The influencing factors on procalcitonin values in newborns with noninfectious conditions during the first week of life

Procalcitonin for Detecting Culture-Positive Sepsis in Neonates: A Prospective, Multicenter Study

INTRODUCTION

It is unclear if serum procalcitonin (PCT) estimated at sepsis suspicion can help detect culture-positive sepsis in neonates. We evaluated the diagnostic performance of PCT in culture-positive sepsis in neonates.

METHODS

This was a prospective study (February 2016 to September 2020) conducted in four level-3 units in India. We enrolled neonates suspected of sepsis in the first 28 days of life. Neonates with birth weight <750 g, asphyxia, shock, and major malformations were excluded. Blood for PCT assay was drawn along with the blood culture at the time of suspicion of sepsis and before antibiotic initiation. The investigators labeled the neonates as having culture-positive sepsis or "no sepsis" based on the culture reports and clinical course. PCT assay was performed by electrochemiluminescence immunoassay, and the clinicians were masked to the PCT levels while assigning the label of sepsis. Primary outcomes were the sensitivity, specificity, and likelihood ratios to identify culture-positive sepsis.

RESULTS

The mean birth weight (SD) and median gestation (IQR) were 2,113 (727) g and 36 (32-38) weeks, respectively. Of the 1,204 neonates with eligible cultures, 155 (12.9%) had culture-positive sepsis. Most (79.4%) were culture-positive within 72 h of birth. The sensitivity, specificity, and positive and negative likelihood ratios at 2 ng/mL PCT threshold were 52.3% (95% confidence interval: 44.1-60.3), 64.5% (60.7-68.1), 1.47 (1.23-1.76), and 0.74 (0.62-0.88), respectively. Adding PCT to assessing neonates with 12.9% pretest probability of sepsis generated posttest probabilities of 18% and 10% for positive and negative test results, respectively.

CONCLUSION

Serum PCT did not reliably identify culture-positive sepsis in neonates.

Prospective multicentre study of host response signatures in neonatal sepsis in Sub Saharan Africa

Few biomarkers for sepsis diagnosis are commonly used in neonatal sepsis. While the role of host response is increasingly recognized in sepsis pathogenesis and prognosis, there is a need for evaluating new biomarkers targeting host response in regions where sepsis burden is high and medico-economic resources are scarce. The objective of the study is to evaluate diagnostic and prognostic accuracy of biomarkers of neonatal sepsis in Sub Saharan Africa. This prospective multicentre study included newborn infants delivered in the Abomey-Calavi region in South Benin and their follow-up from birth to 3 months of age. Accuracy of transcriptional (CD74, CX3CR1), proteic (PCT, IL-6, IL-10, IP-10) biomarkers and clinical characteristics to diagnose and prognose neonatal sepsis were measured. At delivery, cord blood from all consecutive newborns were sampled and analysed, and infants were followed for a 12 weeks' period. Five hundred and eighty-one newborns were enrolled. One hundred and seventy-two newborns developed neonatal sepsis (29.6%) and death occurred in forty-nine infants (8.4%). Although PCT, IL-6 and IP-10 levels were independently associated with sepsis diagnosis, diagnostic accuracy of clinical variables combinations was similar to combinations with biomarkers and superior to biomarkers alone. Nonetheless, CD74, being the only biomarkers independently associated with mortality, showed elevated prognosis accuracy (AUC > 0.9) either alone or in combination with other biomarkers (eg. CD74/IP-10) or clinical criterion (eg. Apgar 1, birth weight). These results suggest that cord blood PCT had a low accuracy for diagnosing early onset neonatal sepsis in Sub Saharan African neonates, while association of clinical criterion showed to be more accurate than any biomarkers taken independently. At birth, CD74, either associated with IP-10 or clinical criterion, had the best accuracy in prognosing sepsis mortality.Trial registration Clinicaltrial.gov registration number: NCT03780712. Registered 19 December 2018. Retrospectively registered.

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

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.

An evaluation into the use of procalcitonin levels as a biomarker of bacterial sepsis to aid the management of intrapartum pyrexia and chorioamnionitis

BACKGROUND

Procalcitonin is an established biomarker for bacterial sepsis in the nonpregnant population with better diagnostic and prognostic value for bacterial infections.

OBJECTIVE

This study aimed to evaluate whether procalcitonin levels could be used in the diagnosis and management of intrapartum sepsis in women and their neonates suspected of intrapartum bacterial sepsis.

STUDY DESIGN

A prospective observational cohort study was conducted at the University Hospitals of Bristol and Weston NHS Foundation Trust. Overall, 117 women and their neonates managed for suspected intrapartum sepsis from June 2020 to October 2020 were included. Procalcitonin levels were measured in addition to routine biomarkers white cell count and C-reactive protein in women and their neonates during the initial septic screen and follow-up blood samples. The placentas underwent detailed histopathology. Maternal and neonatal parameters were used to categorize cases into “high-suspicion bacterial sepsis,” “equivocal bacterial sepsis,” and “low-suspicion bacterial sepsis.” The Kruskal-Wallis test was used to compare categories with biomarker values and placental histology scores.

RESULTS

Procalcitonin level was increased in 6 women in the initial septic screen sample, compared with 100 women with an increased C-reactive protein level. There was a significant difference in maternal postnatal procalcitonin results between “high-suspicion bacterial sepsis” and “low-suspicion bacterial sepsis” categories (P=.004). Moreover, 71.2% of placentas showed varying degrees of chorioamnionitis.

CONCLUSION

In our cohort of women, 94.6% had normal procalcitonin levels while in labor at the time of the septic screen, consistent with the low number of confirmed bacteremia. The result provided a basis that procalcitonin may complement clinical judgment and interpretation of already used prognostic and diagnostic tests, improving patient care in the management of intrapartum sepsis.

Noninfectious influencers of early-onset sepsis biomarkers

Diagnostic tests for sepsis aim to either detect the infectious agent (such as microbiological cultures) or detect host markers that commonly change in response to an infection (such as C-reactive protein). The latter category of tests has advantages compared to culture-based methods, including a quick turnaround time and in some cases lower requirements for blood samples. They also provide information on the immune response of the host, a critical determinant of clinical outcome. However, they do not always differentiate nonspecific host inflammation from true infection and can inadvertently lead to antibiotic overuse. Multiple noninfectious conditions unique to neonates in the first days after birth can lead to inflammatory marker profiles that mimic those seen among infected infants. Our goal was to review noninfectious conditions and patient characteristics that alter host inflammatory markers commonly used for the diagnosis of early-onset sepsis. Recognizing these conditions can focus the use of biomarkers on patients most likely to benefit while avoiding scenarios that promote false positives. We highlight approaches that may improve biomarker performance and emphasize the need to use patient outcomes, in addition to conventional diagnostic performance analysis, to establish clinical utility.

Neonatal Sepsis

Neonatal sepsis is associated with severe morbidity and mortality in the neonatal period. Clinical manifestations range from subclinical infection to severe local or systemic infection. Neonatal sepsis is divided into three groups as early-onset neonatal sepsis, late-onset neonatal sepsis and very late-onset neonatal sepsis according to the time of the onset. It was observed that the incidence of early-onset neonatal sepsis decreased with intrapartum antibiotic treatment. However, the incidence of late-onset neonatal sepsis has increased with the increase in the survival rate of preterm and very low weight babies. The source of the causative pathogen may be acquisition from the intrauterine origin but may also acquisition from maternal flora, hospital or community. Prematurity, low birth weight, chorioamnionitis, premature prolonged rupture of membranes, resuscitation, low APGAR score, inability to breastfeed, prolonged hospital stay and invasive procedures are among the risk factors. This article reviews current information on the definition, classification, epidemiology, risk factors, pathogenesis, clinical symptoms, diagnostic methods and treatment of neonatal sepsis.

Reference ranges of presepsin (soluble CD14 subtype) in term and preterm neonates without infection, in relation to gestational and postnatal age, in the first 28 days of life

OBJECTIVE

To determine the reference ranges of presepsin in term and preterm neonates without infection, with respect to gestational and postnatal age, within the first 28 days of life.

METHODS

A total of 144 neonates born at 24-42 weeks' gestation, including healthy term and preterm neonates without clinical signs or symptoms of infection, were included in this prospective observational study. Presepsin measurements included cord blood levels and serum levels on postnatal days 1, 3, 5, 7, 14, 21, and 28.

RESULTS

The presepsin values corresponding to the 10th percentile ranged from 240.8 pg/mL (on day 1) to 129.9 pg/mL (on day 28), whereas those corresponding to the 90th percentile ranged from 725.8 pg/mL (on day 1) to 471.6 pg/mL (on day 28). Significantly higher presepsin levels were observed in cesarean deliveries than in spontaneous deliveries (p: 0.012 to <0.001), in gestational ages ≤ 32 weeks than in gestational ages ≥37 weeks (p: <0.05 to <0.001), and in cases with a maternal history of chorioamnionitis than in those without (p: <0.05 to <0.001).

CONCLUSION

In conclusion, our findings revealed, for the first time, the reference ranges of presepsin in healthy term and preterm neonates without infection with respect to gestational and postnatal age, sex, and body weight. Presepsin levels within the first 28 days of life seem likely to be affected by the type of delivery, gestational and postnatal age, birth weight, and presence of respiratory distress syndrome or maternal chorioamnionitis.

Is Procalcitonin Useful in Pediatric Critical Care Patients?

This review examines the use of procalcitonin in different clinical situations in the pediatric patient, with special emphasis on those requiring intensive care. We review the latest articles on its potency as a biomarker in both infectious processes at diagnosis and on the response to treatment.

Procalcitonin and Neonatal Sepsis: Is This the Biomarker We Are Looking For?

Researchers estimate the incidence of early onset sepsis as 0.77-1/1,000 live births. It remains as one of the leading causes of neonatal deaths. Clinicians and researchers continue to search for biomarkers for specific neonatal disease processes. Clinicians frequently trend C-reactive protein levels during evaluation for neonatal sepsis. Recently, researchers have begun to explore procalcitonin as a potentially useful diagnostic marker for neonatal sepsis.

Biomarkers for diagnosis of neonatal sepsis: a literature review

Sepsis is an important cause of mortality and morbidity in neonatal populations. There has been constant search of an ideal sepsis biomarker that have high sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), so that both the diagnosis and exclusion of neonatal sepsis can be made at the earliest possible and appropriate antibiotics can be started to neonate. Ideal sepsis biomarker will help in guiding us when not to start antibiotics in case of suspect sepsis and total duration of antibiotics course in case of proven sepsis. There are numerous sepsis biomarkers that have been evaluated for early detection of neonatal sepsis but till date there is no single ideal biomarker that fulfills all essential criteria's for being an ideal biomarker. The most commonly used biomarkers are C-reactive protein (CRP) and procalcitonin (PCT), but both have shown varied sensitivity, specificity, PPV and NPV in different studies. We conducted literature search for various neonatal sepsis biomarkers and this review article will cover briefly all the markers with current available evidence.