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Stocker M, Giannoni E. Game changer or gimmick: inflammatory markers to guide antibiotic treatment decisions in neonatal early-onset sepsis. Clin Microbiol Infect 2024; 30:22-27. [PMID: 36871829 DOI: 10.1016/j.cmi.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/14/2023] [Accepted: 02/25/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND The diagnosis of neonatal early-onset sepsis (EOS) is challenging, and inflammatory markers are widely used to guide decision-making and therapies. OBJECTIVES This narrative review presents the current state of knowledge regarding the diagnostic value and potential pitfalls in the interpretation of inflammatory markers for EOS. SOURCES PubMed until October 2022 and searched references in identified articles using the search terms: neonatal EOS, biomarker or inflammatory marker, and antibiotic therapy or antibiotic stewardship. CONTENT In situations with a high or low probability of sepsis, the measurements of inflammatory markers have no impact on the decision to start or stop antibiotics and are just gimmick, whereas they may be a game changer for neonates with intermediate risk and therefore an unclear situation. There is no single or combination of inflammatory markers that can predict EOS with high probability, allowing us to make decisions regarding the start of antibiotics based only on inflammatory markers. The main reason for the limited accuracy is most probably the numerous noninfectious conditions that influence the levels of inflammatory markers. However, there is evidence that C-reactive protein and procalcitonin have good negative predictive accuracy to rule out sepsis within 24 to 48 hours. Nevertheless, several publications have reported more investigations and prolonged antibiotic treatments with the use of inflammatory markers. Given the limitations of current strategies, using an algorithm with only moderate diagnostic accuracy may have a positive impact, as reported for the EOS calculator and the NeoPInS algorithm. IMPLICATIONS As the decision regarding the start of antibiotic therapy is different from the process of stopping antibiotics, the accuracy of inflammatory markers needs to be evaluated separately. Novel machine learning-based algorithms are required to improve accuracy in the diagnosis of EOS. In the future, inflammatory markers included in algorithms may be a game changer reducing bias and noise in the decision-making process.
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Affiliation(s)
- Martin Stocker
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.
| | - Eric Giannoni
- Clinic of Neonatology, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Switzerland
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Yoshimatsu H, Iwai M, Kitabatake Y, Ozono K, Nakamura K. Prediction scores based on neonatal inflammatory markers for chorioamnionitis and funisitis in extremely low gestational age neonates. Acta Paediatr 2023; 112:726-733. [PMID: 36740931 DOI: 10.1111/apa.16701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 02/07/2023]
Abstract
AIM The aim of the study was to examine the predictive value of inflammatory markers for chorioamnionitis and funisitis in extremely low gestational age neonates. METHODS According to the Redline histopathological classification, extremely low gestational age neonates were classified into: (1) maternal inflammatory response ≤1 or ≥2, based on inflammatory findings of the placenta and (2) foetal inflammatory response ≤1 or ≥2, based on inflammatory findings of the umbilical cord. On admission and 12-36 h postnatally, procalcitonin and high-sensitivity C-reactive protein levels and white blood cell and neutrophil counts were compared. For both maternal and foetal inflammatory responses ≥2, the predictive value of each inflammatory marker was calculated. RESULTS On admission, procalcitonin had the best predictive value for maternal and foetal inflammatory response ≥2. The maternal inflammatory response ≥2 prediction score includes procalcitonin level on admission, high-sensitivity C-reactive protein level and white blood cell count at 12-36 h postnatally. Foetal inflammatory response ≥2 prediction score includes procalcitonin level and white blood cell count on admission and 12-36 h postnatally. The sensitivities were 96.4% and 96.3%, respectively. CONCLUSION Procalcitonin, high-sensitivity C-reactive protein levels and white blood cell count provide highly sensitive prediction scores for chorioamnionitis and funisitis in extremely low gestational age neonates.
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Affiliation(s)
- Hidetaka Yoshimatsu
- Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan.,Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan.,Division of Neonatology, Perinatal Center, Kumamoto City Hospital, Kumamoto, Japan
| | - Masanori Iwai
- Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan.,Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan
| | - Yasuji Kitabatake
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
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Nakamuara T, Iwai M, Inoue T, Irie H, Karasugi T, Seki A, Hamaguchi M, Kuraoka S, Mizukami T, Nakamura K. A neonate with multiple hand flexor tendon ruptures due to methicillin-susceptible Staphylococcus aureus sepsis: a case report. BMC Pediatr 2023; 23:68. [PMID: 36759790 PMCID: PMC9909912 DOI: 10.1186/s12887-023-03871-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Neonatal pyogenic tenosynovitis is a highly emergent soft tissue infection. We report a case of a neonate with pyogenic tendinopathy and tendon rupture diagnosed by ultrasonography (US). He subsequently developed pyogenic arthritis and osteomyelitis during antimicrobial therapy. CASE PRESENTATION A 7-day-old boy was admitted to our hospital with redness and swelling of the right index finger. US on admission showed rupture of the flexor tendon of the right index finger with inactivity. The day after admission, he developed pyogenic arthritis of the right elbow and, subsequently, pyogenic osteomyelitis. Staphylococcus aureus was identified through bacterial culture, and the patient was treated with intravenous antibiotics for 6 weeks. However, after discharge from our hospital, rupture of the flexor tendon of the left thumb was confirmed. A two-stage flexor tendinoplasty was completed at the age of 2 years and 1 month for the flexor tendon rupture on his right index finger. CONCLUSIONS In addition to blood culture, ultrasonographic evaluation should be performed in neonates with erythematous and swollen joints to identify the focus of infection as soon as possible. Moreover, repeated regular US examination is important in the follow-up of bone and soft tissue infections.
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Affiliation(s)
- Tomomi Nakamuara
- grid.411152.20000 0004 0407 1295Department of Pediatrics, Kumamoto University Hospital, 1-1-1 Honjo, 860-8556 Chuoku, Kumamoto, Japan
| | - Masanori Iwai
- Department of Pediatrics, Kumamoto University Hospital, 1-1-1 Honjo, 860-8556, Chuoku, Kumamoto, Japan.
| | - Takeshi Inoue
- grid.411152.20000 0004 0407 1295Department of Pediatrics, Kumamoto University Hospital, 1-1-1 Honjo, 860-8556 Chuoku, Kumamoto, Japan
| | - Hiroki Irie
- grid.411152.20000 0004 0407 1295Department of Emergency Medicine and Critical Care, Kumamoto University Hospital, 1-1-1 Honjo, 860-8556 Chuoku, Kumamoto, Japan
| | - Tatsuki Karasugi
- grid.411152.20000 0004 0407 1295Department of Orthopedic Surgery, Kumamoto University Hospital, 1-1-1 Honjo, 860-8556 Chuoku, Kumamoto, Japan
| | - Atsuhito Seki
- grid.63906.3a0000 0004 0377 2305Department of Orthopedic Surgery, National Center for Child Health and Development, 2-10-1 Ohkura, 157-8535 Setagayaku, Tokyo, Japan
| | - Masayoshi Hamaguchi
- grid.411152.20000 0004 0407 1295Department of Pediatrics, Kumamoto University Hospital, 1-1-1 Honjo, 860-8556 Chuoku, Kumamoto, Japan
| | - Shohei Kuraoka
- grid.411152.20000 0004 0407 1295Department of Pediatrics, Kumamoto University Hospital, 1-1-1 Honjo, 860-8556 Chuoku, Kumamoto, Japan
| | - Tomoyuki Mizukami
- grid.415538.eDepartment of Pediatrics, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, 860-0008 Chuoku, Kumamoto, Japan
| | - Kimitoshi Nakamura
- grid.411152.20000 0004 0407 1295Department of Pediatrics, Kumamoto University Hospital, 1-1-1 Honjo, 860-8556 Chuoku, Kumamoto, Japan
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Tuoni C, Ciantelli M, Morganti R, Violi M, Tamagnini S, Filippi L. Procalcitonin levels in preterm newborns: Reference ranges during the first three days of life. Front Pediatr 2022; 10:925788. [PMID: 36105855 PMCID: PMC9464813 DOI: 10.3389/fped.2022.925788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background Sepsis is one of the most important causes of morbidity and mortality in the neonatal period, especially in preterms. Diagnosis is difficult because of specific signs and symptoms. The diagnostic gold standard is blood culture, but its sensibility is low. Much effort has been made to identify early, sensitive, and specific diagnostic markers; among these markers particular attention was paid to procalcitonin. However, reference ranges of serum procalcitonin (PCT) shortly after birth have not been sufficiently studied in healthy preterms, and literature is still contradictory. Objectives The aim of the study is to define PCT age-specific reference ranges in the first 72 h of life in uninfected VLBW preterms. Methods Serum levels of PCT were assessed for each newborn at birth and every 24 h until the 3rd day of life. The eligible patients were classified into two groups according to their sepsis status. Results Approximately 343 patients were enrolled; 28 were septic and 315 non-septic. In non-septic infants, 1,015 determinations of PCT values were performed. Our data showed a trend in average value of PCT to increase after birth up to a peak between 24 and 48 h of life and, subsequently, to fall. The average peak value was 15.12 ng/ml achieved at nearly 36 h of life. Conclusion Our study shows a PCT nomogram of healthy preterms, which is different from the one of term newborns. Data agree with what is reported in literature on the reference ranges and trends of PCT in non-septic preterms shortly after birth.
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Affiliation(s)
- Cristina Tuoni
- Neonatology and Neonatal Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Massimiliano Ciantelli
- Neonatology and Neonatal Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Riccardo Morganti
- SOD Clinical Trial Statistical Support, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Martina Violi
- Neonatology and Neonatal Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Sara Tamagnini
- Neonatology and Neonatal Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Luca Filippi
- Neonatology and Neonatal Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
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Iwai M, Yoshimatsu H, Naramura T, Imamura H, Nakamura T, Sakamoto R, Inoue T, Tanaka K, Matsumoto S, Nakamura K, Mitsubuchi H. Procalcitonin is associated with postnatal respiratory condition severity in preterm neonate. Pediatr Pulmonol 2022; 57:1272-1281. [PMID: 35064781 DOI: 10.1002/ppul.25846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 12/31/2021] [Accepted: 01/20/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Postnatal respiratory failure is common in preterm neonates and is difficult to distinguish from early-onset neonatal bacterial infection by clinical symptoms. Similar to C-reactive protein (CRP), procalcitonin (PCT) is used as a marker of bacterial infection. Recently, it has been reported that the serum PCT levels increase because of respiratory failure immediately after birth. However, there is insufficient information concerning the relationship between biological inflammation markers, such as PCT and CRP, and postnatal respiratory condition severity. METHODS Preterm neonates were classified according to the received respiratory management as follows: nonrespiratory support (NRS), respiratory support (RS), surfactant administration therapy (STA), and STA with nitric oxide inhalation therapy (NO). The median serum PCT and CRP levels at 12-36 h postnatally were compared among the four groups. Additionally, the median serum PCT and CRP levels in the STA group were compared by STA timing and STA number. RESULTS The PCT levels for the NRS, RS, STA, and NO groups were 1.04, 6.46, 12.93, and 86.79 μg/L, respectively; the CRP levels were 0.40, 0.80, 1.10, and 16.40 mg/L, respectively. The PCT levels were significantly lower among neonates receiving STA in the birth subgroup (4.82 μg/L) than among those receiving STA in the admission subgroup (14.71 μg/L). The PCT levels were significantly higher among the STA multiple-dose subgroup (24.87 μg/L) than among the STA single-dose subgroup (12.47 μg/L). No significant differences in the CRP levels were observed. CONCLUSION The serum PCT levels in preterm neonates were associated with postnatal respiratory condition severity.
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Affiliation(s)
- Masanori Iwai
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hidetaka Yoshimatsu
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Tetsuo Naramura
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hiroko Imamura
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Tomomi Nakamura
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Rieko Sakamoto
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Takeshi Inoue
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tanaka
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Shirou Matsumoto
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Mitsubuchi
- Division of Neonatology, Perinatal Center, Kumamoto University Hospital, Kumamoto, Japan.,Department of Pediatrics, Graduate School of Medical Science, Kumamoto University, Kumamoto, Japan
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