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De Rose DU, Ronchetti MP, Martini L, Rechichi J, Iannetta M, Dotta A, Auriti C. Diagnosis and Management of Neonatal Bacterial Sepsis: Current Challenges and Future Perspectives. Trop Med Infect Dis 2024; 9:199. [PMID: 39330888 PMCID: PMC11435811 DOI: 10.3390/tropicalmed9090199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Revised: 08/23/2024] [Accepted: 08/27/2024] [Indexed: 09/28/2024] Open
Abstract
Sepsis remains the second cause of death among neonates after the pathological consequences of extreme prematurity. In this review we summarized knowledge about pathogens causing early-onset sepsis (EOS) and late-onset sepsis (LOS), the role of perinatal risk factors in determining the EOS risk, and the tools used to reduce unnecessary antibiotics. New molecular assays could improve the accuracy of standard blood cultures, providing the opportunity for a quick and sensitive tool. Different sepsis criteria and biomarkers are available to date, but further research is needed to guide the use of antibiotics according to these tools. Beyond the historical antibiotic regimens in EOS and LOS episodes, antibiotics should be based on the local flora and promptly modulated if specific pathogens are identified. The possibility of an antibiotic lock therapy for central venous catheters should be further investigated. In the near future, artificial intelligence could help us to personalize treatments and reduce the increasing trend of multidrug-resistant bacteria.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, 00165 Rome, Italy
- PhD Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), Faculty of Medicine and Surgery, "Tor Vergata" University of Rome, 00133 Rome, Italy
| | - Maria Paola Ronchetti
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, 00165 Rome, Italy
| | - Ludovica Martini
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, 00165 Rome, Italy
| | - Jole Rechichi
- Neonatal Sub-Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, 00165 Rome, Italy
| | - Marco Iannetta
- Infectious Disease Clinic, Policlinico "Tor Vergata" University Hospital, 00133 Rome, Italy
- Department of System Medicine, "Tor Vergata" University of Rome, 00133 Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, "Bambino Gesù" Children's Hospital IRCCS, 00165 Rome, Italy
| | - Cinzia Auriti
- Pediatrics Department, Saint Camillus International University of Health Sciences, 00131 Rome, Italy
- Casa di Cura Villa Margherita, 00161 Rome, Italy
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Cantey JB. The Emperor Has No Clothes: C-Reactive Protein for Early-Onset Sepsis. J Pediatr 2024:114248. [PMID: 39178941 DOI: 10.1016/j.jpeds.2024.114248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 08/18/2024] [Indexed: 08/26/2024]
Affiliation(s)
- Joseph B Cantey
- Divisions of Neonatology and Immunology & Infectious Diseases, Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX
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Kilpatrick R, Greenberg R, Hansen NI, Shankaran S, Carlo WA, Cotten CM, Stoll BJ. Use and utility of C-reactive protein (CRP) in neonatal early-onset sepsis: a secondary analysis of a prospective surveillance study. J Perinatol 2024:10.1038/s41372-024-02064-5. [PMID: 39103472 DOI: 10.1038/s41372-024-02064-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 06/19/2024] [Accepted: 06/25/2024] [Indexed: 08/07/2024]
Abstract
OBJECTIVE Characterize C-reactive protein (CRP) within 72 postnatal hours in early-onset sepsis (EOS). STUDY DESIGN Secondary analysis of a prospective surveillance study of neonates with EOS 2015-2017. We examined CRP use by center and neonatal characteristics, and CRP levels by time, neonatal characteristics, clinical signs, and pathogen. RESULTS CRP was obtained for 96/235 neonates with EOS, which varied by center (p < 0.001). 71/95 had CRP > 10 mg/L (1 missing). Neonatal characteristics with and without CRP did not differ. There was no relationship between CRP level and timing (p = 0.41) or neonate characteristics. Median CRP was higher with ≥5 vs <5 clinical signs (56, 23 mg/L; p = 0.002), and was not different in Gram-positive vs Gram-negative sepsis (43, 51 mg/L; p = 0.37) or preterm neonates who died vs survived (38, 28 mg/L; p = 0.37). CONCLUSIONS Among neonates with EOS, CRP use varied by center. CRP levels did not differ by time, neonate characteristics, pathogen, or death. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov ID Early-Onset Sepsis an NICHD/CDC Surveillance Study (EOSII): NCT02410486.
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Affiliation(s)
- Ryan Kilpatrick
- Division of Newborn Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | | | - Nellie I Hansen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Barbara J Stoll
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
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Rosa-Mangeret F, Dupuis M, Dewez JE, Muhe LM, Wagner N, Pfister RE. Challenges and opportunities in neonatal sepsis management: insights from a survey among clinicians in 25 Sub-Saharan African countries. BMJ Paediatr Open 2024; 8:e002398. [PMID: 38886111 PMCID: PMC11184178 DOI: 10.1136/bmjpo-2023-002398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 05/31/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Neonatal sepsis (NS) is a global health issue, particularly in Sub-Saharan Africa, where it accounts for a substantial portion of neonatal morbimortality. This multicountry survey aimed to elucidate current practices, challenges and case definitions in managing NS among clinicians in Sub-Saharan Africa. METHODS The survey targeted physicians and medical practitioners working in neonatal care who participated in a Self-Administered Web Questionnaire. The main objective was to understand NS and infection case definitions and management from the clinician's point of view and to identify challenges and opportunities in sepsis management. Participants were queried on demographics, definitions and diagnostic criteria, treatment approaches, and infection prevention and control (IPC) measures. A total of 136 participants from 93 healthcare structures responded, providing valuable insights into NS management practices. RESULTS From May to July 2022 across 21 Sub-Saharan African countries, 136 neonatal clinicians with an average from 93 structures with on average 10-year experience took the survey. NS ranked highest among prevalent neonatal conditions. Diagnostic case definitions between sepsis and infection were attributed to clinical signs, anamnesis, C reactive protein, white blood cll count and blood cultures with no statistically significant differences. Early-onset sepsis was defined within 72 hours by 48%, while late-onset varied. Antibiotics were likely on admission (86.4%) and during the stay (82.2%). Treatment abandonment was reported unlikely. The preferred antibiotic regimen for early-onset sepsis was intravenous amoxicillin (or ampicillin), gentamycin and cefotaxime. Blood culture availability and IPC protocols were reported as limited, particularly concerning patient environment, pharmacy protocols and clean-dirty circuits. CONCLUSIONS This NS survey emphasises clinicians' challenges due to limited access to diagnostic tools and raises concerns about antimicrobial overexposure. IPC also seem limited, according to participants. Addressing these challenges can enhance diagnostic practices, antibiotic stewardship and infection control in the region.
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Affiliation(s)
- Flavia Rosa-Mangeret
- Neonatal and Pediatric Intensive Care, Geneva University Hospitals, Mother, Child and Adolescent Department, Geneva, Geneva, Switzerland
| | - Marc Dupuis
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Juan Emmanuel Dewez
- Pediatrics, Médecins Sans Frontières, Operational Center Geneva, Geneva, Geneva, Switzerland
| | - Lulu M Muhe
- Addis Ababa University College of Health Sciences, Addis Ababa, Oromia, Ethiopia
| | - Noemie Wagner
- Pediatrics, Médecins Sans Frontières, Operational Center Geneva, Geneva, Geneva, Switzerland
- Pediatric Infectious Diseases, Geneva University Hospitals, Child and Adolescent Department, Geneve, Switzerland
| | - Riccardo E Pfister
- Neonatal and Pediatric Intensive Care, Geneva University Hospitals, Mother, Child and Adolescent Department, Geneva, Geneva, Switzerland
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Flannery DD, Coggins SA, Medoro AK. Antibiotic Stewardship in the Neonatal Intensive Care Unit. J Intensive Care Med 2024:8850666241258386. [PMID: 38835250 DOI: 10.1177/08850666241258386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
Antibiotic stewardship is a multidisciplinary, evidence-based approach to optimize antibiotic use and mitigate development of antibiotic resistance. Neonates have high rates of antibiotic exposure, particularly those born preterm and admitted to the NICU, and mounting evidence describes the adverse consequences of such exposures in the absence of infection. Here, we review the general principles of antibiotic stewardship and how they can be applied in NICUs. The unique characteristics of NICUs and patients cared for in this setting, which warrant unique implementation strategies and special considerations are discussed. We summarize current antibiotic use metrics for assessment of responses to stewardship interventions and changes over time, and review evidence-based infection prevention practices in the NICU. Current recommendations for empiric antibiotic use in the NICU and the utility of infection biomarkers are summarized. Lastly, given the growing global threat of increasing antibiotic resistance, specific threats in the NICU are highlighted.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah A Coggins
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra K Medoro
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Sharma V, Grover R, Priyadarshi M, Chaurasia S, Bhat NK, Basu S, Singh P. Point-of-Care Serum Amyloid A as a Diagnostic Marker for Neonatal Sepsis. Indian J Pediatr 2024; 91:571-577. [PMID: 37368220 DOI: 10.1007/s12098-023-04677-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 03/17/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES To evaluate diagnostic accuracy of point-of-care Serum Amyloid A (POC-SAA) and its comparison with procalcitonin for diagnosis of neonatal sepsis. METHODS The present diagnostic accuracy study consecutively recruited neonates with suspected sepsis. Blood samples for sepsis screen, culture, high sensitivity C-reactive protein (CRP) (hs-CRP, as a part of sepsis screen), procalcitonin and POC-SAA were collected before starting antibiotics. The optimum cut-off level of biomarkers (POC-SAA and procalcitonin) was determined by receiver-operating-characteristics curve (ROC) analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of POC-SAA and procalcitonin were derived for 'clinical sepsis (neonates with suspected sepsis and either positive sepsis screen and/or blood culture)' and 'culture positive sepsis' (neonates with suspected sepsis and positive blood culture). RESULTS Seventy-four neonates with mean±SD gestational age of 32.8±3.7 wk were evaluated for suspected sepsis, of which the proportion of 'clinical sepsis' and 'culture positive sepsis' was 37.8% had 16.2%, respectively. At a cut-off of 25.4 mg/L, POC-SAA had sensitivity, specificity, PPV and NPV of 53.6%, 80.4%, 62.5% and 74.0%, respectively for diagnosis of clinical sepsis. The sensitivity, specificity, PPV and NPV of POC-SAA for detection of culture positive sepsis were 83.3%, 61.3%, 29.4% and 95.0%, respectively at a cut-off of 10.3 mg/L. There was no significant difference in the diagnostic accuracy of biomarkers for detection of culture positive sepsis (area under the curve, AUC of POC-SAA vs. procalcitonin vs. hs-CRP: 0.72 vs. 0.85 vs. 0.85; p = 0.21). CONCLUSIONS POC-SAA is comparable to procalcitonin and hs-CRP for diagnosis of neonatal sepsis.
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Affiliation(s)
- Vishakha Sharma
- Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Rajat Grover
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Mayank Priyadarshi
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Suman Chaurasia
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Nowneet Kumar Bhat
- Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Sriparna Basu
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Poonam Singh
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
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Eguchi S, Hisaeda Y, Ukawa T, Koto M, Hosokawa M, Tsurisawa C, Takeda T, Amagata S, Nakao A. Clinical Features of iatrogenic Pharyngo-esophageal perforation in very low birth weight infants. Pediatr Neonatol 2024:S1875-9572(24)00072-X. [PMID: 38769031 DOI: 10.1016/j.pedneo.2023.11.011] [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: 10/05/2023] [Revised: 11/10/2023] [Accepted: 11/27/2023] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Iatrogenic pharyngoesophageal perforation (IPEP) is one of the complications of gastric tube insertion and it tends to occur more frequently in premature infants. Although the frequency is significantly low, attention should be paid as it can lead to serious outcomes with high mortality. This study will help raise awareness with respect to early diagnosis, management, and prevention. METHODS We performed a retrospective cohort study of all very low birth weight infants diagnosed with IPEP between 1993 and 2022. RESULTS A total of 6 patients (0.27% of very low birth weight infants) with the diagnosis of IPEP were included. The median gestational age was 27 + 1 weeks (range 23+5-28 + 6 weeks), and the median birth weight was 823 g (range 630-1232 g). Symptoms included difficulty with gastric tube insertion, bloody secretions in the oral cavity, and increased oral secretions. X-rays revealed aberrant running of the gastric tube in all patients. In three cases, contrast studies demonstrated contrasted mediastinum tapering like a bead. Laryngoscope was used to view the perforation sites but this was not useful in the smallest patient. All patients were treated conservatively with antibiotics and survived. CONCLUSIONS When inserting a gastric tube for premature infants, it is critical to remember that these infants are at risk of IPEP. In addition to a frontal X-ray, a lateral X-ray and contrast study may be useful for early diagnosis.
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Affiliation(s)
- Shu Eguchi
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan.
| | - Yoshiya Hisaeda
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Toshiko Ukawa
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Mayu Koto
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Miku Hosokawa
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Chisa Tsurisawa
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Tomohiro Takeda
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Shusuke Amagata
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
| | - Atsushi Nakao
- Department of Neonatology, Japanese Red Cross Medical Center, Tokyo, Japan, 4-1-22, Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan
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Kraja E, Demirtas F, Kostekci YE, Turker N, Okulu E, Erdeve Ö, Atasay B, Arsan S. Evaluation of the "Neonatal Sequential Organ Failure Assessment" to Predict Mortality in Late-Onset Sepsis in Very Preterm Infants. Z Geburtshilfe Neonatol 2024; 228:174-180. [PMID: 38081215 DOI: 10.1055/a-2165-8307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
INTRODUCTION We aimed to evaluate the use of "Neonatal Sequential Organ Failure Assessment" (nSOFA) scoring in predicting mortality, to compare the accuracy of nSOFA scores at different time points in very preterm infants with late-onset sepsis (LOS), and to investigate other possible parameters that would improve the prediction. METHODS This single-center, retrospective study included preterm infants born atS<32 weeks' gestation with culture-proven LOS. The nSOFA scores of non-fatal and fatal episodes were compared at nine time points. RESULTS Of 120 culture-proven LOS episodes in 106 infants, 90 (75%) episodes were non-fatal and 30 (25%) episodes were fatal. The mean birth weight (BW) of the infants who died was lower than that of survivors (p=0.038). In the fatal LOS episodes, median nSOFA scores were higher at all time points measured before sepsis evaluation, at the time of evaluation, and at all time points measured after the evaluation (p<0.001). nSOFA scores before death and at 48 hours were higher in the fatal episodes (p<0.001). At the time of sepsis assessment, nSOFA score>4 was associated with a 7- to 16-fold increased risk of mortality. Adjustment for BW, lymphocyte and monocyte counts increased the risk to 9- to 18-fold. CONCLUSION This study demonstrated that the use of nSOFA to predict mortality and morbidity in extremely preterm infants seems feasible. The scoring system could be improved by evaluating the other parameters.
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Affiliation(s)
- Elvis Kraja
- Department of Pediatrics, Division of Neonatology, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Ferhan Demirtas
- Department of Pediatrics, Division of Neonatology, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Yasemin Ezgi Kostekci
- Department of Pediatrics, Division of Neonatology, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Nazmiye Turker
- Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Emel Okulu
- Division of Neonatology, Ankara University, Ankara, Turkey
| | - Ömer Erdeve
- Department of Pediatrics, Division of Neonatology, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Begum Atasay
- Department of Pediatrics, Division of Neonatology, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Saadet Arsan
- Department of Pediatrics, Division of Neonatology, Ankara University, Faculty of Medicine, Ankara, Turkey
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Massa-Buck B, Mendoza S, Keiser J, Mohamed MA. Use of Rapid Molecular Polymerase Chain Reaction in Early Detection of Bacteremia in Neonates Prior to Blood Culture Positivity: A Pilot Study. Am J Perinatol 2024; 41:569-574. [PMID: 35148542 DOI: 10.1055/s-0042-1742743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE There has been national strive to decrease the time needed to identify microorganisms in blood culture samples to reduce antibiotic use. This study evaluated rapid molecular polymerase chain reaction (PCR) use in identifying microorganisms in negative culture bottles from neonates with suspected bacterial blood stream infection at 20 to 24 hours of incubation. STUDY DESIGN All blood specimens from neonates with suspected blood stream infection were included. Specimens were incubated using a standard blood culturing instrument that would flag positive if bacterial growth was detected. If the specimen was flagged positive at <20 hours, it was tested by PCR and plated for identification as per standard protocol. In our design, if specimen was not flagged at 20 hours of incubation, the bottle was sterilely accessed and a sample was obtained for PCR testing. The bottle would be returned for incubation for 120 hours or until flagged positive. RESULTS A total of 192 blood specimens were included. Four specimens flagged positive at <20 hours and were all found to be positive by PCR. All other samples did not flag positive by 20 hours of incubation and were tested by PCR between 20 and 24 hours. One sample tested positive via PCR at 21.6 hours then flagged positive on the culturing instrument at 23.5 hours. All other specimens were negative by PCR and remained culture negative at 120 hours. The positive and negative predictive value of PCR verified by blood culture were both equal to 1.0. CONCLUSION Using rapid molecular PCR on blood culture specimens at 20 to 24 hours of incubation provides 100% true negative results possibly allowing providers to discontinue antibiotics at 24 hours. KEY POINTS · Antibiotic overuse leads to adverse neonatal outcomes.. · Molecular PCR may have true negative results.. · Larger study is needed to discontinue antibiotics earlier..
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Affiliation(s)
- Beri Massa-Buck
- Department of Neonatology, Children's National Hospital, Washington, District of Columbia
- Division of Newborn Services, The George Washington University Hospital, Washington, District of Columbia
| | - Salome Mendoza
- Department of Pathology, The George Washington University Hospital, Washington, District of Columbia
| | - John Keiser
- Department of Pathology, The George Washington University Hospital, Washington, District of Columbia
| | - Mohamed A Mohamed
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
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Cao C, Wang S, Liu Y, Yue S, Wang M, Yu X, Ding Y, Lv M, Fang K, Chu M, Liao Z. Factors influencing C-reactive protein status on admission in neonates after birth. BMC Pediatr 2024; 24:89. [PMID: 38302903 PMCID: PMC10832075 DOI: 10.1186/s12887-024-04583-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/21/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE To explore the factors influencing C-reactive protein (CRP) status in neonates on admission after birth. METHODS 820 newborns born and hospitalized at Xiangya Hospital of Central South University from Jan. 2020 to Dec. 2020 were retrospectively analyzed. Maternal medical history and medication use during pregnancy, neonatal demographic information and status at birth were collected through the electronic medical record system. Statistical software was used to analyze the possible relationship between perinatal factors and CRP on admission after birth. RESULTS A total of 820 neonates were analyzed, including 463 males and 357 females with a mean gestational age (GA) of 36.07 ± 3.30 weeks. (1) Multifactor Logistic regression analysis: larger GA (OR: 1.13, 95%CI: 1.00-1.28, P = 0.042), premature rupture of membranes (PROM) ≥ 18 h (OR: 2.39, 95%CI: 1.35-4.23, P = 0.003) and maternal autoimmune diseases (OR: 5.30, 95%CI: 2.15-13.07, P < 0.001) were independent risk factors for CRP ≥ 8 mg/L. Cesarean delivery (OR 0.40, 95%CI: 0.26-0.60, P < 0.001) was independent protective factor for CRP ≥ 8 mg/L. (2) Threshold effect analysis: A non-linear relationship was found between GA and CRP. When GA is less than 33.9 weeks, the risk of CRP ≥ 8 mg/L was reduced by 28% with one week increased (P < 0.001), and when GA is more than 33.9 weeks, the risk of CRP ≥ 8 mg/L was increased by 61% with one week increased (P < 0.001). CONCLUSIONS GA, PROM, maternal autoimmune diseases and cesarean delivery were all independent influences neonatal CRP ≥ 8 mg/L on admission, and there was a nonlinear relationship between GA and neonatal CRP ≥ 8 mg/L on admission.
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Affiliation(s)
- Chuanding Cao
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Shuo Wang
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Yang Liu
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Shaojie Yue
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Mingjie Wang
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Xiaohe Yu
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Ying Ding
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Mei Lv
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Keren Fang
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Meiyan Chu
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China
| | - Zhengchang Liao
- Department of Neonatology, Xiangya Hospital, Central South University, No. 87 Xiangya Road, Changsha, Hunan, 410008, China.
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Bernardi L, Bossù G, Dal Canto G, Giannì G, Esposito S. Biomarkers for Serious Bacterial Infections in Febrile Children. Biomolecules 2024; 14:97. [PMID: 38254697 PMCID: PMC10813546 DOI: 10.3390/biom14010097] [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: 12/10/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Febrile infections in children are a common cause of presentation to the emergency department (ED). While viral infections are usually self-limiting, sometimes bacterial illnesses may lead to sepsis and severe complications. Inflammatory biomarkers such as C reactive protein (CRP) and procalcitonin are usually the first blood exams performed in the ED to differentiate bacterial and viral infections; nowadays, a better understanding of immunochemical pathways has led to the discovery of new and more specific biomarkers that could play a role in the emergency setting. The aim of this narrative review is to provide the most recent evidence on biomarkers and predictor models, combining them for serious bacterial infection (SBI) diagnosis in febrile children. Literature analysis shows that inflammatory response is a complex mechanism in which many biochemical and immunological factors contribute to the host response in SBI. CRP and procalcitonin still represent the most used biomarkers in the pediatric ED for the diagnosis of SBI. Their sensibility and sensitivity increase when combined, and for this reason, it is reasonable to take them both into consideration in the evaluation of febrile children. The potential of machine learning tools, which represent a real novelty in medical practice, in conjunction with routine clinical and biological information, may improve the accuracy of diagnosis and target therapeutic options in SBI. However, studies on this matter are not yet validated in younger populations, making their relevance in pediatric precision medicine still uncertain. More data from further research are needed to improve clinical practice and decision making using these new technologies.
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Affiliation(s)
| | | | | | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.B.); (G.B.); (G.D.C.); (G.G.)
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12
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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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13
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Malchau Carlsen EL, Dungu KHS, Lewis A, Vissing NH, Aunsholt L, Trautner S, Stanchev H, Dayani GK, Pedersen AJL, Bjerager M, De Salas M, Vestergaard K, Pedersen P, Frimodt-Møller N, Greisen G, Hansen BM, Nygaard U. Switch from intravenous-to-oral antibiotics in neonatal probable and proven early-onset infection: a prospective population-based real-life multicentre cohort study. Arch Dis Child Fetal Neonatal Ed 2023; 109:34-40. [PMID: 37369601 DOI: 10.1136/archdischild-2023-325386] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
- Emma Louise Malchau Carlsen
- Department of Neonatology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Department of Pediatrics, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Kia Hee Schultz Dungu
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Anna Lewis
- Department of Pediatrics, Hillerød Hospital, University of Copenhagen, Hillerod, Denmark
| | - Nadja Hawwa Vissing
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Lise Aunsholt
- Department of Neonatology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Comparative Pediatrics and Nutrition, University of Copenhagen, Copenhagen, Denmark
| | - Simon Trautner
- Department of Neonatology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Hristo Stanchev
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | | | | | - Mia Bjerager
- Department of Pediatrics, Hillerød Hospital, University of Copenhagen, Hillerod, Denmark
| | - Maria De Salas
- Department of Pediatrics, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Pernille Pedersen
- Department of Pediatrics, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Niels Frimodt-Møller
- Department of Microbiology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
| | - Bo Mølholm Hansen
- Department of Pediatrics, Hillerød Hospital, University of Copenhagen, Hillerod, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
| | - Ulrikka Nygaard
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
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14
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Attia Hussein Mahmoud H, Parekh R, Dhandibhotla S, Sai T, Pradhan A, Alugula S, Cevallos-Cueva M, Hayes BK, Athanti S, Abdin Z, K B. Insight Into Neonatal Sepsis: An Overview. Cureus 2023; 15:e45530. [PMID: 37868444 PMCID: PMC10585949 DOI: 10.7759/cureus.45530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
There are approximately 1.3 million cases of neonatal sepsis reported worldwide with deaths occurring more commonly in preterm and low-weight newborns. Neonatal sepsis is the third major cause of neonatal deaths resulting in 203,000 deaths per year. It is divided into two subtypes based on time of occurrence: early-onset neonatal sepsis (ENS), occurring within the first 72 hours of birth usually due to perinatal risk factors, and late-onset neonatal sepsis (LOS) usually occurring after the first week of life and up to 28th day of life. There are many complications associated with neonatal sepsis including septic shock, multiple organ failure, and death. It is vital for clinicians to know the signs and symptoms of neonatal sepsis in order to diagnose it early. Preventive measures, early diagnosis, appropriate antibiotic administration, timely supportive management, and the establishment of efficient management are vital in the prevention of severe complications or death. In this review, we aim to provide the most up-to-date information regarding risk factors, pathophysiology, signs and symptoms, diagnosis, and treatment of neonatal sepsis. We discuss the maternal and neonatal risk factors involved in the pathogenesis of neonatal sepsis and the signs and symptoms of early and late neonatal sepsis. We focus on the different pathogens involved and the markers used in the diagnosis and treatments available for each.
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Affiliation(s)
| | - Ritika Parekh
- Community Health, K. J. Somaiya Medical College and Research Centre, Mumbai, IND
| | | | - Tarun Sai
- Pediatrics, Sri Balaji Medical College Hospital and Research Institute, Tirupati, IND
| | - Aayush Pradhan
- Pediatric Emergency, International Friendship Children's Hospital, Kathmandu, NPL
| | - Shiny Alugula
- Pediatric Surgery, New Vision University, Eluru, IND
| | | | - Barbara K Hayes
- Pediatric Intensive Care Unit, Suburbio Hospital, Salvador, BRA
| | - Saranya Athanti
- Pediatrics, Employees' State Insurance Corporation Medical College and Hospital, Hyderabad, IND
| | - Zain Abdin
- Critical Care Medicine, IMG (International Medical Graduate) Helping Hands, Albuquerque, USA
| | - Basant K
- Medicine, Tanta University, Tanta, EGY
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15
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Boscarino G, Migliorino R, Carbone G, Davino G, Dell’Orto VG, Perrone S, Principi N, Esposito S. Biomarkers of Neonatal Sepsis: Where We Are and Where We Are Going. Antibiotics (Basel) 2023; 12:1233. [PMID: 37627653 PMCID: PMC10451659 DOI: 10.3390/antibiotics12081233] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/27/2023] Open
Abstract
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.
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Affiliation(s)
- Giovanni Boscarino
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.B.); (R.M.); (G.C.); (G.D.)
| | - Rossana Migliorino
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.B.); (R.M.); (G.C.); (G.D.)
| | - Giulia Carbone
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.B.); (R.M.); (G.C.); (G.D.)
| | - Giusy Davino
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.B.); (R.M.); (G.C.); (G.D.)
| | | | - Serafina Perrone
- Neonatal Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (V.G.D.); (S.P.)
| | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.B.); (R.M.); (G.C.); (G.D.)
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16
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Dhudasia MB, Benitz WE, Flannery DD, Christ L, Rub D, Remaschi G, Puopolo KM, Mukhopadhyay S. Diagnostic Performance and Patient Outcomes With C-Reactive Protein Use in Early-Onset Sepsis Evaluations. J Pediatr 2023; 256:98-104.e6. [PMID: 36529283 PMCID: PMC10164676 DOI: 10.1016/j.jpeds.2022.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/31/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Miren B Dhudasia
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA
| | - Dustin D Flannery
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lori Christ
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David Rub
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Giulia Remaschi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Karen M Puopolo
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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17
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Rallis D, Giapros V, Serbis A, Kosmeri C, Baltogianni M. Fighting Antimicrobial Resistance in Neonatal Intensive Care Units: Rational Use of Antibiotics in Neonatal Sepsis. Antibiotics (Basel) 2023; 12:508. [PMID: 36978375 PMCID: PMC10044400 DOI: 10.3390/antibiotics12030508] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
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.
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Affiliation(s)
- Dimitrios Rallis
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Anastasios Serbis
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Chrysoula Kosmeri
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
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18
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Camargo JF, Almeida JL, Fernandes LF, Marba STM, Caldas JPS. Conservative management of newborns with 35 weeks or more of gestational age at risk for early-onset sepsis: a Brazilian cohort study. J Pediatr (Rio J) 2023; 99:181-186. [PMID: 36183743 PMCID: PMC10031319 DOI: 10.1016/j.jped.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Juliana F Camargo
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil.
| | - Juliana L Almeida
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Lívia F Fernandes
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Sergio Tadeu M Marba
- Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Jamil Pedro S Caldas
- Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
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19
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Rød E, Solberg V, Stenersen EO, Garberg HT, Mjelle AB, Tølløfsrud PA, Rønnestad AE, Solevåg AL. Biochemical surveillance versus clinical observation of term infants born after prolonged rupture of membranes - A quality assurance initiative. Acta Paediatr 2023; 112:391-397. [PMID: 36478463 PMCID: PMC10107997 DOI: 10.1111/apa.16617] [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: 10/17/2022] [Revised: 11/23/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
AIM To examine whether biochemical surveillance vs clinical observation of term infants with prolonged rupture of membranes as a risk factor for early-onset sepsis is associated with differences in patient trajectories in maternity and neonatal intensive care units. METHODS A retrospective study of live-born infants with gestational age ≥ 37 + 0 weeks born after prolonged rupture of membranes (≥24 h) in four Norwegian hospitals 2017-2019. Two hospitals used biochemical surveillance, and two used predominantly clinical observation to identify early-onset sepsis cases. RESULTS The biochemical surveillance hospitals had more C-reactive protein measurements (p < 0.001), neonatal intensive care unit admissions (p < 0.001) and antibiotic treatment (p < 0.001). Hospitals using predominantly clinical observation initiated antibiotic treatment earlier in infants with suspected early-onset sepsis (p = 0.04) but not in infants fulfilling early-onset sepsis diagnostic criteria (p = 0.09). There was no difference in antibiotic treatment duration (p = 0.59), fraction of infants fulfilling early-onset sepsis diagnostic criteria (p = 0.49) or length of hospitalisation (p = 0.30), and no early-onset sepsis-related adverse outcomes. CONCLUSION The biochemical surveillance hospitals had more C-reactive protein measurements, but there was no difference in antibiotic treatment duration, early-onset sepsis cases, length of hospitalisation or adverse outcomes. Personnel resources needed for clinical surveillance should be weighed against the limitation of potentially painful procedures.
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Affiliation(s)
- Emma Rød
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Vilde Solberg
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Eydís Oddsdóttir Stenersen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Institute of clinical medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Anders Batman Mjelle
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Per Arne Tølløfsrud
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Arild Erland Rønnestad
- Institute of clinical medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Anne Lee Solevåg
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
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20
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Tucker MH, Yeh HW, Oh D, Shaw N, Kumar N, Sampath V. Preterm sepsis is associated with acute lung injury as measured by pulmonary severity score. Pediatr Res 2023; 93:1050-1056. [PMID: 35906303 DOI: 10.1038/s41390-022-02218-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/30/2022] [Accepted: 07/12/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Sepsis related acute lung injury (ALI) is established in adults but has not been investigated in premature infants. Herein, we used pulmonary severity score (PSS) trajectories and C-reactive protein (CRP) to examine the relation between sepsis and ALI in premature infants. METHODS This retrospective study identified 211 sepsis and 123 rule out (RO) events in 443 infants born <31 weeks and <1500 grams. The PSS was calculated prior to, at the time of, and up to 1 week after each event. Initial and peak CRP values were collected for each event. RESULTS PSS significantly increased at 0 h from baseline (-72h) and remained increased at all subsequent time points (all p < 0.002) in sepsis events. Mean PSS in sepsis episodes were also higher compared to RO events at +24 h, +48 h, +72 h, and +168 h (all p < 0.004). A positive correlation was noted between peak CRP values in sepsis events and PSS at 0 h, +24 h, +48 h, and +72 h. CONCLUSIONS The temporal PSS trends and correlation with CRP levels observed in sepsis but not in RO events supports the hypothesis that neonatal sepsis is associated with ALI and contributes to the accumulating evidence that neonatal ARDS occurs. IMPACT To evaluate pulmonary severity scores and c-reactive protein values over time to establish an association between preterm neonatal sepsis and acute lung injury (ALI). Though sepsis is well established as the most common indirect cause of ALI leading to acute respiratory distress syndrome (ARDS) in adults and pediatrics, this phenomenon remains undefined in neonates. This study validates the proposal by the Neonatal ARDS Project that ARDS also occurs in neonates by demonstrating acute and sustained changes in markers of pulmonary injury temporally related to a diagnosis of neonatal sepsis in preterm infants.
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Affiliation(s)
- Megan Hudson Tucker
- Division of Neonatology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, MO, USA.
| | - Hung-Wen Yeh
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel Oh
- University of Missouri at Kansas City School of Medicine, Kansas City, MO, USA
| | - Nicole Shaw
- Division of Neonatology, Hurley Children's Hospital, Flint, MI, USA
| | - Navin Kumar
- Division of Neonatology, Hurley Children's Hospital, Flint, MI, USA
| | - Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, MO, USA
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21
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Wang X, Shi L, Wang C, Ma X. Therapeutic hypothermia can cause non-infective C-reactive protein elevating. Front Pediatr 2023; 11:1157417. [PMID: 37168805 PMCID: PMC10164936 DOI: 10.3389/fped.2023.1157417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/27/2023] [Indexed: 05/13/2023] Open
Abstract
Objective To analyze the relationship between therapeutic hypothermia (TH) and whole blood high-sensitivity C-reactive protein (hs-CRP) in neonates with hypoxic-ischemic encephalopathy (HIE). Method Retrospective analysis was made on the clinical data of hospitalized infants diagnosed with asphyxia in our neonatal intensive care unit from January 2014 to June 2021. According to whether TH was performed, they were divided into two groups, the control group (missed the time in other hospitals and did not receive TH) and the treatment group (TH group). In their first ten days, analysis was made on the hs-CRP, white blood cell (WBC) count, neutrophil percentage, platelet count (PLT), and brain MRI. The correlation analysis was carried out based on the severity of brain injury displayed by the brain MRI and the time of hs-CRP elevation to summarize the relationship between TH and the time of hs-CRP elevation and the severity of HIE. Results 83 infants were included, 28 in the control group and 55 in the TH group. After birth, 33 infants (60.0%) in the TH group and 2 patients (7.1%) in the control group had elevated hs-CRP, which was statistically significant (P < 0.05). The time window for CRP elevation after TH was 72-96 h after the end of treatment; The results of the brain MRI showed 23 in the TH group and 11in the control group with moderate and severe HIE. 21 infants (all in the TH group) had elevated hs-CRP. MRI showed that the number of infants with mild injury or regular infants whose hs-CRP raised in the TH group was 12, and the rate of hs-CRP elevation was 37.5%; in the control group, the rate was 11.8%. The difference was significant. TH can decrease PLT and WBC, but no significance in the two groups. Blood and sputum cultures were negative in all infants, and there were no signs of infection. Conclusions TH can increase the blood hs-CRP of HIE neonates, and the probability of its occurrence is related to the severity of HIE. The heavier the HIE, the higher the risk of hs-CRP elevation after TH; The hs-CRP elevation has little to do with infection, and it doesn't recommend using antibiotics actively.
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22
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Fleiss N, Schwabenbauer K, Randis TM, Polin RA. What's new in the management of neonatal early-onset sepsis? Arch Dis Child Fetal Neonatal Ed 2023; 108:10-14. [PMID: 35618407 DOI: 10.1136/archdischild-2021-323532] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/06/2022] [Indexed: 11/03/2022]
Abstract
The expert guidelines highlighted in this review provide an evidence-based framework for approaching at-risk infants and allow for a more limited and standardised approach to antibiotic use. While these guidelines have significantly reduced antibiotic utilisation worldwide, optimally each unit would individualise their approach to early onset sepsis (EOS) based on the neonatal population they serve and available resources. As advancements in EOS research continue and limitations with sepsis prediction tools are addressed, it is inevitable that our risk stratification and management guidelines will become more precise.
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Affiliation(s)
- Noa Fleiss
- Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kathleen Schwabenbauer
- Pediatrics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Tara M Randis
- Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Richard A Polin
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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23
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Sullivan BA, Kausch SL, Fairchild KD. Artificial and human intelligence for early identification of neonatal sepsis. Pediatr Res 2023; 93:350-356. [PMID: 36127407 DOI: 10.1038/s41390-022-02274-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
Artificial intelligence may have a role in the early detection of sepsis in neonates. Machine learning can identify patterns that predict high or increasing risk for clinical deterioration from a sepsis-like illness. In developing this potential addition to NICU care, careful consideration should be given to the data and methods used to develop, validate, and evaluate prediction models. When an AI system alerts clinicians to a change in a patient's condition that warrants a bedside evaluation, human intelligence and experience come into play to determine an appropriate course of action: evaluate and treat or wait and watch closely. With intelligently developed, validated, and implemented AI sepsis systems, both clinicians and patients stand to benefit. IMPACT: This narrative review highlights the application of AI in neonatal sepsis prediction. It describes issues in clinical prediction model development specific to this population. This article reviews the methods, considerations, and literature on neonatal sepsis model development and validation. Challenges of AI technology and potential barriers to using sepsis AI systems in the NICU are discussed.
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Affiliation(s)
- Brynne A Sullivan
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Sherry L Kausch
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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24
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Nakamura Y, Iwata S, Yokoi K, Mizutani Y, Yoshikane M, Kawase K, Kato T, Kobayashi S, Goto H, Saitoh S, Iwata O. Influence of Intrauterine Inflammation, Delivery, and Postnatal Feeding on the Temporal Changes of Serum Alpha 1 Acid Glycoprotein Levels in Extremely-Low-Birth-Weight Infants. Nutrients 2022; 14:5162. [PMID: 36501194 PMCID: PMC9736676 DOI: 10.3390/nu14235162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/09/2022] Open
Abstract
Infection remains the primary cause of death in extremely-low-birth-weight infants (ELBWIs). Alpha 1 acid glycoprotein (α1AG), an acute-phase protein, has been shown to be elevated in sporadic cases of septic ELBWIs prior to abnormal clinical signs. To delineate the roles of inflammation, delivery, and feeding in postnatal α1AG changes in ELBWIs, 75 ELBWIs of 26.5 ± 2.2 weeks of gestation born between May 2011 and August 2017 were retrospectively studied. The dependence of α1AG levels obtained on days 0−5 on the clinical variables was examined by incorporating interactions with age, followed by estimations of regression coefficients between clinical variables and α1AG levels at the early and late postnatal ages, defined by their standard deviation. Chorioamnionitis (p < 0.001), funisitis (p = 0.045), vaginal delivery (p = 0.025), enteral feeding (p = 0.022), and probiotics (p = 0.005) were associated with early α1AG elevations. Hypertensive disorder of pregnancy (p < 0.001) and gestational age (p = 0.001) were associated with late α1AG elevation; premature rupture of membranes (p < 0.001), funisitis (p = 0.021), body weight z-scores (p < 0.001), and enteral feeding (p = 0.045) were associated with late α1AG reduction. Postnatal α1AG changes in ELBWIs were associated with variables representative of age, growth, delivery, inflammation, and enteral feeding, potentially reflecting the process of sensitization to extrinsic microbes in utero, at birth, and thereafter.
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Affiliation(s)
- Yasuhisa Nakamura
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Sachiko Iwata
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Kyoko Yokoi
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Yuko Mizutani
- Department of Pediatrics, Nagoya City University West Medical Center, 1-1-1, Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
| | - Masatoshi Yoshikane
- Department of Pediatrics, Nagoya City University West Medical Center, 1-1-1, Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
| | - Koya Kawase
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Takenori Kato
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Satoru Kobayashi
- Department of Pediatrics, Nagoya City University West Medical Center, 1-1-1, Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
| | - Haruo Goto
- Department of Pediatrics, Nagoya City University West Medical Center, 1-1-1, Hirate-cho, Kita-ku, Nagoya 462-8508, Japan
| | - Shinji Saitoh
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Osuke Iwata
- Center for Human Development and Family Science, Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, 1, Kawasumi Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
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Abstract
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.
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Affiliation(s)
- Sarah A. Coggins
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kirsten Glaser
- Division of Neonatology, Department of Women’s and Children’s Health, University of Leipzig Medical Center, Leipzig, Germany
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26
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Cao I, Lippmann N, Thome UH. The Value of Perinatal Factors, Blood Biomarkers and Microbiological Colonization Screening in Predicting Neonatal Sepsis. J Clin Med 2022; 11:5837. [PMID: 36233706 PMCID: PMC9571877 DOI: 10.3390/jcm11195837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/22/2022] [Accepted: 09/28/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Neonatal sepsis is one of the most important causes of elevated morbidity and mortality rates in neonatal intensive care units worldwide. While the clinical manifestations of neonatal sepsis tend to be nonspecific, its rapid development and life-threatening potential call for reliable markers for early detection. Methods: We conducted a retrospective single-center study including all neonates suspected of having developed neonatal sepsis from 2013 to 2016. Perinatal and clinical characteristics as well as microbiological and laboratory findings were evaluated. Neonatal sepsis was defined as either culture-proven sepsis (positive blood culture) or clinical sepsis (at least one symptom and elevated C-reactive protein (CRP) concentrations within 72 h with negative blood culture). We further differentiated between early-onset (EOS) and late-onset (LOS) sepsis. Results: Microbiological colonization screening by throat and rectal swabs frequently did not detect the organism that subsequently caused the sepsis. Depending on the age of the newborn with sepsis (EOS or LOS), associations between different anamnestic and clinical factors (prenatal or postnatal ones) were found. In particular, the central−peripheral temperature difference showed a strong association with LOS. Laboratory results useful for the early detection of neonatal sepsis included interleukin-6 (IL-6) and CRP concentrations. Conclusions: Elevated IL-6 >100 ng/L was a strong marker for neonatal sepsis. When choosing the antibiotics for treatment, data from microbiological colonization screening should be considered but not solely relied on. Some indicators of infection also depended on postnatal age.
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Affiliation(s)
- Isabel Cao
- Divison of Neonatology, Center for Pediatric Research, University Hospital for Children, Liebigstraße 20a, 04103 Leipzig, Germany
| | - Norman Lippmann
- Institute for Medical Microbiology and Virology, University of Leipzig, 04103 Leipzig, Germany
| | - Ulrich H. Thome
- Divison of Neonatology, Center for Pediatric Research, University Hospital for Children, Liebigstraße 20a, 04103 Leipzig, Germany
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27
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Rodrigues Wilde MO, Mezadri T, Gouveia PB, Grillo LP, Valete C. Prediction of early-onset neonatal sepsis in umbilical cord blood analysis: an integrative review. J Matern Fetal Neonatal Med 2022; 35:10187-10198. [PMID: 36100266 DOI: 10.1080/14767058.2022.2122798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The aim of this study was to describe the inflammatory markers studied in umbilical cord blood and to analyze the performance of the three markers most frequently studied for the prediction of early-onset neonatal sepsis. DATA SOURCES An integrative review from 1995 to 2021 was performed, with a search in the MEDLINE, Embase, Cochrane Library, SciELO, and gray literature databases, using the terms "neonates," "newborns," "neonatal sepsis," "early-onset neonatal sepsis," "neonatal infection," "inflammatory markers," "biomarkers," "cord blood," "fetal blood." STUDY SELECTION AND DATA EXTRACTIONS Study evaluation was limited to primary studies, prospective, observational or intervention, descriptive or analytical, that assessed the diagnosis of early-onset neonatal sepsis using inflammatory markers in umbilical cord blood, in Portuguese, English, or Spanish. Qualitative studies, reports, review studies, and case series were excluded. Only studies with a punctuation ≥ 6 in the Newcastle-Ottawa scale were included. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Sixteen studies were included in the qualitative synthesis. Procalcitonin, C-reactive protein, and interleukin-6 were the most frequently studied markers. The best performance for C-reactive protein was observed at a 0.2 mg/L cutoff, with a sensitivity of 82% and a negative predictive value of 99%. Procalcitonin presented the best performance at a 0.5 ng/mL cutoff with 87.5% sensitivity and 98.7% negative predictive value. Interleukin-6 presented the best performance at a 108.5 ng/mL cutoff, with 95% sensitivity and 97.4% negative predictive value. CONCLUSION The evaluation of markers in the umbilical cord for the diagnosis of early-onset neonatal sepsis, could contribute to a more assertive therapy for the neonate and anticipate sepsis screening. Since the cost is less and technically easier, C-reactive protein is recommended for routine use.
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Affiliation(s)
| | - Tatiana Mezadri
- Professional Master's Program in Health and Work Management, University of the Vale do Itajaí, Itajai, Brazil
| | | | - Luciane Peter Grillo
- Professional Master's Program in Health and Work Management, University of the Vale do Itajaí, Itajai, Brazil
| | - Cristina Valete
- Department of Medicine, Universidade Federal de São Carlos, Sao Carlos, Brazil
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28
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Orfanos I, Sotoca Fernandez J, Elfving K, Alfvén T, Eklund EA. Paediatric emergency departments should manage young febrile and afebrile infants the same if they have a fever before presenting. Acta Paediatr 2022; 111:2004-2009. [PMID: 35808896 PMCID: PMC9539858 DOI: 10.1111/apa.16483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/04/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Abstract
Aim Our aim was to evaluate the risk of bacterial meningitis, bacteremia, and urinary tract infection (UTI) in infants ≤60 days who presented to paediatric emergency departments (PEDs) after having fever at home. We also investigated any differences between infants who were afebrile or febrile on presentation. Methods This was a multicenter retrospective study of infants ≤60 days presented to four Swedish PEDs during 2014–2020 with reported fever at home. We used relative risks (RR) to compare the prevalence of UTI, bacteremia, and bacterial meningitis between the infants who were afebrile and the infants who were still febrile when they presented to the PED. Results The cohort comprised 1926 infants, and 702 (36%) were afebrile on presentation. The prevalence of UTI in the afebrile and febrile infants was 6.1% [95% confidence interval (CI) 4.5–8.2] versus 14.2% (95% CI 12.3–16.2), corresponding to an RR of 0.43 (95% CI 0.31–0.59). In infants ≤28 days, the RR for meningitis was 1.05 (95% CI 0.18–6.23) for afebrile versus febrile infants. Five times more febrile infants underwent a lumbar puncture. Conclusion Infants who were afebrile on presentation underwent fewer lumbar punctures, but they had similar rates of bacterial meningitis to febrile infants. Different management approaches are not justified.
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Affiliation(s)
- Ioannis Orfanos
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Pediatrics, Skåne University Hospital, Lund, Sweden
| | | | - Kristina Elfving
- Department of Pediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Tobias Alfvén
- Dept. of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Erik A Eklund
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Pediatrics, Skåne University Hospital, Lund, Sweden
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29
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Li J, Lillehoj PB. Ultrafast Electrothermal Flow-Enhanced Magneto Biosensor for Highly Sensitive Protein Detection in Whole Blood. Angew Chem Int Ed Engl 2022; 61:e202200206. [PMID: 35293092 PMCID: PMC9117500 DOI: 10.1002/anie.202200206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Indexed: 12/13/2022]
Abstract
Current diagnostic tests for sensitive protein detection rely on immunological techniques, such as ELISA, which require sample purification, multiple washing steps and lengthy incubation, hindering their use for rapid testing. Here, we report a simple electrothermal flow-enhanced biosensor for ultrafast, high sensitivity measurements of protein biomarkers in whole blood. Magnetic nanobeads dually-labeled with a detection antibody and enzyme reporter are used to form immunocomplexes with the target protein, which are readily transported to the sensor via magnetic concentration. The incorporation of electrothermal flows enhances immunocomplex formation, allowing for rapid and sensitive detection without requiring blood purification or lengthy incubation. Proof of concept was carried out using Plasmodium falciparum histidine-rich protein 2 (PfHRP2), a malaria parasite biomarker, which could be detected at concentrations as low as 5.7 pg mL-1 (95 fM) in whole blood in 7 min. The speed, sensitivity and simplicity of this device make it attractive for rapid diagnostic testing.
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Affiliation(s)
- Jiran Li
- Department of Mechanical Engineering, Rice University, Houston, TX 77005, USA
| | - Peter B Lillehoj
- Department of Mechanical Engineering, Rice University, Houston, TX 77005, USA
- Department of Bioengineering, Rice University, Houston, TX 77030, USA
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30
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Goel N, Cannell S, Davies G, Natti MS, Kirupaalar V, Abelian A, Saeed S, Smith R, Manikonda R, Pitchaikani PK, Davies D, Morris RM, Edwards L, Govindaraju R, Creese K, Jones J, Choudhary J, Rowley S, Sethuraman C, Muxworthy H, Curtis F, Donnelly P, Joishy M, Barnard I, Kenny C, Pal R, Jones K, Banerjee S. Implementation of an adapted Sepsis Risk Calculator algorithm to reduce antibiotic usage in the management of early onset neonatal sepsis: a multicentre initiative in Wales, UK. Arch Dis Child Fetal Neonatal Ed 2022; 107:303-310. [PMID: 34551917 DOI: 10.1136/archdischild-2020-321489] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/06/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Assess the impact of introducing a consensus guideline incorporating an adapted Sepsis Risk Calculator (SRC) algorithm, in the management of early onset neonatal sepsis (EONS), on antibiotic usage and patient safety. DESIGN Multicentre prospective study SETTING: Ten perinatal hospitals in Wales, UK. PATIENTS All live births ≥34 weeks' gestation over a 12-month period (April 2019-March 2020) compared with infants in the preceding 15-month period (January 2018-March 2019) as a baseline. METHODS The consensus guideline was introduced in clinical practice on 1 April 2019. It incorporated a modified SRC algorithm, enhanced in-hospital surveillance, ongoing quality assurance, standardised staff training and parent education. The main outcome measure was antibiotic usage/1000 live births, balancing this with analysis of harm from delayed diagnosis and treatment, disease severity and readmissions from true sepsis. Outcome measures were analysed using statistical process control charts. MAIN OUTCOME MEASURES Proportion of antibiotic use in infants ≥34 weeks' gestation. RESULTS 4304 (14.3%) of the 30 105 live-born infants received antibiotics in the baseline period compared with 1917 (7.7%) of 24 749 infants in the intervention period (45.5% mean reduction). All 19 infants with culture-positive sepsis in the postimplementation phase were identified and treated appropriately. There were no increases in sepsis-related neonatal unit admissions, disease morbidity and late readmissions. CONCLUSIONS This multicentre study provides evidence that a judicious adaptation of the SRC incorporating enhanced surveillance can be safely introduced in the National Health Service and is effective in reducing antibiotic use for EONS without increasing morbidity and mortality.
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Affiliation(s)
- Nitin Goel
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Gemma Davies
- Department of Neonatal Medicine, Singleton Hospital, Swansea, UK
| | | | | | - Artur Abelian
- Department of Paediatrics, Wrexham Maelor Hospital, Wrexham, UK
| | - Shakir Saeed
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Rhian Smith
- Department of Neonatal Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Ravi Manikonda
- Department of Paediatrics, Nevill Hall Hospital, Abergavenny, UK
| | | | - Dawn Davies
- Department of Paediatrics, Bronglais General Hospital, Aberystwyth, Ceredigion, UK
| | - Rachel May Morris
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | - Lynsey Edwards
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Kate Creese
- Department of Paediatrics, Princess of Wales Hospital, Bridgend, UK
| | - Jane Jones
- Department of Paediatrics, Wrexham Maelor Hospital, Wrexham, UK
| | - Jalil Choudhary
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Sarah Rowley
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Helen Muxworthy
- Department of Women's Health, Singleton Hospital, Swansea, UK
| | - Felicity Curtis
- Department of Women's Health, Singleton Hospital, Swansea, UK
| | | | - Manohar Joishy
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Ian Barnard
- Department of Neonatal Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Celyn Kenny
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | - Rajarshi Pal
- Department of Paediatrics, Glangwili General Hospital, Carmarthen, Carmarthenshire, UK
| | - Karen Jones
- Department of Paediatrics, Glangwili General Hospital, Carmarthen, Carmarthenshire, UK
| | - Sujoy Banerjee
- Department of Neonatal Medicine, Singleton Hospital, Swansea, UK
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31
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Rosa-Mangeret F, Benski AC, Golaz A, Zala PZ, Kyokan M, Wagner N, Muhe LM, Pfister RE. 2.5 Million Annual Deaths-Are Neonates in Low- and Middle-Income Countries Too Small to Be Seen? A Bottom-Up Overview on Neonatal Morbi-Mortality. Trop Med Infect Dis 2022; 7:64. [PMID: 35622691 PMCID: PMC9148074 DOI: 10.3390/tropicalmed7050064] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/25/2022] [Accepted: 04/11/2022] [Indexed: 12/29/2022] Open
Abstract
(1) Background: Every year, 2.5 million neonates die, mostly in low- and middle-income countries (LMIC), in total disregard of their fundamental human rights. Many of these deaths are preventable. For decades, the leading causes of neonatal mortality (prematurity, perinatal hypoxia, and infection) have been known, so why does neonatal mortality fail to diminish effectively? A bottom-up understanding of neonatal morbi-mortality and neonatal rights is essential to achieve adequate progress, and so is increased visibility. (2) Methods: We performed an overview on the leading causes of neonatal morbi-mortality and analyzed the key interventions to reduce it with a bottom-up approach: from the clinician in the field to the policy maker. (3) Results and Conclusions: Overall, more than half of neonatal deaths in LMIC are avoidable through established and well-known cost-effective interventions, good quality antenatal and intrapartum care, neonatal resuscitation, thermal care, nasal CPAP, infection control and prevention, and antibiotic stewardship. Implementing these requires education and training, particularly at the bottom of the healthcare pyramid, and advocacy at the highest levels of government for health policies supporting better newborn care. Moreover, to plan and follow interventions, better-quality data are paramount. For healthcare developments and improvement, neonates must be acknowledged as humans entitled to rights and freedoms, as stipulated by international law. Most importantly, they deserve more respectful care.
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Affiliation(s)
- Flavia Rosa-Mangeret
- Neonatal Division, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.Z.Z.); (R.E.P.)
- Global Health Institute, University of Geneva, 1205 Geneva, Switzerland;
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - Anne-Caroline Benski
- Obstetrics Division, Geneva University Hospitals, 1205 Geneva, Switzerland;
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Anne Golaz
- Center for Education and Research in Humanitarian Action, Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland;
| | - Persis Z. Zala
- Neonatal Division, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.Z.Z.); (R.E.P.)
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
- Centre Medico-Chirurgical-Pédiatrique Persis, Ouahigouya BP267, Burkina Faso
| | - Michiko Kyokan
- Global Health Institute, University of Geneva, 1205 Geneva, Switzerland;
| | - Noémie Wagner
- Pediatric Infectious Diseases Division, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Lulu M. Muhe
- College of Health Sciences, Addis Ababa University, Addis Ababa 1000, Ethiopia;
| | - Riccardo E. Pfister
- Neonatal Division, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.Z.Z.); (R.E.P.)
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
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Li J, Lillehoj PB. Ultrafast Electrothermal Flow‐Enhanced Magneto Biosensor for Highly Sensitive Protein Detection in Whole Blood. Angew Chem Int Ed Engl 2022. [DOI: 10.1002/ange.202200206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Jiran Li
- Department of Mechanical Engineering Rice University Houston TX 77005 USA
| | - Peter B. Lillehoj
- Department of Mechanical Engineering Rice University Houston TX 77005 USA
- Department of Bioengineering Rice University Houston TX 77030 USA
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Eichberger J, Resch E, Resch B. Diagnosis of Neonatal Sepsis: The Role of Inflammatory Markers. Front Pediatr 2022; 10:840288. [PMID: 35345614 PMCID: PMC8957220 DOI: 10.3389/fped.2022.840288] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/14/2022] [Indexed: 01/12/2023] Open
Abstract
This is a narrative review on the role of biomarkers in the diagnosis of neonatal sepsis. We describe the difficulties to obtain standardized definitions in neonatal sepsis and discuss the limitations of published evidence of cut-off values and their sensitivities and specificities. Maternal risk factors influence the results of inflammatory markers as do gestational age, the time of sampling, the use of either cord blood or neonatal peripheral blood, and some non-infectious causes. Current evidence suggests that the use of promising diagnostic markers such as CD11b, CD64, IL-6, IL-8, PCT, and CRP, either alone or in combination, might enable clinicians discontinuing antibiotics confidently within 24-48 h. However, none of the current diagnostic markers is sensitive and specific enough to support the decision of withholding antibiotic treatment without considering clinical findings. It therefore seems to be justified that antibiotics are often initiated in ill term and especially preterm infants. Early markers like IL-6 and later markers like CRP are helpful in the diagnosis of neonatal sepsis considering the clinical aspect of the neonate, the gestational age, maternal risk factors and the time (age of the neonate regarding early-onset sepsis) of blood sampling.
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Affiliation(s)
- Julia Eichberger
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria
| | - Elisabeth Resch
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria
| | - Bernhard Resch
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Development of a Novel Assessment Tool and Code Sepsis Checklist for Neonatal Late-Onset Sepsis. Adv Neonatal Care 2022; 22:6-14. [PMID: 34334674 DOI: 10.1097/anc.0000000000000896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Hibbert J, Armstrong NJ, Granland C, Ng S, Simmer K, Richmond P, Burgner D, Strunk T, Currie A. Plasma secretory phospholipase A2 as an early marker for late-onset sepsis in preterm infants-a pilot study. Acta Paediatr 2021; 110:3011-3013. [PMID: 34091943 DOI: 10.1111/apa.15969] [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: 02/17/2021] [Revised: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 11/29/2022]
Abstract
Preterm infants are particularly susceptible to bacterial late-onset sepsis (LOS). Diagnosis by blood culture and inflammatory markers have sub-optimal sensitivity and specificity and prolonged reporting times. There is an urgent need for more rapid, accurate adjunctive diagnostics in LOS to improve management and minimise antibiotic exposure. We measured the diagnostic performance of secretory phospholipase A2 type IIA (sPLA2-IIA) in very preterm infants (<30 weeks gestational age) with suspected LOS. Plasma sPLA2-IIA levels were elevated in infants with LOS (n = 28) compared to those without LOS (n = 21; median 30,970 vs. 2534 pg/ml, p < 0.0001). The mean area under the curve was 0.884 (95% CI: 0.771, 0.977) with a sensitivity of 0.907 (95% CI: 0.667, 1.00) and specificity of 0.804 (95% CI: 0.600, 1.00). The positive and negative predictive values were 0.833 (95% CI: 0.664, 0.927) and 0.842 (95% CI: 0.624, 0.945), respectively. This pilot study suggests that sPLA2-IIA may have clinical utility for the early diagnosis of LOS in very preterm infants, potentially informing clinical management and antibiotic stewardship.
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Affiliation(s)
- Julie Hibbert
- Neonatal Directorate, Child and Adolescent Health Service Perth WA Australia
- School of Medicine University of Western Australia Perth WA Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases Telethon Kids Institute Perth WA Australia
| | | | - Caitlyn Granland
- Wesfarmers Centre of Vaccines and Infectious Diseases Telethon Kids Institute Perth WA Australia
| | - Sherrianne Ng
- Imperial College Parturition Research Group Imperial College London London UK
- March of Dimes European Prematurity Research Centre Imperial College London London UK
| | - Karen Simmer
- School of Medicine University of Western Australia Perth WA Australia
| | - Peter Richmond
- School of Medicine University of Western Australia Perth WA Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases Telethon Kids Institute Perth WA Australia
| | - David Burgner
- Murdoch Children’s Research Institute Royal Children’s Hospital Parkville VIC Australia
- Department of Paediatrics University of Melbourne Melbourne VIC Australia
| | - Tobias Strunk
- Neonatal Directorate, Child and Adolescent Health Service Perth WA Australia
- School of Medicine University of Western Australia Perth WA Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases Telethon Kids Institute Perth WA Australia
| | - Andrew Currie
- Wesfarmers Centre of Vaccines and Infectious Diseases Telethon Kids Institute Perth WA Australia
- Centre for Molecular Medicine & Innovative Therapeutics Murdoch University Perth WA Australia
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Camargo JFD, Caldas JPDS, Marba STM. Early neonatal sepsis: prevalence, complications and outcomes in newborns with 35 weeks of gestational age or more. REVISTA PAULISTA DE PEDIATRIA 2021; 40:e2020388. [PMID: 34614138 PMCID: PMC8543790 DOI: 10.1590/1984-0462/2022/40/2020388] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/25/2021] [Indexed: 03/29/2024]
Abstract
Objective: To analyze the incidence, complications, and hospital discharge status in newborns with ≥35 weeks of gestational age with early neonatal sepsis. Methods: This is a cross-sectional, retrospective study. Cases of early-onset sepsis registered from January 2016 to December 2019 in neonates with gestational age of 35 weeks or more were reviewed in a level III neonatal unit. The diagnoses were performed based on the criteria by the Brazilian Health Regulatory Agency (Anvisa), and the episodes were classified according to microbiological classification and site of infection. The following complications were evaluated: shock, coagulation disorders, and sequelae of the central nervous system. The conditions at hospital discharge were also assessed. The collected data were analyzed with the descriptive analysis. Results: In the period, early neonatal sepsis occurred in 46 newborns, corresponding to 1.8% of all newborns admitted to the neonatal unit, with a prevalence of 4/1,000 live births. Culture confirmed sepsis ocurred in three patients (0.3/1,000 live births), with the following agents: S. pneumoniae, S. epidermidis and S. agalactiae. As to site of infection, there were 35 cases of primary bloodstream infection, seven cases of pneumonia and four cases of meningitis. Most patients (78.3%) had at least one risk factor for sepsis, and all were symptomatic at admission. There were no deaths. Complications occurred in 28.2% of the cases, especially shock (10 cases – 21.7%). Conclusions: The prevalence of proven early neonatal sepsis was low. Despite the common occurrence of complications, there were no deaths.
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Singh N, Gray JE. Antibiotic stewardship in NICU: De-implementing routine CRP to reduce antibiotic usage in neonates at risk for early-onset sepsis. J Perinatol 2021; 41:2488-2494. [PMID: 34103671 DOI: 10.1038/s41372-021-01110-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/30/2021] [Accepted: 05/18/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Antibiotic overuse is common in the neonatal intensive care units (NICUs). We evaluated the change in antibiotic utilization rate (AUR) by eliminating routine CRP in the management of early-onset sepsis (EOS). METHODS Retrospective before-after cohort study in a Level 3B NICU. We made the following practice changes in the management of EOS: (1) stop routine CRP and (2) implement an automatic stop order (ASO) for antibiotics at 48 h. We compared the AUR, defined as any antibiotic use per 1000 patient days before and after practice change. RESULT There was an absolute reduction of 30% in AUR and a decrease in the proportion of neonates receiving antibiotics from the day of life 3-6 in postintervention period. We did not identify any case of partially treated EOS with change in practice. CONCLUSION Elimination of routine CRP and ASO implementation for antibiotics in neonates at risk for EOS decreased AUR.
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Affiliation(s)
- Neetu Singh
- Children's Hospital at Dartmouth, Lebanon, NH, USA.
| | - James E Gray
- Children's Hospital at Dartmouth, Lebanon, NH, USA
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Retrospective cohort study of neonatal early onset of sepsis and the role of the EOS calculator in a level II nursery. Pediatr Neonatol 2021; 62:512-521. [PMID: 34092529 DOI: 10.1016/j.pedneo.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/31/2021] [Accepted: 05/10/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sepsis is a major cause of mortality and morbidity in neonates. With the improvement in health care standards, the incidence of neonatal Early Onset Sepsis (EOS) has reduced significantly. A recent Web-based EOS-calculator has been introduced with the aim to reduce the use of IV antibiotics in neonates. The role of the EOS-calculator has yet to be ascertained in this regional Special Care Nursery (SCN) in Western Australia. This study aims at examining the local incidence of culture proven EOS and the role of the EOS calculator. METHOD It is a retrospective study examining all newborns ≥35 weeks gestation throughout 2019 (Jan-Dec 2019) who received IV-antibiotics. The local incidence of culture-proven EOS was established and applied onto the EOS calculator. The recommended management by the EOS-calculator was cross-examined with the local EOS guideline. Overall proportion of reduction in IV antibiotics use was formulated. Other relevant laboratory data extracted was analysed with Pearson's correlation test with the EOS scores. RESULTS Total included sample was n = 252 with an annual birth of 1880s indicating 13.4% of all neonates born throughout year 2019 was treated with IV antibiotics. The local incidence of culture-proven EOS was 0.5/1000. By applying the EOS-calculator, a significant reduction of IV antibiotics usage from 13.4% to 3.9% (z value 10.4, p < 0.0001) could be achieved in this cohort. Sixty three percent of neonates who received IV antibiotics in this cohort were classified as 'clinically well' based on the EOS-calculator. CONCLUSION The EOS-calculator could reduce the use of IV antibiotics in the neonatal population significantly in this regional SCN (from 13.4% to 3.9%). Judicial use of IV antibiotics is imperative as part of the holistic care for the neonates. Implementation of the EOS-calculator must be done strategically considering the local incidence of EOS and other health care policies.
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40
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Payton KSE, Brunetti MA. Antibiotic Stewardship in Pediatrics. Adv Pediatr 2021; 68:37-53. [PMID: 34243858 DOI: 10.1016/j.yapd.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kurlen S E Payton
- Department of Pediatrics, Division of Neonatology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, NT Suite 4221, Los Angeles, CA 90048, USA.
| | - Marissa A Brunetti
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard Suite 8NE51, Philadelphia, PA 19104, USA
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A retrospective review of serious infections in febrile infants 0–90 days old. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/20101058211026003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Fever without source in infants is a common clinical problem that accounts for many ambulatory care visits and hospitalisations. Currently, there is no reliable method of identifying those at risk of serious infection (SI). Objective: The goal of this study was to determine the incidence and identify the predictors of SI in febrile infants who presented to the emergency department (ED). Methods: This was a single-centre retrospective cohort study of children presenting to a Singapore tertiary hospital paediatric unit between 1 July 2018 and 31 December 2018. Children were included if they were aged 0–90 days and presented to the ED with a fever. SI was defined as urinary tract infection (UTI), sepsis, bacteraemia, meningitis (viral and bacterial), enterocolitis, osteomyelitis, abscess or pneumonia. Results: Of the 659 infants, 161 (24.4%) were diagnosed with SI. Meningitis (49.7%) was the most common SI, followed by UTI (45.3%), enterocolitis (5.6%), sepsis (3.1%) and bacteraemia (2.5%). Factors significantly associated with SI were aged 29–60 days, male sex, Severity Index Score (SIS) <10, absolute neutrophil counts >10×109/L, C-reactive protein (CRP) >20 mg/L and procalcitonin >0.5 ng/mL. Multivariate analysis entering all these items retained only male sex, SIS <10 and CRP >20. Conclusion: Among hospitalised infants aged 0–90 days, the incidence of SI was 24.4%, and invasive bacterial infection was 0.6%. Meningitis was the most common SI followed by UTI. SIS and CRP can be used to predict SI in infants <90 days old.
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Zheng H, Glauser J. Review and Updates on Pediatric Fever. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021. [DOI: 10.1007/s40138-021-00227-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reconciling markedly discordant values of serum ferritin versus reticulocyte hemoglobin content. J Perinatol 2021; 41:619-626. [PMID: 33012780 DOI: 10.1038/s41372-020-00845-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/02/2020] [Accepted: 09/24/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine why serum ferritin and reticulocyte hemoglobin (RET-He), drawn to assess neonatal iron sufficiency, sometimes have markedly discordant results. STUDY DESIGN Retrospective records review of five NICUs over 28 months, identifying all patients with a ferritin and RET-He within 48 h. We examined records of all who had marked discordance (one value >95th % reference interval, the other <5th %). RESULTS Of 190 paired ferritin and RET-He measurements, 16 (8%) were markedly discordant. Fifteen of the 16 discordant samples involved a high ferritin and a low RET-He. In these, low MCV and high %Micro-R, and low MCH and high %HYPO-He were present. In total, 8 of the 15 had laboratory or clinical evidence of an inflammatory process and five had suspicion of infection documented. CONCLUSIONS When ferritin and RET-He were discordant, erythrocyte microcytosis and hypochromasia suggested that the RET-He gave the more accurate interpretation; that iron deficiency was likely present.
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Rallis D, Balomenou F, Kappatou K, Karantanou K, Tzoufi M, Giapros V. C-reactive protein in infants with no evidence of early-onset sepsis. J Matern Fetal Neonatal Med 2021; 35:5659-5664. [PMID: 33596753 DOI: 10.1080/14767058.2021.1888921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE C-reactive protein (CRP) is one of the most extensively used biomarkers in the investigation of early-onset sepsis (EOS). Current evidence suggests the normal kinetics of serum CRP should be considered when evaluating infants for presumable EOS. The current study aimed to evaluate the CRP kinetics, and to establish percentiles in a cohort of term and near-term infants with no evidence of confirmed or clinical EOS. METHODS We retrospectively reviewed the medical records of all neonates ≥34 weeks' gestation screened for presumable EOS, from January until December 2019. We also recorded the clinical management, the blood culture, serial CRP, and white blood cell count analysis of each infant. All infants that received antibiotics for confirmed or presumed EOS were excluded from the analysis. RESULTS During the study period, 145 infants were detected; 109 (75%) term and 36 (25%) preterm. Term infants had significantly higher median values of CRP at all time points in comparison to preterm infants. Term infants presented a significant rise of CRP at 24 and 36 h, with a peak at 24 h (median 4 (range 1-12) mg/L). Preterm infants had a significant rise of CRP at 24 but not at 36 h, with a peak at 24 h (median 3 (range 1-9) mg/L). In term infants, the 90th percentile of CRP at 24 h was 10.80 mg/L and the 97th percentile was 12.00 mg/L. In preterm infants, the 90th percentile of CRP at 24 h was 7.60 mg/L and the 97th percentile was 8.00 mg/L. CONCLUSIONS Term and near-term asymptomatic infants had a rise in CRP during the first days of life. Term infants had a more pronounced CRP response in comparison to preterm infants.
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Affiliation(s)
- Dimitrios Rallis
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Foteini Balomenou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Kleio Kappatou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Konstantina Karantanou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Meropi Tzoufi
- Department of Paediatrics, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, Ioannina, Greece
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Datla S, Kitchanan S, Sethuraman G. Diagnostic Reliability of Salivary C-Reactive Protein as an Alternative Noninvasive Biomarker of Neonatal Sepsis. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2284-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Friedman N, Yochpaz S, Zirkin S, Herzlich J, Marom R. C-reactive protein and the neonatal early-onset sepsis calculator for the diagnosis of neonatal sepsis. Eur J Clin Microbiol Infect Dis 2021; 40:1227-1234. [PMID: 33443655 DOI: 10.1007/s10096-021-04156-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/07/2021] [Indexed: 01/19/2023]
Abstract
Our aim was to evaluate the utility of the neonatal early-onset sepsis risk calculator (NEOSC) to the utility of C-reactive protein (CRP) for diagnosing neonatal EOS. This retrospective study reviewed the records of neonates who underwent sepsis workups due to equivocal symptoms and compared their CRP values to the calculator's recommendations and their cultures. A total of 382 newborns who underwent sepsis work-up due to equivocal symptoms were included in our study. The calculator's recommendations would have reduced the number of newborns who underwent sepsis workups by 82.5% and antibiotic treatment by 83.4% (n = 315). Considering that 373 of 382 (97.6%) ultimately had no sepsis, the calculator's specificity was higher than that of CRP (83.9% versus 76.1%). When comparing the maximal CRP value with the risk according to the neonatal sepsis calculator, a significant correlation was found between them (P < 0.01), but the relationship was not strong (Pearson's correlation = 0.27). We found a significant correlation between the risk of sepsis according to the NEOSC and the CRP values, although the correlation was not strong. The calculator's high specificity enables safe avoidance of multiple blood tests and antibiotic treatments for suspected neonates who are not infected. CRP tests can reduce the number of infected newborns the calculator may miss, at the cost of unnecessary blood tests and antibiotic therapy to many newborns.
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Affiliation(s)
- Nati Friedman
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sivan Yochpaz
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Semyon Zirkin
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacky Herzlich
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronella Marom
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.
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Kurul Ş, Simons SHP, Ramakers CRB, De Rijke YB, Kornelisse RF, Reiss IKM, Taal HR. Association of inflammatory biomarkers with subsequent clinical course in suspected late onset sepsis in preterm neonates. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:12. [PMID: 33407770 PMCID: PMC7788923 DOI: 10.1186/s13054-020-03423-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/02/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sepsis is a major health issue in preterm infants. Biomarkers are used to diagnose and monitor patients with sepsis, but C-reactive protein (CRP) is proven not predictive at onset of late onset neonatal sepsis (LONS) diagnosis. The aim of this study was to evaluate the association of interleukin-6(IL-6), procalcitonin (PCT) and CRP with subsequent sepsis severity and mortality in preterm infants suspected of late onset neonatal sepsis. METHODS The study was conducted at the Erasmus University Medical Center-Sophia Children's Hospital Rotterdam. Patient data from January 2018 until October 2019 were reviewed for all preterm neonates born with a gestational age below 32 weeks with signs and symptoms suggestive of systemic infection, in whom blood was taken for blood culture and for inflammatory biomarkers determinations. Plasma IL-6 and PCT were assessed next to CRP at the moment of suspicion. We assessed the association with 7-day mortality and sepsis severity (neonatal sequential organ failure assessment (nSOFA) score, need for inotropic support, invasive ventilation and thrombocytopenia). RESULTS A total of 480 suspected late onset neonatal sepsis episodes in 208 preterm neonates (gestational age < 32 weeks) were retrospectively analyzed, of which 143 episodes were classified as sepsis (29.8%), with 56 (11.7%) cases of culture negative, 63 (13.1%) cases of gram-positive and 24(5.0%) cases of gram-negative sepsis. A total of 24 (5.0%) sepsis episodes resulted in death within 7 days after suspicion of LONS. Both IL-6 (adjusted hazard ratio (aHR): 2.28; 95% CI 1.64-3.16; p < 0.001) and PCT (aHR: 2.91; 95% CI 1.70-5.00; p < 0.001) levels were associated with 7-day mortality; however, CRP levels were not significantly correlated with 7-day mortality (aHR: 1.16; 95% CI (0.68-2.00; p = 0.56). Log IL-6, log PCT and log CRP levels were all significantly correlated with the need for inotropic support. CONCLUSIONS Our findings show that serum IL-6 and PCT levels at moment of suspected late onset neonatal sepsis offer valuable information about sepsis severity and mortality risk in infants born below 32 weeks of gestation. The discriminative value was superior to that of CRP. Determining these biomarkers in suspected sepsis may help identify patients with imminent severe sepsis, who may require more intensive monitoring and therapy.
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Affiliation(s)
- Şerife Kurul
- Department of Pediatrics, Division Neonatology, Erasmus Medical Center, Erasmus MC, University Medical Center-Sophia Children's Hospital, Research Neonatology (Sk-4246), PO Box 2060, 300 CB, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division Neonatology, Erasmus Medical Center, Erasmus MC, University Medical Center-Sophia Children's Hospital, Research Neonatology (Sk-4246), PO Box 2060, 300 CB, Rotterdam, The Netherlands
| | - Christian R B Ramakers
- Department of Clinical Chemistry, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Yolanda B De Rijke
- Department of Clinical Chemistry, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - René F Kornelisse
- Department of Pediatrics, Division Neonatology, Erasmus Medical Center, Erasmus MC, University Medical Center-Sophia Children's Hospital, Research Neonatology (Sk-4246), PO Box 2060, 300 CB, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division Neonatology, Erasmus Medical Center, Erasmus MC, University Medical Center-Sophia Children's Hospital, Research Neonatology (Sk-4246), PO Box 2060, 300 CB, Rotterdam, The Netherlands
| | - H Rob Taal
- Department of Pediatrics, Division Neonatology, Erasmus Medical Center, Erasmus MC, University Medical Center-Sophia Children's Hospital, Research Neonatology (Sk-4246), PO Box 2060, 300 CB, Rotterdam, The Netherlands.
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48
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Chang SSY, Lim AZ, Ong GYK, Piragasam R, Allen JC, Ng KC, Maconochie I, Chong SL. Predictors of serious bacterial infections using serum biomarkers in an infant population aged 0 to 90 days: a prospective cohort study. BMJ Paediatr Open 2021; 5:e000861. [PMID: 34192187 PMCID: PMC7818843 DOI: 10.1136/bmjpo-2020-000861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/17/2020] [Accepted: 12/26/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Young febrile infants represent a vulnerable population at risk for serious bacterial infections (SBI). We aimed to evaluate the diagnostic accuracy of components of the complete blood count in comparison with C-reactive protein (CRP) to predict SBI among febrile infants. DESIGN AND SETTING Prospective cohort study conducted in a tertiary emergency department between December 2018 and November 2019. PATIENTS We included febrile infants ≤3 months old with complete blood count results. We analysed their white blood cell count (WBC), absolute neutrophil ratio (ANC), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, mean platelet volume to platelet count ratio, and compared these to the performance of CRP. MAIN OUTCOME MEASURES SBIs were defined as urinary tract infection, bacteraemia, bacterial meningitis, sepsis, pneumonia, skin and soft tissue infection, bacterial enteritis, septic arthritis or osteomyelitis. RESULTS Of the 187 infants analysed, 54 (28.9%) were diagnosed with SBI. Median values of WBC, ANC, NLR and CRP were significantly higher in infants with SBI: WBC (13.8 vs 11.4×109/L, p=0.004), ANC (6.7 vs 4.1×109/L, p<0.001), NLR (1.3 vs 0.9, p=0.001) and CRP (21.0 vs 2.3 mg/L, p<0.001), compared with those without. CRP had the best discriminatory values for SBI, with area under the curve (AUC) of 0.815 (95% CI 0.747 to 0.883), compared with WBC, ANC and NLR. A predictive model consisting of WBC, ANC and NLR in combination with clinical parameters, had an AUC of 0.814 (95% CI 0.746 to 0.883). There was increased discriminative performance when this predictive model was combined with CRP, (AUC of 0.844, 95% CI 0.782 to 0.906). CONCLUSION In young febrile infants, CRP was the best discriminatory biomarker for SBI. WBC, ANC and NLR when used in combination have potential diagnostic utility in this population.
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Affiliation(s)
- Serena Su Ying Chang
- Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Amanda Zhirui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Kee Chong Ng
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Ian Maconochie
- Section of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
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49
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Majumdar A, Biswas S, Jana A. Platelet indices as an earlier and economical marker of neonatal sepsis. IRAQI JOURNAL OF HEMATOLOGY 2021. [DOI: 10.4103/ijh.ijh_15_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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50
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Keij FM, Achten NB, Tramper-Stranders GA, Allegaert K, van Rossum AMC, Reiss IKM, Kornelisse RF. Stratified Management for Bacterial Infections in Late Preterm and Term Neonates: Current Strategies and Future Opportunities Toward Precision Medicine. Front Pediatr 2021; 9:590969. [PMID: 33869108 PMCID: PMC8049115 DOI: 10.3389/fped.2021.590969] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/01/2021] [Indexed: 12/20/2022] Open
Abstract
Bacterial infections remain a major cause of morbidity and mortality in the neonatal period. Therefore, many neonates, including late preterm and term neonates, are exposed to antibiotics in the first weeks of life. Data on the importance of inter-individual differences and disease signatures are accumulating. Differences that may potentially influence treatment requirement and success rate. However, currently, many neonates are treated following a "one size fits all" approach, based on general protocols and standard antibiotic treatment regimens. Precision medicine has emerged in the last years and is perceived as a new, holistic, way of stratifying patients based on large-scale data including patient characteristics and disease specific features. Specific to sepsis, differences in disease susceptibility, disease severity, immune response and pharmacokinetics and -dynamics can be used for the development of treatment algorithms helping clinicians decide when and how to treat a specific patient or a specific subpopulation. In this review, we highlight the current and future developments that could allow transition to a more precise manner of antibiotic treatment in late preterm and term neonates, and propose a research agenda toward precision medicine for neonatal bacterial infections.
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Affiliation(s)
- Fleur M Keij
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatrics, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Niek B Achten
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Gerdien A Tramper-Stranders
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatrics, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, Department of Pharmaceutical and Pharmacological Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Annemarie M C van Rossum
- Division of Infectious Diseases, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - René F Kornelisse
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
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