature-to-total neutrophil ratio in the histological chorioamnionitis among neonatal intensive care unit infants

OBJECTIVE

Histological chorioamnionitis (hCAM) is a major risk factor for early-onset sepsis. Predictive methods for hCAM are needed in clinical practice during the early postnatal period. To examine the relationship between hCAM and perinatal variables including early postnatal immature-to-total neutrophil ratio (ITR).

STUDY DESIGN

A single-center study was undertaken at Ohta Nishinouchi Hospital between April 1, 2016 and June 30, 2023. Blood samples and placenta collected from study candidate infants admitted to the neonatal intensive care unit were assessed by univariate analyses and multivariate logistic regression analysis. We also assessed the test performance of ITR and maternal white blood cell (WBC) counts by area under a receiver operating characteristic (ROC) curves.

RESULTS

A total of 725 infants were analyzed (496 in the non-hCAM group and 229 in the hCAM group). Significant relationships were observed between hCAM and ITR (p < 0.001, odds ratio (OR), 1.067; 95% confidence interval (CI), 1.041 to 1.093). Per the ROC curves, an ITR (%) of 7.15 could predict hCAM at a sensitivity of 55.9% and specificity of 71.9% [area under the curve (AUC) = 0.691, p < 0.001, 95% CI, 0.649 to 0.733]. Further, maternal WBC counts of 9.85 ( × 109/L) predicted hCAM with 69.0% sensitivity and 67.3% specificity (AUC = 0.710, p < 0.001, 95%CI, 0.669 to 0.750).

CONCLUSIONS

Early postnatal ITR was high in cases with greater leukocyte invasion into the placenta tissue, which may be a biomarker of the presence and/or severity of hCAM. Histological CAM should be considered when the early neonatal ITR (%) is 7.15 or higher.

Sepsis Huddles in the Neonatal Intensive Care Unit: A Retrospective Cohort Study of Late-onset Infection Recognition and Severity Assessment

OBJECTIVE

To analyze relationships between provider-documented signs prompting sepsis evaluations, assessments of illness severity, and late-onset infection (LOI).

STUDY DESIGN

Retrospective cohort study of all infants receiving a sepsis huddle in conjunction with a LOI evaluation. Participants were ≥3 days old and admitted to a level IV neonatal intensive care unit (NICU) from September 2018 through May 2021. Data were extracted from standardized sepsis huddle notes in the electronic health record, including clinical signs prompting LOI evaluations, illness severity assessments (from least to most severe: green, yellow, and red), and management plans. To analyze relationships of sepsis huddle characteristics with the detection of culture-confirmed LOI (bacteremia, urinary tract infection, or meningitis), we utilized diagnostic test statistics, area under the receiver-operator characteristic analyses, and multivariable logistic regression.

RESULTS

We identified 1209 eligible sepsis huddles among 604 infants. There were 111 culture-confirmed LOI episodes (9% of all huddles). Twelve clinical signs of infection poorly distinguished infants with and without LOI, with sensitivity for each ranging from 2% to 36% and area under the receiver-operator characteristic ranging 0.49-0.53. Multivariable logistic regression identified increasing odds of infection with higher perceived illness severity at the time of sepsis huddle, adjusted for gestational age and receipt of intensive care supports.

CONCLUSIONS

Clinical signs prompting sepsis huddles were nonspecific and not predictive of concurrent LOI. Higher perceived illness severity was associated with presence of infection, despite some misclassification based on objective criteria. In level IV NICUs, antimicrobial stewardship through development of criteria for antibiotic noninitiation may be challenging, as presenting signs of LOI are similar among infants with and without confirmed infection.

Microbial cell-free DNA-sequencing as an addition to conventional diagnostics in neonatal sepsis

BACKGROUND

Bloodstream infections remain a challenge for neonatologists, as traditional culture-based methods are time-consuming and rely on adequate blood volume. Next-generation sequencing (NGS) offers an alternative, as it can identify microbial cell-free DNA (mcfDNA) in a small blood sample, providing rapid pathogen detection. This study aimed to assess the diagnostic performance of DISQVER®-NGS compared to blood cultures in neonatal patients with suspected sepsis.

METHODS

In neonates with suspected sepsis, blood cultures and samples for NGS were prospectively collected. Patients were divided into four categories: 1) sepsis, blood culture positive, 2) clinical sepsis, culture negative, 3) suspected sepsis, 4) validation cohort.

RESULTS

NGS detected bacterial, viral or fungal mcfDNA in 24 of 82 samples. Blood cultures were collected in 46 of 84 patients (15/46 positive). DISQVER® correctly identified pathogens in 9/15 patients with a positive blood culture, two with intrinsic resistance to their antibiotic regimen. In seven samples NGS reported the mcfDNA of bacteria that could have theoretically grown in culture but did not.

CONCLUSIONS

NGS may enhance sensitivity in sepsis diagnostics by detecting mcfDNA in neonates with suspected sepsis. Interpreting NGS results requires correlation with clinical data, laboratory values, and routine microbiological tests for a comprehensive understanding of the patient's condition.

IMPACT

Conventional blood culture methods have limitations in accuracy and turnaround time. The study aimed to investigate the diagnostic performance of the Next-Generation Sequencing method DISQVER® compared to traditional blood cultures in neonatal patients with suspected sepsis. Our findings suggest that NGS has the potential to augment the precision of conventional diagnostic techniques, can lead to improved detection of pathogens and targeted treatment approaches in neonatal sepsis. It is emphasized that further validation and integration with clinical and microbiological data are required to ensure optimal clinical utility.

The Validity of Positive Coagulase-Negative Staphylococcus Cultures for the Diagnosis of Sepsis in the Neonatal Unit

OBJECTIVE

Coagulase-negative Staphylococcus (CoNS) is the most frequent pathogen causing late-onset sepsis (LOS) in neonatal intensive care units (NICUs). Technical difficulties hinder blood culture (BC) collection and obtaining only one culture before initiating antibiotic therapy is a common practice. We sought to assess specific clinical information and CoNS cultures for the diagnosis of true bacteremia in the NICU.

STUDY DESIGN

This historical cohort study was conducted in NICUs at the Hadassah-Hebrew University Medical Center of Jerusalem in Israel. Clinical and laboratory data in every CoNS bacteremia were collected and compared between bacteremia groups as follows: true positive, two positive BCs; contaminant, one positive BC out of two; undefined, one BC obtained and found positive.

RESULTS

For 3.5 years, CoNS was isolated in 139 episodes. True positive was identified in 44 of 139 (31.7%), contaminant in 42 of 139 (30.2%), and the event was undefined in 53 of 139 (38.1%). Vancomycin treatment was more frequent in the true positive and undefined groups than the contaminant group (100, 90.6, and 73.8% respectively, p = 0.001); treatment was also prolonged in these two groups (p < 0.001). No clinical variables were associated with true bacteremia on multivariable analysis.

CONCLUSION

Diagnosis should definitely be based on at least two positive BCs, despite objective difficulties in obtaining BCs in neonates.

KEY POINTS

· CoNS is a frequent pathogen causing LOS in neonates.. · Due to technical difficulties, often only one culture is collected prior to antibiotic therapy.. · No clinical/laboratory variables were associated with the diagnosis of true CoNS bacteremia..

D-dimer as a Useful Biomarker in Early Diagnosis of Neonatal Sepsis: A Single-Center Study From Romania

BACKGROUND

This study evaluates the role of D-dimer in identifying neonatal sepsis and their potential value in clinical decision-making due to challenges in early detection.

METHODOLOGY

A case-control study was conducted on 102 neonates at the Children's Clinical Hospital "Louis Turcanu" in Timisoara, Romania, from October 2018 to July 2023. The participants were divided into two groups: those with neonatal sepsis and those without sepsis.

RESULTS

The study found that neonates with sepsis were more likely to be delivered by cesarean section and had higher rates of premature ruptured membranes compared to those without sepsis. The D-dimer biomarker's predictive value for sepsis was assessed using a receiver operating characteristic (ROC) curve, with an area under the curve (AUC) exceeding 0.982 and an optimum cutoff value of 342 ng/mL. An increase in neonatal D-dimer significantly increases the likelihood of sepsis by 2.7% per unit increase. A value above 250 ng/mL indicates a 127-fold increased likelihood of sepsis. The D-dimer's ability to predict mortality in newborns with sepsis is unsatisfactory, with an AUC of 0.528.

CONCLUSIONS

D-dimer, a potential biomarker of neonatal sepsis, warrants further clinical investigation to enhance diagnostic sensitivity and specificity, demonstrating its potential in conjunction with other sepsis markers.

Late Neonatal Sepsis in Very-low-birth-weight Premature Newborns Is Associated With Alterations in Neurodevelopment at Twenty-five Months of Age

AIM

To evaluate the impact of late-onset sepsis (LOS) on the neurodevelopment of very-low-birth-weight (VLBW) premature infants.

METHODS

This is a retrospective cohort study of VLBW premature infants. The Mental Development Index (MDI) was determined for a population of 546 VLBW infants, at 14 and 25 months of age, and evaluated using the Bayley test. A history of meningitis or early neonatal sepsis was considered an exclusion criterion. The study parameters analyzed included perinatal variables, the development of neonatal comorbidities and a history of LOS. Multivariate linear regression and multinomial logistic regression analyses were performed.

RESULTS

LOS was observed in 115 newborns, among whom microbiological testing showed that 65.0% presented Gram-positive bacteria, with Staphylococcus epidermidis being responsible for 55.4%. There was a significant association between the 25-month MDI and a history of LOS. This represents a decrease of 7.9 points in the MDI evaluation of newborns with a history of LOS. The latter history is also associated with the following neurodevelopmental alternations: mild motor disorders [odds ratio (OR): 2.75; 95% confidence intervals (CI): 1.07-7.05], moderate cognitive delay (OR: 3.07; 95% CI: 1.17-8.00) and cerebral palsy (OR: 2.41; 95% CI: 1.09-5.35).

CONCLUSIONS

In our study cohort, LOS was associated with alterations in neurodevelopment, including reduced MDI, together with motor and cognitive disorders and cerebral palsy. To improve neurodevelopmental outcomes in this group of newborns, neonatal intensive care unit personnel should focus attention on preventing hospital-acquired infections.

Reintroduction of Legacy Antibiotics in Neonatal Sepsis: The Special Role of Fosfomycin and Colistin

Neonatal sepsis is a leading cause of morbidity and mortality in neonates, particularly in low- and middle-income countries. The emergence of antimicrobial resistance is a rapidly growing global problem. A significant proportion of the pathogens that commonly cause neonatal sepsis are resistant to multiple antibiotics. Therefore, for the empirical treatment of neonatal sepsis, the repurposing of older antibiotics that are effective against multidrug-resistant pathogens is being investigated. This review aims to provide an overview of current research and experience using the repurposed antibiotics colistin and fosfomycin for the empirical treatment of neonatal sepsis. Based on current knowledge, colistin and fosfomycin may be potentially helpful for the empirical treatment of sepsis in neonates due to their efficacy against a wide range of pathogens and acceptable safety profile.

Late onset neonatal sepsis: Can plasma gelsolin be a promising diagnostic marker?

Plasma gelsolin (pGSN) correlates with clinical improvement in septic patients. We aimed to investigate pGSN levels as a diagnostic and prognostic marker of neonatal late-onset-sepsis (LOS). A case-control study was done on 184 neonates (92 with LOS and 92 controls). All participants were subjected to detailed history taking, full clinical evaluation, sepsis workup, and pGSN enzyme-linked immunosorbent-assay measurement. We detected significantly lower pGSN level among cases compared to controls (90.63 ± 20.64 vs 451.83 ± 209.59). It was significantly related to the severity of sepsis and mortality, with significantly lower values among cases with septic shock and multiorgan failure and non-survivors. Follow-up pGSN significantly increased after sepsis improvement in survivors compared to admission values. pGSN might be a reliable diagnostic and prognostic marker for LOS.

The Relationship Between Blood Culture, C-reactive Protein, and Neonatal Sepsis: A Cross-Sectional Study

Background Sepsis is one of the most common causes of morbidity and mortality in newborns. Diagnosis of neonatal sepsis may be difficult because the clinical presentations are often nonspecific. Neonatal sepsis may have an early onset (zero to three days) or a late onset (four days or later). Onset is most rapid in premature neonates. In this study, we aimed to assess the correlation between positive cultures, high C-reactive protein (CRP) levels, and the diagnosis of neonatal sepsis. Methodology This descriptive, prospective, cross-sectional study was undertaken over four months starting from December 15, 2019, to April 15, 2020, in Atbara Teaching Hospital, Sudan. Data were collected from 71 patients. CRP levels were measured, and blood cultures were performed. Results High CRP level >10 mg/L was seen in patients having positive blood culture (55.3%), mainly in preterm babies (CRP >10 mg/dL (61.1%), positive culture (55.6%)) and very low birth weight babies (CRP >10 mg/dL (83.3%) and positive culture (67%)). Conclusions Our findings suggest that Klebsiella is an important cause of neonatal sepsis. CRP was positive in babies mainly with proven sepsis. There is a high correlation between CRP and blood culture in patients with neonatal sepsis which may give access to remodeling the prioritization of the management options in the clinical setting.

Bacteriological profile and antibiotic susceptibility pattern of septicemia in neonatal intensive care units in Palestine: A retrospective study

Objectives

The aim of this study was to identify the prevalent pathogens that caused neonatal septicemia and their corresponding antimicrobial sensitivities in the neonatal intensive care unit (NICU) in the West Bank.

Methods

In this retrospective study, we extracted records of neonates with suspected neonatal sepsis (NS) admitted to three NICUs in the West Bank between 2019 and 2021 from the Ministry of Health's electronic database.

Results

Out of 6090 suspected episodes of NS, 884 tested positive for blood cultures, and 554 were primary cases; 59.5% were male, 26.6% were preterm, and 52.7% were aged 0-7 days. Moreover, 29% of 884 positive cultures were contributed by multidrug-resistant organisms (MDRO). Only 14.6% of episodes aligned with both Word Health Organization-recommended antibiotic regimens, 5.2% matched with one regimen, and 80.3% did not match either regimen. Specifically, 19.6% of cases matched with ampicillin-gentamicin, and 14.7% matched with ampicillin-cefotaxime. The likelihood of a match between early-onset sepsis and empiric antibiotic regimens was greater than late-onset sepsis (odds ratio = 2.549, [95% confidence interval: 1.276-5.092]). MDRO was more likely than non-MDRO to match with one antibiotic regimen (odds ratio = 4.142 [95% confidence interval: 1.913-8.966]).

Conclusion

There is an alarming prevalence of MDRO among Palestinian neonates in the NICU of the West Bank. The study highlights the urgent need for implementation of effective infection control measures and antimicrobial stewardship programs in the NICUs of hospitals in the West Bank to reduce the prevalence of MDRO and improve neonatal health outcomes.

Bone and joint infection complicated with sepsis in neonates and infants under three months of age

OBJECTIVE

Studies focusing on bone and joint infections (BJIs) in young infants are rare. Some cases of BJI are accompanied by sepsis. This study aimed to identify the clinical and bacteriological features of sepsis in neonates and young infants with BJIs.

METHODS

Neonates and infants younger than 3 months diagnosed with BJI in the present institution from 2014 to 2021 were retrospectively reviewed. Patient characteristics, clinical data, and outcomes were documented and compared between those with and without sepsis.

RESULTS

Twenty-five patients with a mean age of 34.8 days were included. Nine BJI cases had concomitant sepsis (group A), and 16 had BJI without sepsis (group B). Within group A, staphylococcus aureus was the major pathogenic germ (5 cases, of which 4 were of the methicillin-resistant staphylococcus aureus (MRSA) type). There was no statistical difference in male-to-female ratio, age, history of hospitalization, anemia, birth asphyxia, peripheral leukocyte counts, C-reactive protein on admission, and sequelae between groups. Univariate analyses indicated a significant difference in the incidence of septic arthritis (SA) combined with osteomyelitis (OM) (88.9% vs 37.5%), congenital deformities (44.4% vs 0%), and mean duration of symptoms (2.83 days vs 9.21 days) in comparisons between groups A and B.

CONCLUSION

Staphylococcus aureus is the main pathogenic bacteria in BJI cases complicated with sepsis in neonates and young infants. Among infants younger than 3 months diagnosed with BJI, those with concurrent SA and OM, MRSA infection, or congenital deformities are more likely to develop sepsis.

Contribution of Concurrent Comorbidities to Sepsis-Related Mortality in Preterm Infants ≤32 Weeks of Gestation at an Academic Neonatal Intensive Care Network

OBJECTIVE

This study sought to identify concurrent major comorbidities in preterm infants ≤32 weeks of gestation that may have contributed to sepsis-related mortality following a diagnosis of bacteremia or blood culture-negative sepsis within the neonatal period (≤28 days of life).

STUDY DESIGN

This is a retrospective chart review of infants ≤32 weeks of gestation who were admitted to a single academic network of multiple neonatal intensive care units between January 1, 2012, and December 31, 2015, to determine the primary cause(s) and timing of death in those diagnosed with bacteremia or blood culture-negative sepsis. Direct comparisons between early-onset sepsis (EOS; ≤72 hours) and late-onset sepsis (LOS; >72 hours) were made.

RESULTS

In our study cohort, of 939 total patients with ≤32 weeks of gestation, 182 infants were diagnosed with 198 episodes of sepsis and 7.7% (14/182) died. Mortality rates did not significantly differ between neonates with bacteremia or blood culture-negative sepsis (7/14 each group), and those diagnosed with EOS compared with LOS (6/14 vs. 8/14). Nearly 80% (11/14) of infants were transitioned to comfort care prior to their death secondary to a coinciding diagnosis of severe grade-3 or -4 intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, and/or intestinal perforation.

CONCLUSION

Preexisting comorbidities commonly associated with extreme preterm birth contributed to sepsis-related mortality in our patient cohort.

KEY POINTS

· Concurrent comorbidities contribute to, and may artificially inflate, sepsis-related mortality.. · Absence of a consensus definition for neonatal sepsis complicates the investigation of infection.. · Accurate assessment of the incidence of sepsis in very low birth weight infants is vital for future investigations..

Switch from intravenous-to-oral antibiotics in neonatal probable and proven early-onset infection: a prospective population-based real-life multicentre cohort study

OBJECTIVE

To evaluate the implementation of switch from intravenous-to-oral antibiotic therapy with amoxicillin in neonates with early-onset infection (EOI).

DESIGN, SETTING AND PATIENTS

A population-based multicentre cohort study. All term-born neonates with EOI were prospectively included between 1 December 2018 to 30 November 2020.

INTERVENTION

Intravenous-to-oral switch antibiotic therapy in clinically stable neonates.

MAIN OUTCOME MEASURES

The primary outcome was readmission due to infection. Secondary outcomes were days of hospitalisation and antibiotic use in the pre-implementation versus post implementation period.

RESULTS

During 2 years, 835 neonates commenced antibiotics for EOI (1.5% (95% CI 1.4% to 1.6%)) of all term live births). Of those, 554 (66%) underwent a full course of treatment. There were 23 episodes of culture-proven infection (0.42 per 1000 term live births (95% CI 0.27 to 0.63)). A total of 478 of 531 (90%) neonates with probable infection underwent switch therapy. None was readmitted due to infection. The median duration of hospitalisation was 3.0 days (IQR 2.5-3.5) and 7.4 days (IQR 7.0-7.5) in the switch and intravenous therapy groups, respectively. According to antibiotic surveillance data, 1.2% underwent a full course of treatment following implementation of oral switch therapy (2019-2020), compared with 1.2% before (2017-2018).

CONCLUSION

In clinical practice, switch therapy was safe and used in 9 of 10 neonates with probable EOI. Knowledge of the safety of antibiotic de-escalation is important as home-based oral therapy ameliorates the treatment burden for neonates, caregivers and healthcare systems. Despite the ease of oral administration, implementation of switch therapy did not increase the overall use of antibiotics.

Protocol for the development of a core outcome set for neonatal sepsis (NESCOS)

Neonatal sepsis is a serious public health problem; however, there is substantial heterogeneity in the outcomes measured and reported in research evaluating the effectiveness of the treatments. Therefore, we aim to develop a Core Outcome Set (COS) for studies evaluating the effectiveness of treatments for neonatal sepsis. Since a systematic review of key outcomes from randomised trials of therapeutic interventions in neonatal sepsis was published recently, we will complement this with a qualitative systematic review of the key outcomes of neonatal sepsis identified by parents, other family members, parent representatives, healthcare providers, policymakers, and researchers. We will interpret the outcomes of both studies using a previously established framework. Stakeholders across three different groups i.e., (1) researchers, (2) healthcare providers, and (3) patients' parents/family members and parent representatives will rate the importance of the outcomes in an online Real-Time Delphi Survey. Afterwards, consensus meetings will be held to agree on the final COS through online discussions with key stakeholders. This COS is expected to minimize outcome heterogeneity in measurements and publications, improve comparability and synthesis, and decrease research waste.

Clinical Utility of Procalcitonin and C-Reactive Protein in the Management of Neonatal Sepsis in a Resource-Limited Nigerian Hospital

BACKGROUND

Neonatal sepsis is an invasive infection of the bloodstream in neonates and a leading cause of morbidity and mortality among them.

AIM

To investigate the role of procalcitonin (PCT) and C-reactive protein (CRP) in the management of neonatal sepsis.

MATERIALS AND METHODS

This was a prospective case-control study over one-year period using convenience sampling. Blood samples for PCT and CRP were taken from all neonates, while blood culture and white blood cell count samples were additionally taken from babies with neonatal sepsis. PCT and CRP were repeated at 24 and 48 hours. The continuous variables were found to have a nonparametric distribution. They were presented as median and interquartile range, and compared using Wilcoxon signed rank and Friedman test as appropriate.

RESULTS

The blood culture analysis yielded a prevalence of 12.7% with Staphylococcus aureus being the commonest organism. Baseline concentrations of PCT (1.28 ng/ml) and CRP (17.31 mg/L) in neonates with sepsis were higher than that of controls (PCT-0.63 ng/ml, CRP-5.40 mg/L). PCT concentrations decreased after two days of antibiotic treatment, while CRP concentrations decreased after a day. The concentration of both decreased to normal levels after two days of treatment.

CONCLUSION

This study showed that CRP was more reliable in monitoring antibiotic therapy, unlike other studies which suggested PCT. In cases where the management of neonatal sepsis may be limited by a low blood culture yield, therapeutic monitoring may be aided by CRP and/or PCT.

Long-term neurological and neurodevelopmental outcome of neonatal listeriosis in France: a prospective, matched, observational cohort study

BACKGROUND

Maternal-neonatal listeriosis is a rare and serious infection. The long-term outcome of surviving infants with early-onset or late-onset listeriosis remains unknown. We aimed to determine the long-term neurological and neurodevelopmental outcome of neonatal listeriosis.

METHODS

In this prospective, matched, observational cohort study, we evaluated children born with microbiologically confirmed maternal-neonatal listeriosis in the French MONALISA cohort. At age 5 years, children underwent neurological and neurodevelopmental assessments of sensory deficits, executive function, adaptive behaviour, and cognitive and motor coordination function. The cognitive domain was assessed using the French version of the Wechsler Preschool and Primary Scale of Intelligence, fourth edition, and scored by Full Scale Intelligence Quotient (FSIQ). The motor domain was assessed by physical examination designed to screen for cerebral palsy and developmental coordination disorder. Executive functioning was assessed using the statue and inhibition subtests of Neuropsychological Assessment, second version. The sensory domain was assessed by parental interview, medical report, and clinical assessment. Adaptive behaviour was measured using the Vineland-II behaviour scale from parent-reported assessments of functional communication, socialisation, daily living, and motor skills. Results were compared with gestational age-matched children from two national prospective cohorts: EPIPAGE-2 (preterm infants) and ELFE (term infants from a general population of infants >32 weeks gestation). This study is registered with ClinicalTrials.gov (NCT02580812).

FINDINGS

Of 59 children who were alive and eligible to participate in the study, 53 (median age 5 years, IQR 5-6) were enrolled for neurodevelopmental assessments between Oct 26, 2016, and Oct 29, 2019. Of 53 children, 31 (58%) had been born preterm, 22 (42%) had early-onset systemic infection, 18 (34%) had early-onset non-systemic infection, and six (11%) had late-onset systemic infection, all with meningitis. 29 (66%) of 44 children, in whom neurodevelopmental disabilities scores were available, developed at least one disability; eight (18%) children had severe neurodevelopmental disabilities. Of four children with late-onset infection and in whom neurodevelopmental disabilities scores were available, three developed at least one neurodevelopmental disability. Neurological and neurodevelopmental outcomes of children with neonatal listeriosis did not differ from those of gestational age-matched control children without infection (relative risk [RR] of at least one disability 0·99 [95% CI 0·65-1·51; p=0·97]; RR of FSIQ less than -1 SD 0·92 [0·54-1·54; p=0·74]).

INTERPRETATION

These results highlight the burden of persistent disability and dominant contribution of prematurity to long-term outcomes in children born with neonatal listeriosis. The findings support the implementation of systematic long-term screening and provision of tailored education and special needs support.

FUNDING

Institut Pasteur, Inserm, French Public Health Agency, Contrat de Recherche Clinique, and Assistance Publique-Hôpitaux de Paris.

Nonsynchronized nasal intermittent positive pressure ventilation versus continuous positive airway pressure as a primary mode of respiratory support in neonates (26-40 weeks) admitted in a tertiary care center: A randomized controlled trial

INTRODUCTION

Continuous positive airway pressure (CPAP) is a standard respiratory care for neonates for last few decades but it too has a high failure rate. Nasal intermittent positive pressure ventilation (NIPPV) is proven to be superior to CPAP in maintaining higher mean airway pressure in neonates with Respiratory Distress Syndrome. The main objective of this study was to compare failure within 72 h of initiation of primary respiratory support between nonsynchronized NIPPV and CPAP in all causes of respiratory distress in newborn infants. Secondarily feed intolerance, Necrotizing enterocolitis (NEC > stage II), hemodynamically significant patent ductus arteriosus, intraventricular hemorrhage (IVH > gradeIII), retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), duration of support and mortality were also compared.

METHODS

This was a single center randomized controlled trial. Stratified randomization was done for 216 neonates, based on the gestational age in two subgroups 26-33 weeks and 34-40 weeks whopresented with respiratory distress within 5 days of birth, to receive either NIPPV or CPAP. Primary and secondary outcomes were documented.

RESULTS

Statisticalsignificant difference was noted for primary outcome (RR 0.48 [confidence interval = 0.301-0.786], p = 0.003) but not for other secondary outcomes. NIPPV appeared superior in respect to noninvasiveventilation days, BPD occurrence and hospitalization duration.

CONCLUSION

As a primary mode, nonsynchronized NIPPV was more efficacious than CPAP in preventing intubation within 72 h of initiation of respiratory support. Further multicenter studies are warranted to explore the benefits of this respiratory support.

Prognostic value of blood inflammatory parameters for predicting mortality in neonates with sepsis

BACKGROUND

Neonatal sepsis is a major cause of morbidity and mortality in neonates. The diagnosis of neonatal sepsis has been widely explored using blood inflammatory parameters. However, few researches have focused on the predictive significance of blood inflammation parameters for predicting mortality. This study aimed to evaluate the prognostic value of blood inflammatory parameters, including white blood cell (WBC), neutrophil, lymphocyte, monocyte, platelet and C-reactive protein (CRP) for predicting mortality in neonates with sepsis.

METHODS

Neonates with culture-proven sepsis were enrolled in this study. The clinical characteristics and levels of white blood cell, neutrophil, lymphocyte, monocyte, platelet and CRP were recorded. The receiver-operating characteristic (ROC) curve was applied to calculate the area under the curve (AUC) and determine the optimal cutoff values. Multivariable Cox regression model was used to evaluate the independent prognostic significance of variables. Kaplan-Meier curve was used to assess survival.

RESULTS

A total of 188 neonates with culture-proven sepsis were included for analysis. The 7-day mortality rate was 11.2 % (21/188) and the 28-day mortality rate was 13.8 % (26/188). The levels of white blood cell, neutrophil, monocyte and platelet in non-survivors were lower than those in survivors (P < 0.05). Platelet yielded higher AUC values than other parameters for predicting mortality with the best cutoff value of 132 × 109/L, followed by WBC with the optimal cutoff value of 6.15 × 109/L. Multivariable Cox regression analysis showed platelet and WBC were independent prognostic factors for predicting mortality. Low platelet group showed lower survival according to Kaplan-Meier method.

CONCLUSIONS

In conclusion, the levels of platelet and WBC on the day of sepsis onset are valuable indicators for predicting mortality in neonates with sepsis.

Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Neonates with Early-Onset Infection

BACKGROUND

The discriminative utility of the neonatal sequential organ failure assessment (nSOFA) for early-onset sepsis (EOS) mortality in the neonatal intensive care unit (NICU) is unknown.

OBJECTIVES

The objective of the study was to determine the utility of nSOFA for EOS mortality.

METHODS

Multicenter, retrospective cohort study of NICU patients with EOS between 2012 and 2023. nSOFA scores of survivors and non-survivors were compared, and area under the receiver operating characteristics curve (AUROC) for mortality was calculated.

RESULTS

104 subjects were identified (88 lived, 16 died). AUROC at blood culture collection (T0), 6 h after collection (T6), and the maximum nSOFA at T0 or T6 (T0-6max) were 0.76 (95% CI: 0.62, 0.91), 0.89 (0.80, 0.99), and 0.87 (0.77, 0.97), respectively. Analyses restricted to birthweight (<1.5, <1 kg) or gestational age (<32, <29 week) cutoffs revealed AUROC ranges of 0.86-0.92 for T6 and 0.82-0.84 for T0-6max.

CONCLUSIONS

The nSOFA showed good-to-excellent discrimination of mortality among infants with EOS in the NICU.

Biomarkers of Neonatal Sepsis: Where We Are and Where We Are Going

Neonatal sepsis is a bacterial bloodstream infection leading to severe clinical manifestations frequently associated with death or irreversible long-term deficits. Antibiotics are the drug of choice to treat sepsis, regardless of age. In neonates, the lack of reliable criteria for a definite diagnosis and the supposition that an early antibiotic administration could reduce sepsis development in children at risk have led to a relevant antibiotic overuse for both prevention and therapy. The availability of biomarkers of neonatal sepsis that could alert the physician to an early diagnosis of neonatal sepsis could improve the short and long-term outcomes of true sepsis cases and reduce the indiscriminate and deleterious use of preventive antibiotics. The main aim of this narrative review is to summarize the main results in this regard and to detail the accuracy of currently used biomarkers for the early diagnosis of neonatal sepsis. Literature analysis showed that, despite intense research, the diagnosis of neonatal sepsis and the conduct of antibiotic therapy cannot be at present decided on the basis of a single biomarker. Given the importance of the problem and the need to reduce the abuse of antibiotics, further studies are urgently required. However, instead of looking for new biomarkers, it seems easier and more productive to test combinations of two or more of the presently available biomarkers. Moreover, studies based on omics technologies should be strongly boosted. However, while waiting for new information, the use of the clinical scores prepared by some scientific institutions could be suggested. Based on maternal risk factors and infant clinical indicators, sepsis risk can be calculated, and a significant reduction in antibiotic consumption can be obtained.

Molecularly Imprinted Polymer-Based Electrochemical Sensors for the Diagnosis of Infectious Diseases

The appearance of biological molecules, so-called biomarkers in body fluids at abnormal concentrations, is considered a good tool for detecting disease. Biomarkers are usually looked for in the most common body fluids, such as blood, nasopharyngeal fluids, urine, tears, sweat, etc. Even with significant advances in diagnostic technology, many patients with suspected infections receive empiric antimicrobial therapy rather than appropriate treatment, which is driven by rapid identification of the infectious agent, leading to increased antimicrobial resistance. To positively impact healthcare, new tests are needed that are pathogen-specific, easy to use, and produce results quickly. Molecularly imprinted polymer (MIP)-based biosensors can achieve these general goals and have enormous potential for disease detection. This article aimed to overview recent articles dedicated to electrochemical sensors modified with MIP to detect protein-based biomarkers of certain infectious diseases in human beings, particularly the biomarkers of infectious diseases, such as HIV-1, COVID-19, Dengue virus, and others. Some biomarkers, such as C-reactive protein (CRP) found in blood tests, are not specific for a particular disease but are used to identify any inflammation process in the body and are also under consideration in this review. Other biomarkers are specific to a particular disease, e.g., SARS-CoV-2-S spike glycoprotein. This article analyzes the development of electrochemical sensors using molecular imprinting technology and the used materials' influence. The research methods, the application of different electrodes, the influence of the polymers, and the established detection limits are reviewed and compared.

Use of an electronic medical record to optimize a neonatal sepsis score for mortality prediction

OBJECTIVE

Late-onset sepsis (LOS) is a significant cause of mortality in preterm infants. The neonatal sequential organ failure assessment (nSOFA) provides an objective assessment of sepsis risk but requires manual calculation. We developed an EMR pipeline to automate nSOFA calculation for more granular analysis of score performance and to identify optimal alerting thresholds.

METHODS

Infants born <33 weeks of gestation with LOS were included. A SQL-based pipeline calculated hourly nSOFA scores 48 h before/after sepsis evaluation. Sensitivity analysis identified the optimal timing and threshold of nSOFA for LOS mortality.

RESULTS

Eighty episodes of LOS were identified (67 survivors, 13 non-survivor). Non-survivors had persistently elevated nSOFA scores, markedly increasing 12 h prior to culture. At sepsis evaluation, the AUC for nSOFA >2 was 0.744 (p = 0.0047); thresholds of >3 and >4 produced lower AUCs.

CONCLUSIONS

nSOFA is persistently elevated for infants with LOS mortality compared to survivors with an optimal alert threshold >2.

Antiseptic solutions for skin preparation during central catheter insertion in neonates

BACKGROUND

Central venous catheters (CVC) are associated with potentially dangerous complications such as thromboses, pericardial effusions, extravasation, and infections in neonates. Indwelling catheters are amongst the main risk factors for nosocomial infections. The use of skin antiseptics during the preparation for central catheter insertion may prevent catheter-related bloodstream infections (CRBSI) and central line-associated bloodstream infections (CLABSI). However, it is still not clear which antiseptic solution is the best to prevent infection with minimal side effects.

OBJECTIVES

To systematically evaluate the safety and efficacy of different antiseptic solutions in preventing CRBSI and other related outcomes in neonates with CVC.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and trial registries up to 22 April 2022. We checked reference lists of included trials and systematic reviews that related to the intervention or population examined in this Cochrane Review.  SELECTION CRITERIA: Randomised controlled trials (RCTs) or cluster-RCTs were eligible for inclusion in this review if they were performed in the neonatal intensive care unit (NICU), and were comparing any antiseptic solution (single or in combination) against any other type of antiseptic solution or no antiseptic solution or placebo in preparation for central catheter insertion. We excluded cross-over trials and quasi-RCTs.

DATA COLLECTION AND ANALYSIS

We used the standard methods from Cochrane Neonatal. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included three trials that had two different comparisons: 2% chlorhexidine in 70% isopropyl alcohol (CHG-IPA) versus 10% povidone-iodine (PI) (two trials); and CHG-IPA versus 2% chlorhexidine in aqueous solution (CHG-A) (one trial). A total of 466 neonates from level III NICUs were evaluated. All included trials were at high risk of bias. The certainty of the evidence for the primary and some important secondary outcomes ranged from very low to moderate. There were no included trials that compared antiseptic skin solutions with no antiseptic solution or placebo. CHG-IPA versus 10% PI Compared to PI, CHG-IPA may result in little to no difference in CRBSI (risk ratio (RR) 1.32, 95% confidence interval (CI) 0.53 to 3.25; risk difference (RD) 0.01, 95% CI -0.03 to 0.06; 352 infants, 2 trials, low-certainty evidence) and all-cause mortality (RR 0.88, 95% CI 0.46 to 1.68; RD -0.01, 95% CI -0.08 to 0.06; 304 infants, 1 trial, low-certainty evidence). The evidence is very uncertain about the effect of CHG-IPA on CLABSI (RR 1.00, 95% CI 0.07 to 15.08; RD 0.00, 95% CI -0.11 to 0.11; 48 infants, 1 trial; very low-certainty evidence) and chemical burns (RR 1.04, 95% CI 0.24 to 4.48; RD 0.00, 95% CI -0.03 to 0.03; 352 infants, 2 trials, very low-certainty evidence), compared to PI. Based on a single trial, infants receiving CHG-IPA appeared less likely to develop thyroid dysfunction compared to PI (RR 0.05, 95% CI 0.00 to 0.85; RD -0.06, 95% CI -0.10 to -0.02; number needed to treat for an additional harmful outcome (NNTH) 17, 95% CI 10 to 50; 304 infants). Neither of the two included trials assessed the outcome of premature central line removal or the proportion of infants or catheters with exit-site infection. CHG-IPA versus CHG-A The evidence suggests CHG-IPA may result in little to no difference in the rate of proven CRBSI when applied on the skin of neonates prior to central line insertion (RR 0.80, 95% CI 0.34 to 1.87; RD -0.05, 95% CI -0.22 to 0.13; 106 infants, 1 trial, low-certainty evidence) and CLABSI (RR 1.14, 95% CI 0.34 to 3.84; RD 0.02, 95% CI -0.12 to 0.15; 106 infants, 1 trial, low-certainty evidence), compared to CHG-A. Compared to CHG-A, CHG-IPA probably results in little to no difference in premature catheter removal (RR 0.91, 95% CI 0.26 to 3.19; RD -0.01, 95% CI -0.15 to 0.13; 106 infants, 1 trial, moderate-certainty evidence) and chemical burns (RR 0.98, 95% CI 0.47 to 2.03; RD -0.01, 95% CI -0.20 to 0.18; 114 infants, 1 trial, moderate-certainty evidence). No trial assessed the outcome of all-cause mortality and the proportion of infants or catheters with exit-site infection.

AUTHORS' CONCLUSIONS

Based on current evidence, compared to PI, CHG-IPA may result in little to no difference in CRBSI and mortality. The evidence is very uncertain about the effect of CHG-IPA on CLABSI and chemical burns. One trial showed a statistically significant increase in thyroid dysfunction with the use of PI compared to CHG-IPA. The evidence suggests CHG-IPA may result in little to no difference in the rate of proven CRBSI and CLABSI when applied on the skin of neonates prior to central line insertion. Compared to CHG-A, CHG-IPA probably results in little to no difference in chemical burns and premature catheter removal. Further trials that compare different antiseptic solutions are required, especially in low- and middle-income countries, before stronger conclusions can be made.

Diagnostic Performance and Patient Outcomes With C-Reactive Protein Use in Early-Onset Sepsis Evaluations

OBJECTIVES

To determine performance of C-reactive protein (CRP) in the diagnosis of early-onset sepsis, and to assess patient outcomes with and without routine use of CRP.

STUDY DESIGN

This was a retrospective cohort study of infants admitted to 2 neonatal intensive care units. CRP was used routinely in early-onset sepsis evaluations during 2009-2014; this period was used to determine CRP performance at a cut-off of ≥10 mg/L in diagnosis of culture-confirmed early-onset sepsis. Routine CRP use was discontinued during 2018-2020; outcomes among infants admitted during this period were compared with those in 2012-2014.

RESULTS

From 2009 to 2014, 10 134 infants were admitted; 9103 (89.8%) had CRP and 7549 (74.5%) had blood culture obtained within 3 days of birth. CRP obtained ±4 hours from blood culture had a sensitivity of 41.7%, specificity 89.9%, and positive likelihood ratio 4.12 in diagnosis of early-onset sepsis. When obtained 24-72 hours after blood culture, sensitivity of CRP increased (89.5%), but specificity (55.7%) and positive likelihood ratio (2.02) decreased. Comparing the periods with (n = 4977) and without (n = 5135) routine use of CRP, we observed lower rates of early-onset sepsis evaluation (74.5% vs 50.5%), antibiotic initiation (65.0% vs 50.8%), and antibiotic prolongation in the absence of early-onset sepsis (17.3% vs 7.2%) in the later period. Rate and timing of early-onset sepsis detection, transfer to a greater level of care, and in-hospital mortality were not different between periods.

CONCLUSIONS

CRP diagnostic performance was not sufficient to guide decision-making in early-onset sepsis. Discontinuation of routine CRP use was not associated with differences in patient outcomes despite lower rates of antibiotic administration.

Bacterial Aetiology of Neonatal Sepsis and Antimicrobial Resistance Pattern at the Regional Referral Hospital, Dar es Salam, Tanzania; A Call to Strengthening Antibiotic Stewardship Program

The diagnosis of neonatal sepsis in lower-income countries is mainly based on clinical presentation. The practice necessitates empirical treatment with limited aetiology and antibiotic susceptibility profile knowledge, prompting the emergence and spread of antimicrobial resistance. We conducted a cross-sectional study to determine the aetiology of neonatal sepsis and antimicrobial resistance patterns. We recruited 658 neonates admitted to the neonatal ward with signs and symptoms of sepsis and performed 639 automated blood cultures and antimicrobial susceptibility testing. Around 72% of the samples were culture positive; Gram-positive bacteria were predominantly isolated, contributing to 81%. Coagulase-negative Staphylococci were the most isolates, followed by Streptococcus agalactiae. Overall, antibiotic resistance among Gram-positive pathogens ranged from 23% (Chloramphenicol) to 93% (Penicillin) and from 24.7% (amikacin) to 91% (ampicillin) for Gram-negative bacteria. Moreover, about 69% of Gram-positive and 75% of Gram-negative bacteria were multidrug-resistant (MDR). We observed about 70% overall proportion of MDR strains, non-significantly more in Gram-negative than Gram-positive pathogens (p = 0.334). In conclusion, the pathogen causing neonatal sepsis in our setting exhibited a high resistance rate to commonly used antibiotics. The high rate of MDR pathogens calls for strengthening antibiotic stewardship programs.

Sequential organ failure assessment scores to predict outcomes: from adults to neonates

PURPOSE OF REVIEW

Organ dysfunction severity scores (sequential organ failure assessment or SOFA) are commonly used in the adult and pediatric populations when assessing risk of mortality and adverse outcomes from sepsis. In contrast to sepsis definition in adults and children, clinical and laboratory criteria for defining neonatal sepsis have been inconclusive. More recently, studies have attempted to better understand the clinical progression of neonatal sepsis and associated mortality. This data has guided the development of a neonatal SOFA (nSOFA) score, based on common patterns of organ dysfunction observed in this population.

RECENT FINDINGS

Although SOFA scores in the adult and pediatric populations have their limitations with moderate sensitivities and specificities depending on the clinical setting, the nSOFA score has been validated in predicting sepsis attributable mortality in very low birth weight (VLBW) infants across several patient cohorts. Furthermore, the nSOFA score has been adapted for use in neonatal disease states, other than sepsis, with similar prognostic utility.

SUMMARY

Utilizing an nSOFA scoring system for prediction of sepsis attributable mortality in preterm infants allows for targeted interventions based on risk stratification, as well as better delineation of neonatal sepsis with subsequent improvements in research and patient safety outcomes.

Interventions for reducing late-onset sepsis in neonates: an umbrella review

OBJECTIVES

Neonatal sepsis is one of the leading causes of neonatal deaths in neonatal intensive care units. Hence, it is essential to review the evidence from systematic reviews on interventions for reducing late-onset sepsis (LOS) in neonates.

METHODS

PubMed and the Cochrane Central were searched from inception through August 2020 without any language restriction. Cochrane reviews of randomized clinical trials (RCTs) assessing any intervention in the neonatal period and including one or more RCTs reporting LOS. Two authors independently performed screening, data extraction, assessed the quality of evidence using Cochrane Grading of Recommendations Assessment, Development and Evaluation, and assessed the quality of reviews using a measurement tool to assess of multiple systematic reviews 2 tool.

RESULTS

A total of 101 high-quality Cochrane reviews involving 612 RCTs and 193,713 neonates, evaluating 141 interventions were included. High-quality evidence showed a reduction in any or culture-proven LOS using antibiotic lock therapy for neonates with central venous catheters (CVC). Moderate-quality evidence showed a decrease in any LOS with antibiotic prophylaxis or vancomycin prophylaxis for neonates with CVC, chlorhexidine for skin or cord care, and kangaroo care for low birth weight babies. Similarly, moderate-quality evidence showed reduced culture-proven LOS with intravenous immunoglobulin prophylaxis for preterm infants and probiotic supplementation for very low birth weight (VLBW) infants. Lastly, moderate-quality evidence showed a reduction in fungal LOS with the use of systemic antifungal prophylaxis in VLBW infants.

CONCLUSIONS

The overview summarizes the evidence from the Cochrane reviews assessing interventions for reducing LOS in neonates, and can be utilized by clinicians, researchers, policymakers, and consumers for decision-making and translating evidence into clinical practice.

Effects of Sepsis on Immune Response, Microbiome and Oxidative Metabolism in Preterm Infants

This is a narrative review about the mechanisms involved in bacterial sepsis in preterm infants, which is an illness with a high incidence, morbidity, and mortality. The role of the innate immune response and its relationship with oxidative stress in the pathogenesis are described as well as their potential implementation as early biomarkers. Moreover, we address the impact that all the mechanisms triggered by sepsis have on the dysbiosis and the changes on neonatal microbiota.

The Role of Coagulase-Negative Staphylococci Biofilms on Late-Onset Sepsis: Current Challenges and Emerging Diagnostics and Therapies

Infections are one of the most significant complications of neonates, especially those born preterm, with sepsis as one of the principal causes of mortality. Coagulase-negative staphylococci (CoNS), a group of staphylococcal species that naturally inhabit healthy human skin and mucosa, are the most common cause of late-onset sepsis, especially in preterms. One of the risk factors for the development of CoNS infections is the presence of implanted biomedical devices, which are frequently used for medications and/or nutrient delivery, as they serve as a scaffold for biofilm formation. The major concerns related to CoNS infections have to do with the increasing resistance to multiple antibiotics observed among this bacterial group and biofilm cells’ increased tolerance to antibiotics. As such, the treatment of CoNS biofilm-associated infections with antibiotics is increasingly challenging and considering that antibiotics remain the primary form of treatment, this issue will likely persist in upcoming years. For that reason, the development of innovative and efficient therapeutic measures is of utmost importance. This narrative review assesses the current challenges and emerging diagnostic tools and therapies for the treatment of CoNS biofilm-associated infections, with a special focus on late-onset sepsis.

Global, regional, and national burden of neonatal sepsis and other neonatal infections, 1990-2019: findings from the Global Burden of Disease Study 2019

To provide an overview of the global, regional, and national incidence and mortality of neonatal sepsis and other neonatal infections (NS) and their change trends from 1990 to 2019, based on the data from the 2019 Global Burden of Disease study. This was a retrospective demographic analysis based on aggregated data. Annual incident cases, deaths, age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR) and their percentage changes of NS during 1990-2019 were collected from the 2019 Global Burden of Disease study. Globally, the incident cases of NS increased by 12.79% (from 5.59 million in 1990 to 6.31 million in 2019), and the deaths decreased by 12.93% (from 0.26 million in 1990 to 0.23 million in 2019). In the globe, the ASIR of NS per 100,000 population increased by 14.35% (from 85.21 in 1990 to 97.43 in 2019), and the ASMR decreased by 11.91% (from 3.97 in 1990 to 3.5 in 2019).

CONCLUSION

Increasing trends in incidence and decreasing trends in mortality of NS were observed worldwide from 1990 to 2019. More robust epidemiological research and effective health strategies are urgently needed to reduce the disease burden of neonatal sepsis worldwide.

WHAT IS KNOWN

• Neonatal sepsis has significant impacts on neonatal health, but estimates on the global burden and trends of neonatal sepsis are scarce and existing findings vary considerably.

WHAT IS NEW

• Globally, there were 6.31 million incident cases of neonatal sepsis and 0.23 million deaths due to neonatal sepsis. • Increasing trends in incidence and decreasing trends in mortality of neonatal sepsis were observed worldwide from 1990 to 2019, with the highest absolute burden in sub-Saharan Africa and Asia.

Fighting Antimicrobial Resistance in Neonatal Intensive Care Units: Rational Use of Antibiotics in Neonatal Sepsis

Antibiotics are the most frequently prescribed drugs in neonatal intensive care units (NICUs) due to the severity of complications accompanying neonatal sepsis. However, antimicrobial drugs are often used inappropriately due to the difficulties in diagnosing sepsis in the neonatal population. The reckless use of antibiotics leads to the development of resistant strains, rendering multidrug-resistant pathogens a serious problem in NICUs and a global threat to public health. The aim of this narrative review is to provide a brief overview of neonatal sepsis and an update on the data regarding indications for antimicrobial therapy initiation, current guidance in the empirical antimicrobial selection and duration of therapy, and indications for early discontinuation.

Conservative management of newborns with 35 weeks or more of gestational age at risk for early-onset sepsis: a Brazilian cohort study

OBJECTIVE

To evaluate the conservative management of newborns born at ≥35 weeks of gestational age, at risk for early-onset neonatal sepsis (EOS).

METHODS

Retrospective, analytic cohort study (2016 to 2019), including newborns ≥35 weeks of gestational at risk of EOS, asymptomatic at birth, managed conservatively in full rooming-in: serial physical examination and clinical observation for at least 48 h. They were classified into three groups, according to the clinical course: asymptomatic (group A), symptomatic for other reasons (group B), and with sepsis (group C). Risk factors, clinical signs and differential diagnoses of sepsis, length of stay, and discharge conditions were evaluated.

RESULTS

The authors evaluated 769 asymptomatic newborns at risk of EOS. (mean birth weight 2999 ± 485 g and gestational age 37.6 ± 1.7 weeks, respectively) corresponding to 12.2% of rooming-in admissions. The most prevalent risk factors were colonization by Group B Streptococcus (29%), prolonged rupture membrane duration (21.9%) and preterm labor (21.4%). Most of all of them (53.9%) remained asymptomatic (group A). Group B corresponded for 45.3%, and the most common clinical signs were hypothermia (24.5%), tremors (8.7%) and vomiting (8%). Environmental dysthermia (50.7%), prematurity (20.0%), and feeding intolerance (15.7%) were common in Group B. Laboratory tests were performed in 3.5%. Five patients (one confirmed) comprised group C (0.8/1,000 live births). There were no deaths. The median length of stay was 64 h (IQR 50-93).

CONCLUSION

The rate of clinical/confirmed EOS was low. Most of the symptomatic patients only needed clinical evaluation to rule out sepsis. Management was shown to be safe.

Clinical and laboratory findings to differentiate late-onset sepsis caused by Gram-negative vs Gram-positive bacteria among perterm neonates: A retrospective cohort study

PURPOSE

Late-onset sepsis (LOS) is a clinical condition that results in serious morbidity and mortality in preterm neonates. The aim of this study was to identify differences in clinical and laboratory findings of LOS caused by Gram-negative vs Gram-positive bacteria among perterm neonates and to evaluate the diagnostic accuracy of biomarkers.

METHODS

The retrospective cohort study included 649 preterm neonates with LOS assigned to either the Gram-positive group (n = 194, 29.89 %) or the Gram-negative group (n = 455, 70.11 %). Demographic data, serum levels of C-reactive protein (CRP), and complete blood counts at 0-24 h (T1), 24-48 h (T2), and 48-72 h (T3) were retrieved and compared.

RESULTS

At T1, T2, and T3, serum CRP levels were higher (p < 0.001), while platelet (PTL) counts were significantly lower (p < 0.001) in the Gram-negative group vs Gram-positive group. The area under the curve (AUC) of the PLT count was 0.688 (95 % confidence interval [CI] = 0.644-0.731) at T1, 0.795 (95 % CI = 0.743-0.848) at T2, and 0.785 (95 % CI = 0.739-0.831) at T3, indicating good discriminatory power, while the AUC of serum CRP was 0.654 (95 % CI = 0.61-0.697) at T1, 0.831 (95 % CI = 0.781-0.888) at T2, and 0.94 (95 % CI = 0.744-0.843) at T3.

CONCLUSIONS

Neonatal LOS caused by Gram-negative bacteria was associated with higher CRP and lower PLT levels. These results suggested that PLT and CRP values may be useful biomarkers to differentiate sepsis caused by Gram-negative vs Gram-positive bacteria among perterm neonates.

TRAINED IMMUNITY: A POTENTIAL APPROACH FOR IMPROVING HOST IMMUNITY IN NEONATAL SEPSIS

ABSTRACT

Sepsis, a dysregulated host immune response to infection, is one of the leading causes of neonatal mortality worldwide. Improved understanding of the perinatal immune system is critical to improve therapies to both term and preterm neonates at increased risk of sepsis. Our narrative outlines the known and unknown aspects of the human immune system through both the immune tolerant in utero period and the rapidly changing antigen-rich period after birth. We will highlight the key differences in innate and adaptive immunity noted through these developmental stages and how the unique immune phenotype in early life contributes to the elevated risk of overwhelming infection and dysregulated immune responses to infection upon exposure to external antigens shortly after birth. Given an initial dependence on neonatal innate immune host responses, we will discuss the concept of innate immune memory, or "trained immunity," and describe several potential immune modulators, which show promise in altering the dysregulated immune response in newborns and improving resilience to sepsis.

Early Diagnosis of Late-Onset Neonatal Sepsis Using a Sepsis Prediction Score

Sepsis represents a common cause of morbidity in the Neonatal Intensive Care Unit (NICU). Our objective was to assess the value of clinical and laboratory parameters in predicting septicemia (positive blood culture) in NICU infants. In the first part of the present study (derivation cohort) we retrospectively reviewed the clinical files of 120 neonates with symptoms of suspected sepsis and identified clinical and laboratory parameters associated with proven sepsis on the day the blood culture was taken, as well as 24 h and 48 h earlier. These parameters were combined into a sepsis prediction score (SPS). Subsequently (validation study), we prospectively validated the performance of the SPS in a cohort of 145 neonates. The identified parameters were: temperature instability, platelet count < 150,000/mm³, feeding volume decrease > 20%, changes in blood glucose > 50%, CRP > 1 mg/dL, circulatory and respiratory deterioration. In the retrospective cohort, on the day the blood culture was obtained, a SPS ≥ 3 could predict sepsis with 82.54% sensitivity, 85.96% specificity, 5.88 PLR (Positive Likelihood Ratio), 0.20 NLR (Negative Likelihood Ratio), 86.67% PPV (Positive Predictive Value), 81.67% NPV (Negative Predictive Value) and 84.17% accuracy. In the prospective cohort, on the day the blood culture was obtained, a SPS ≥ 3 could predict sepsis with 76.60% sensitivity, 72.55% specificity, 2.79 PLR, 0.32 NLR, 83.72% PPV, 62.71% NPV and 75.17% accuracy. We concluded that this combination of clinical and laboratory parameters may assist in the prediction of septicemia in NICUs.

Clinical Prediction Model Development and Validation for the Detection of Newborn Sepsis, Diagnostic Research Protocol

BACKGROUND

Neonatal sepsis is a leading cause of sickness and death in the entire world. Diagnosis is usually difficult because of the nonspecific clinical symptoms and the paucity of laboratory diagnostics in many low- and middle-income nations (LMICs). Clinical prediction models may increase diagnostic precision and rationalize the use of antibiotics in neonatal facilities, which could lead to a decrease in antimicrobial resistance and better neonatal outcomes. Early detection of newborn sepsis is critical to prevent serious consequences and reduce the need for unneeded drugs.

OBJECTIVE

The aim is to develop and validate a clinical prediction model for the detection of newborn sepsis.

METHODS

A cross-sectional study based on an institution will be carried out. The sample size was determined by assuming 10 events per predictor, based on this assumption, the total sample sizes were 467. Data will be collected using a structured checklist through chart review. Data will be coded, inputted, and analyzed using R statistical programming language version 4.0.4 after being entered into Epidata version 3.02 and further processed and analyzed. Bivariable logistic regression will be done to identify the relationship between each predictor and neonatal sepsis. In a multivariable logistic regression model, significant factors (P< 0.05) will be kept, while variables with (P< 0.25) from the bivariable analysis will be added. By calculating the area under the ROC curve (discrimination) and the calibration plot (calibration), respectively, the model's accuracy and goodness of fit will be evaluated.

Updates in Late-Onset Sepsis: Risk Assessment, Therapy, and Outcomes

Neonatal late-onset sepsis (LOS) continues to threaten morbidity and mortality in the NICU and poses ongoing diagnostic and therapeutic challenges. Early recognition of clinical signs, rapid evaluation, and prompt initiation of treatment are critical to prevent life-threatening deterioration. Preterm infants-born at ever-decreasing gestational ages-are at particularly high risk for life-long morbidities and death. This changing NICU population necessitates continual reassessments of diagnostic and preventive measures and evidence-based treatment for LOS. The clinical presentation of LOS is varied and nonspecific. Despite ongoing research, reliable, specific laboratory biomarkers facilitating early diagnosis are lacking. These limitations drive an ongoing practice of liberal initiation of empiric antibiotics among infants with suspected LOS. Subsequent promotion of multidrug-resistant microorganisms threatens the future of antimicrobial therapy and puts preterm and chronically ill infants at even higher risk of nosocomial infection. Efforts to identify adjunctive therapies counteracting sepsis-driven hyperinflammation and sepsis-related functional immunosuppression are ongoing. However, most approaches have either failed to improve LOS prognosis or are not yet ready for clinical application. This article provides an overview of the epidemiology, risk factors, diagnostic tools, and treatment options of LOS in the context of increasing numbers of extremely preterm infants. It addresses the question of whether LOS could be identified earlier and more precisely to allow for earlier and more targeted therapy and discusses rational approaches to antibiotic therapy to avoid overuse. Finally, this review elucidates the necessity of long-term follow-up of infants with a history of LOS.

Predictors of Death in Patients with Neonatal Sepsis in a Peruvian Hospital

Reducing neonatal mortality is a global challenge. This study’s objective was to determine the predictors of mortality in patients with neonatal sepsis. The study was a retrospective cohort study in a Peruvian hospital from January 2014 to April 2022. Neonates diagnosed with sepsis were included. To find predictors of mortality, we used Cox proportional regression models. We evaluated 288 neonates with sepsis; the median birth weight and hospitalization time were 3270 g and seven days, respectively. During follow-up, 18.4% did not survive, and the most common complications were jaundice (35.42%), respiratory distress syndrome (29.51%), and septic shock (12.5%). The most isolated bacteria were Klebsiella pneumoniae. The risk factors associated with higher mortality were prematurity (aHR = 13.92; 95% CI: 1.71−113.51), platelets <150,000 (aHR = 3.64; 1.22−10.88), creatinine greater than 1.10 (aHR = 3.03; 1.09−8.45), septic shock (aHR = 4.41; 2.23−8.74), and admission to IMV (aHR = 5.61; 1.86−16.88), On the other hand, breastfeeding was associated with a lower risk of death (aHR = 0.25; 0.13−0.48). In conclusion, we report a high incidence of death and identify clinical (prematurity, septic shock, admission to IMV) and laboratory characteristics (elevated creatinine and thrombocytopenia) associated with higher mortality in patients with neonatal sepsis. Breastfeeding was a factor associated with survival in these patients.

Neonatal Sequential Organ Failure Assessment as a late-onset sepsis mortality predictor in very low birth weight newborns: a Brazilian cohort study

Death is a frequent occurrence in late-onset neonatal sepsis (LOS). We aimed to evaluate if the Neonatal Sequential Organ Failure Assessment (nSOFA) is associated with mortality due to LOS in very low birth weight (VLBW) infants. This is a single-center Brazilian cohort study including VLBW infants admitted between 2006 and 2020 who were diagnosed with LOS caused by Staphylococcus aureus, Enterococcus sp or Gram-negative bacteria. The primary outcome was mortality associated with sepsis. Two groups of patients-survivors and non-survivors-were compared regarding descriptive maternal and neonatal variables and the nSOFA score, evaluated at nine moments, from 48 hours before the diagnosis of sepsis to 48 hours later (T-48, T-24, T-12, T-6, T0, T+6, T+12, T+24, T+48). Diagnostic accuracy was expressed as the area under the curve (AUC). Among the 1574 VLBW infants hospitalized in the period, 114 episodes of culture-confirmed LOS occurred. There were 21 sepsis-related deaths (18.4%), mostly from Gram-negative bacteria and Enterococcus sp. There were no statistically significant differences between the groups regarding maternal and neonatal variables. Median nSOFA was significantly higher in the non-survivor group at all time points (range 2 to 13 versus 1 to 3). In the logistic regression analysis, each increment of one point in the score significantly increases the risk of death in eight of the nine moments, but no difference was found in T-24. Time T-6 had the best accuracy (88.1%).   Conclusion: The nSOFA score was significantly associated with the risk of death from LOS in VLBW infants. What is Known: • The neonatal sepsis may result in organ dysfunction and death, and it is important to find indicators that could identify this clinical progression. • The nSOFA score was proposed in 2020 to predict mortality from LOS, but since it is recent and still in the research phase, further studies are important to improve it before being widely used in clinical practice. What is New: • We showed a significative association between higher nSOFA scores and mortality. Our results corroborate the validity and the importance of the nSOFA score and highlight its high NPV.

Group B Streptococcus among Pregnant Women and Neonates in Saudi Arabia: A Systemic Review

Sepsis caused by Group B Streptococcus (GBS) continues to cause mortality and morbidity in newborns, especially in developing countries. Bacterial sepsis in newborns varies nationally and even within countries. Developing countries have reported 34 deaths per 1000 live births compared to 5 in developed countries. This systemic review aimed to assess the prevalence of GBS colonization among pregnant women and the incidence of neonatal GBS sepsis in Saudi Arabia. A literature search of PubMed, MEDLINE Ovid, and Google Scholar was conducted. A total of 21 studies were found: 15 described maternal GBS colonization and 6 studies described neonatal GBS infections. The GBS colonization prevalence among pregnant women ranged from 2.1% to 32.8%. Inconsistencies in the reporting method for neonatal GBS infection rates were observed. Only two studies have the incidence of neonatal GBS as the primary outcome. No national multicenter studies exist on the GBS rates among neonates. Nationwide studies are warranted to assess the burden of GBS infections in neonates. These studies would guide appropriate GBS screening strategies during pregnancy for application in a national public health program.

Clinical and laboratory factors associated with neonatal sepsis mortality at a major Vietnamese children's hospital

Sepsis is a major cause of neonatal mortality and children born in low- and middle-income countries (LMICs) are at greater risk of severe neonatal infections than those in higher-income countries. Despite this disparity, there are limited contemporaneous data linking the clinical features of neonatal sepsis with outcome in LMICs. Here, we aimed to identify factors associated with mortality from neonatal sepsis in Vietnam. We conducted a prospective, observational study to describe the clinical features, laboratory characteristics, and mortality rate of neonatal sepsis at a major children's hospital in Ho Chi Minh City. All in-patient neonates clinically diagnosed with probable or culture-confirmed sepsis meeting inclusion criteria from January 2017 to June 2018 were enrolled. We performed univariable analysis and logistic regression to identify factors independently associated with mortality. 524 neonates were recruited. Most cases were defined as late-onset neonatal sepsis and were hospital-acquired (91.4% and 73.3%, respectively). The median (IQR) duration of hospital stay was 23 (13-41) days, 344/524 (65.6%) had a positive blood culture (of which 393 non-contaminant organisms were isolated), and 69/524 (13.2%) patients died. Coagulase-negative staphylococci (232/405; 57.3%), Klebsiella spp. (28/405; 6.9%), and Escherichia coli (27/405; 6.7%) were the most isolated organisms. Sclerema (OR = 11.4), leukopenia <4,000/mm3 (OR = 7.8), thrombocytopenia <100,000/mm3 (OR = 3.7), base excess < -20 mEq/L (OR = 3.6), serum lactate >4 mmol/L (OR = 3.4), extremely low birth weight (OR = 3.2), and hyperglycaemia >180 mg/dL (OR = 2.6) were all significantly (p<0.05) associated with mortality. The identified risk factors can be adopted as prognostic factors for the diagnosis and treatment of neonatal sepsis and enable early risk stratification and interventions appropriate to reduce neonatal sepsis in LMIC settings.

Pathogen Distribution and Antimicrobial Resistance of Early Onset Sepsis in Very Premature Infants: A Real-World Study

INTRODUCTION

Early onset sepsis (EOS) remains a potentially fatal newborn condition, especially in very preterm infants. Data on the pathogen distribution and antibiotic susceptibility patterns of EOS among very preterm infants are scarce but essential for the choice of empirical antibiotic administration. We sought to assess the epidemiologic characteristics and antibiotic susceptibility patterns of pathogens causing EOS among a cohort of very preterm infants in China.

METHODS

This prospective, observational study included a cohort of infants born at a gestational age (GA) less than 32 weeks of 32 newborn intensive care units (NICUs) in China between January 1, 2018 and December 31, 2020. EOS was defined by isolation of pathogenic species from blood culture within 72 h of birth.

RESULTS

A total of 108 EOS cases (18.4 per 1000 admissions) were identified among 5865 very preterm infants. Incidence of EOS increased with the decrease of GA and birthweight. Escherichia coli (n = 44, 40.7%) was the most common pathogen, followed by Klebsiella spp. (n = 10, 9.3%). The distribution and proportion of pathogenic bacteria varied significantly by GA. E. coli and Klebsiella spp. showed high resistance to ampicillin and third-generation cephalosporins, while they showed good susceptibility to carbapenem antibiotics and piperacillin-tazobactam.

CONCLUSION

Our data demonstrated that pathogens causing neonatal EOS showed high rates of resistance to ampicillin and third-generation cephalosporins. This raised questions about the best empirical antibiotic choice for preterm infants suspected of having EOS in low- and middle-income countries (LMICs).

Predictive Scores for Late-Onset Neonatal Sepsis as an Early Diagnostic and Antimicrobial Stewardship Tool: What Have We Done So Far?

Background: Late-onset neonatal sepsis (LOS) represents a significant cause of morbidity and mortality worldwide, and early diagnosis remains a challenge. Various ‘sepsis scores’ have been developed to improve early identification. The aim of the current review is to summarize the current knowledge on the utility of predictive scores in LOS as a tool for early sepsis recognition, as well as an antimicrobial stewardship tool. Methods: The following research question was developed: Can we diagnose LOS with accuracy in neonates using a predictive score? A systematic search was performed in the PubMed database from 1982 (first predictive score published) to December 2021. Results: Some (1352) articles were identified—out of which, 16 were included in the review. Eight were original scores, five were validations of already existing scores and two were mixed. Predictive models were developed by combining a variety of clinical, laboratory and other variables. The majority were found to assist in early diagnosis, but almost all had a limited diagnostic accuracy. Conclusions: There is an increasing need worldwide for a simple and accurate score to promptly predict LOS. Combinations of the selected parameters may be helpful, but until now, a single score has not been proven to be comprehensive.

Assessment of a score's performance in predicting positive culture studies in preterm neonates with clinical suspicion of sepsis

The goal of this study is to assess the use of a score composed of markers of inflammation and organ failure to predict positive cultures for preterm newborns with clinical suspicion of late-onset sepsis. The score was calculated at the first suspicion and 24-48 hours later. We retrospectively compared score results between neonates with positive and negative cultures. Neonates with positive cultures had a significantly higher score at the second instance; the receiver operator characteristics curve presented an area under the curve of 0.798 (p=0.007). A score for early prediction of sepsis could be an important tool for prognostic improvement in the future.

Development of a Novel Assessment Tool and Code Sepsis Checklist for Neonatal Late-Onset Sepsis

BACKGROUND

Accurate diagnosis and timely management of neonatal late-onset sepsis (nLOS) have been less well-studied than those of early-onset sepsis. We noticed a delay in nLOS detection and management in our neonatal intensive care unit.

PURPOSE

To develop an assessment tool to aid in the recognition and reporting of nLOS and to standardize the management process once sepsis is recognized.

METHODS

The Plan-Do-Study-Act (PDSA) improvement model provided the framework for interventions for our antibiotic stewardship program, including the aims of this project. A literature review was performed to evaluate tools and other literature available to guide the evaluation and management of suspected sepsis. A quality improvement project was initiated to develop tools for the detection and management of nLOS.

RESULTS

An nLOS assessment tool to help identify neonates at risk for nLOS and a Code Sepsis checklist to standardize the process of evaluation and management of nLOS were developed. The guiding principles of this tool development were empowerment of nurses to initiate the assessment process, clarification of team roles, and removal of barriers to appropriate antibiotic administration.

IMPLICATIONS FOR PRACTICE

Useful and practical tools valued by nursing and the multidisciplinary team may facilitate timely identification and treatment of infants with nLOS.

IMPLICATIONS FOR RESEARCH

Future directions include validation of the nLOS assessment tool and the Code Sepsis checklist as well as ensuring the reliability of the tool to improve detection of nLOS and to reduce time to administer antibiotics in cases of nLOS.

Development and validation of a sepsis diagnostic scoring model for neonates with suspected sepsis

BACKGROUND

We aimed to develop and validate a diagnostic model for sepsis among neonates evaluated for suspected sepsis, by incorporating thromboelastometry parameters, maternal/neonatal risk factors, clinical signs/symptoms and laboratory results.

METHODS

This retrospective cohort study included 291 neonates with presumed sepsis, hospitalized in a NICU, from 07/2014 to 07/2021. Laboratory tests were obtained on disease onset and prior to initiating antibiotic therapy. Τhromboelastometry extrinsically activated (EXTEM) assay was performed simultaneously and Tοllner and nSOFA scores were calculated. Sepsis diagnosis was the outcome variable. A 10-fold cross-validation least absolute shrinkage and selection operator logit regression procedure was applied to derive the final multivariable score. Clinical utility was evaluated by decision curve analysis.

RESULTS

Gestational age, CRP, considerable skin discoloration, liver enlargement, neutrophil left shift, and EXTEM A10, were identified as the strongest predictors and included in the Neonatal Sepsis Diagnostic (NeoSeD) model. NeoSeD score demonstrated excellent discrimination capacity for sepsis and septic shock with an AUC: 0.918 (95% CI, 0.884-0.952) and 0.974 (95% CI, 0.958-0.989) respectively, which was significantly higher compared to Töllner and nSOFA scores.

CONCLUSIONS

The NeoSeD score is simple, accurate, practical, and may contribute to a timely diagnosis of sepsis in neonates with suspected sepsis. External validation in multinational cohorts is necessary before clinical application.