Diagnosis of Neonatal Sepsis: The Role of Inflammatory Markers

A machine learning-based electronic nose for detecting neonatal sepsis: Analysis of volatile organic compound biomarkers in fecal samples

BACKGROUND

Neonatal sepsis is a global health threat, contributing to high morbidity and mortality rates among newborns. Recognizing the profound impact of neonatal sepsis on long-term health outcomes emphasizes the critical need for timely detection to mitigate its consequences and ensure optimal health for the affected newborns. Currently, various diagnostic approaches have been implemented, but they are limited by their invasiveness, high costs, centralized testing, frequent delays, inaccuracies in results, and the need for sophisticated laboratory equipment.

METHODS

We introduced a novel, non-invasive, cost-efficient, and easy-to-use technology that can provide rapid results at a point-of-care. The technology utilized a lab-built metal oxide semiconductor-based electronic nose (cNose) combined with volatile organic compound (VOC) biomarkers identified through gas chromatography-mass spectrometry (GC-MS) analysis. The system was evaluated using fecal profiling tests involving a total of 32 samples, including 17 positive and 15 negative sepsis, confirmed by blood culture. To assess the performance in discriminating patients from healthy controls, four machine learning algorithms were implemented.

RESULTS

Based on the cross-validation results, the MLPNN model provided the best results in distinguishing between neonates with positive and negative sepsis, achieving high-performance results of 90.63 % accuracy, 88.24 % sensitivity, and 93.33 % specificity at a 95 % confidence interval. Specific VOCs associated with neonatal sepsis, such as alcohols, acids, and esters, were successfully identified through GC-MS analysis, further validating the diagnostic capability of the cNose device.

CONCLUSION

The overall observations show the feasibility of using cNose system as a promising tool for real-time and bedside sepsis detection, potentially improving patient outcomes.

Utility of interleukin-6 to identify serious bacterial infections in febrile infants aged ≤60 days

AIM

The aim of this study is to investigate the utility of interleukin-6 (IL-6) in the early diagnosis of serious bacterial infections (SBI) in febrile infants and to compare it with C-reactive protein (CRP).

METHODS

Retrospective study conducted in the paediatric emergency department in Gothenburg, Sweden, on previously healthy, full-term infants aged ≤60 days with fever without a source (FWS) from 2014 to 2017.

RESULTS

We included 536 infants with FWS, of whom IL-6 was analysed in 364 (68%) and CRP was analysed in 494 (92%). Approximately 70% of the infants presented with a fever duration of less than 12 h. The prevalence of SBIs was 14.8% (95% CI,11.3-18.9) in the IL-6 group and 17.8% (95% CI,14.5-21.5) in the CRP group. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of IL-6 ≥50 ng/L were 93%, 66%, 98% and 33%, respectively. For CRP ≥20 mg/L, the sensitivity, specificity, NPV, and PPV were 76%, 89%, 95%, and 55%, respectively. Logistic regression analysis showed that CRP was significantly associated with SBI (p < 0.0001) in the entire population, whereas IL-6 was not.

CONCLUSION

Interleukin-6 showed high sensitivity and NPV, which might assist in identifying SBIs early in febrile infants. However, IL-6 was not shown to be superior to CRP and further studies are needed to investigate whether IL-6 should be incorporated in clinical management.

Antimicrobial utilisation patterns between 2013 and 2022 in Canadian neonates born at less than 33 weeks gestation: a retrospective cohort study

Background

Excessive antimicrobial exposure is associated with an increase in neonatal mortality, morbidities and adverse neurodevelopment. Canadian Neonatal Network has been promoting judicious antimicrobial use through the Evidence-based Practice for Improving Quality processes. Our objective was to evaluate the antimicrobial consumption among neonates in tertiary neonatal intensive care units (NICU) in Canada in the recent decade.

Methods

This is a retrospective cohort study including data from very preterm infants (born at <33 weeks gestational age) admitted to all NICUs in Canada between January 1, 2013, and December 31, 2022. Nationwide antimicrobial utilization rate (AUR) benchmarking started in 2016, and quality improvement initiatives were continued in the subsequent years to promote judicious use of antimicrobials across the network. AUR is defined as the number of days with ≥1 antimicrobial divided by the total patient days (PD). Culture-proven sepsis refers to a neonate with positive culture of pathogens in blood and/or cerebrospinal fluid. The outcomes were evaluated during pre- (2013-2017) and post-intervention periods (2018-2022). Interrupted time-series analysis was used, and comparison of AUR calculated per each 3-month time block and the slope changes were conducted across the pre- and post-intervention periods regarding total patients and subgroups.

Findings

A total of 41,253 infants were included, with 22,644 (55%) being male. The AUR was significantly lower among infants from the post- vs. those from the pre-intervention periods (152 vs. 184, p < 0.0001). Among 35,670 infants without culture-proven sepsis or necrotizing enterocolitis ≥ Stage 2, AUR was significantly lower in the post-intervention group vs. the pre-intervention group (110 vs. 136, p < 0.0001). Interrupted time-series showed significant reduction in AUR during both pre- and post-intervention periods among all infants with and without culture proven sepsis or necrotizing enterocolitis ≥ Stage 2 (all p < 0.0001), as well as those born at <29 weeks gestational age.

Interpretation

A comprehensive, network-wide quality improvement initiatives led to a significant and sustained reduction in antimicrobial use among preterm infants born at <33 weeks gestational age with and without culture-proven sepsis or necrotizing enterocolitis ≥ Stage 2.

Funding

This study was supported by the Canadian Institutes of Health Research Project Grant 2019 (201903PJT-420294-CA2-CAAA-245530), matched funding from the British Columbia Women's Health Foundation and start-up funding from the Women and Children's Health Research Institute, University of Alberta. The coordinating center in Toronto is funded by the Canadian Institutes of Health Research grant for the Canadian Preterm Birth Network (PBN 150642).

Nurses' experiences in neonatal sepsis prevention and management: a qualitative cross-sectional study at selected hospitals in a metropolitan area

BACKGROUND

Neonatal sepsis represents a significant cause of morbidity and mortality among infants in healthcare settings. This study explored nurses' experiences in preventing and managing neonatal sepsis in the Tamale metropolis.

METHODS

An exploratory, descriptive qualitative cross-sectional study design was used, and data was collected using semi-structured interviews. The sample size was determined at the point of data saturation of fifteen participants. Thematic analysis was employed to identify codes, subthemes, and themes within the interview transcripts.

RESULTS

Three major challenges nurses face in preventing and managing neonatal sepsis, including (1) the absence of a protocol for handling newborns upon admission, (2) an excessive workload that made it difficult for staff to follow infection prevention protocols, and (3) inadequate, obsolete and/or lack of equipment that caused devices to be overused. The nurses also identified critical psychological and emotional difficulties they encounter as a result of working within such a stressful environment. Other activities nurses conducted were handwashing before and after every procedure, infection prevention, and separating the babies in the incubator. In managing babies with neonatal sepsis, nurses provided daily treatment, hygiene care, and supported activities of living. The nurses also assert that the availability of resources, appropriate staff, and critical skills are important for preventing and managing neonatal sepsis.

CONCLUSION

The lack of basic working consumables like gloves, syringes, and needles, inadequate staff, and lack of defined protocol of care were identified as critical challenges that hamper the care provided in neonatal care units. Hospital authorities must focus attention on addressing the critical challenges faced by neonatal care units. Also, measures should be instituted to address the emotional and psychological concerns associated with nursing care. Future research must consider the level of influence of each of the challenges enumerated on nurses' overall health.

Assessment of an Antimicrobial Stewardship Program for Enhancing Clinical Knowledge in Neonatal Care Settings With High Antimicrobial Resistance

INTRODUCTION

Antimicrobial resistance (AMR) is a global problem, which is particularly challenging in developing countries like India. This study attempts to determine the competencies of health care professionals and to update evidence-based policies to address AMR.

METHOD

A survey-based educational interventional study was conducted using a validated structured survey and knowledge questionnaire under 3 domains through an antimicrobial stewardship program. Pooled data were analyzed using SPSS version 16.0.

RESULTS

Out of 58 participants, 53 (91%) have observed an increasing trend of multidrug-resistant infections over the last 5 years. There is a significant difference between the overall pretest mean scores (8.12 ± 2.10) and posttest mean scores (12.5 ± 1.49) of clinicians' knowledge with a mean difference of 4.38 ± 0.61, 95% CI of 5.003-3.92, t(57) = 16.62, P < .001).

DISCUSSION

The antimicrobial stewardship program was effective in improving the competencies of clinical physicians to improve antimicrobial prescribing and reduce AMR. Moreover, improving the knowledge and competencies among health care professionals will minimize neonatal morbidity and mortality.

Neonatal Sepsis: Aetiology, Pathophysiology, Diagnostic Advances and Management Strategies

Neonatal sepsis, a bloodstream infection in the first 28 days of life, is a leading cause of morbidity and mortality among infants in both developing and developed countries. Additionally, sepsis is distinguished in neonates by unique pathophysiological and presentational factors relating to its development in immature neonatal immune systems. This review focuses on the current understanding of the mechanics and implications of neonatal sepsis, providing a comprehensive overview of the epidemiology, aetiology, pathophysiology, major risk factors, signs and symptoms and recent consensus on the diagnosis and management of both early-onset and late-onset neonatal sepsis. It also includes a discussion on novel biomarkers and upcoming treatment strategies for the condition as well as the potential of COVID-19 infection to progress to sepsis in infants.

Associations between SII, SIRI, and cardiovascular disease in obese individuals: a nationwide cross-sectional analysis

Background

Systemic immune-inflammation index (SII) and systemic inflammation response index (SIRI) are comprehensive markers of inflammatory status. However, the correlation between SII and SIRI and the prevalence of cardiovascular disease (CVD) in populations with obesity remains unknown.

Methods

This is a cross-sectional study with data obtained from the National Health and Nutrition Examination Survey from 1999 to 2018. SII and SIRI were calculated using the following equations: SII = (platelet count × neutrophil count)/lymphocyte count. SIRI = (neutrophil count × monocyte count)/lymphocyte count. Spearman's rank correlation coefficient was used to assess the relationship between SII and SIRI and baseline variables. Logistic regression models and generalized additive model (GAM) with a spline smoothing function were used to evaluate the association between SIRI and CVD prevalence. Nomogram and receiver operating characteristic curve (ROC) analysis were used to assess the value of the risk prediction model.

Results

A total of 17,261 participants with obesity and SII and SIRI publicly available data were used for this study. Multivariate logistic regression analysis revealed that SIRI, rather than SII, was an independent risk factor for CVD prevalence. For every standard deviation increase in SIRI, there was a 13%, 15%, and 28% increase in the odds ratios of CVD prevalence (OR = 1.13, 95% CI: 1.04-1.22, P = 0.01), coronary heart disease (OR = 1.15, 95% CI: 1.05-1.26, P = 0.002), and congestive heart failure (OR = 1.28, 95% CI: 1.16-1.41, P < 0.001). ROC results demonstrated that SIRI had a certain accuracy in predicting CVD prevalence (AUC = 0.604), especially when combined with other variables used in the nomogram (AUC = 0.828). The smooth curve fitting regression analysis demonstrated a significant linear association between the risk of SIRI and the odds ratio of CVD prevalence (P for nonlinear = 0.275).

Conclusions

SIRI is a relatively stable indicator of inflammation and is independently associated with the prevalence of CVD. It may serve as a novel inflammatory indicator to estimate CVD prevalence in populations with obesity.

DEVELOPMENT AND VALIDATION OF A MODEL FOR PREDICTION OF SEPTIC SHOCK IN NEONATES WITH SEPSIS

ABSTRACT

Purpose: This study aimed to develop and validate a model for prediction of septic shock in neonates with sepsis. Materials and methods: This retrospective study included early-onset septic neonates in the Renmin Hospital of Wuhan University between January 2017 and June 2021. The neonates were divided into the training set and the validation set in a ratio of 7:3 and further categorized into septic shock group and none-shock group according to presence or absence of shock symptoms. Results: A total of 406 septic neonates were enrolled, including 217 in septic shock group. Sex (odds ratio [OR] = 0.092, 95% confidence interval [CI]: 0.012 to 0.683, P = 0.020), C-reactive protein at 6 h (OR = 8.475, 95% CI: 3.154 to 22.774, P < 0.001), serum amyloid A at 6 h (OR = 1.179, 95% CI: 1.094 to 1.269, P < 0.01), white blood cells at 6 h (OR = 0.173, 95% CI: 0.092 to 0.326, P < 0.001), platelets at 6 h (OR = 0.985, 95% CI: 0.975 to 0.995, P < 0.001), and Ca 2+ at 6 h (OR = 1.44 × 10 11 , 95% CI: 2.70 × 10 6 to 7.70 × 10 15 , P < 0.001) were identified as independent risk factors for septic shock and were further included in the nomogram. The areas under the receiver operator characteristic curve were 0.873 and 0.920 in training and validation sets, respectively. Conclusions: A predictive model for early diagnosis of septic shock in neonates was developed and initially validated in this study, allowing for timely intervention.

Role of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in diagnosing neonatal sepsis

Clinical manifestations of neonatal sepsis are often unspecified. Therefore, sepsis biomarkers could be used to support diagnosis while waiting for blood culture results, such as the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). The aim of this study was to evaluate the role of NLR and PLR as diagnostic markers in neonatal sepsis. A cross-sectional study was conducted at Haji Adam Malik General Hospital, Medan, Indonesia, from April to October 2019. This study included neonates aged less than 28 days, diagnosed with suspected sepsis, and had no previous history of antibiotics administration. Patients underwent clinical assessment, laboratory examination, and blood culture. Patients were grouped into sepsis and non-sepsis based on the blood culture results. The median hematological examination and the range of NLR and PLR in both the sepsis and non-sepsis groups were subjected to analysis using the Mann-Whitney U test to assess differences. NLR and PLR optimal cut-off values were determined using a receiver operator curve (ROC) with a confidence interval of 95%. A total of 137 neonates were enrolled, of which 49 were classified as sepsis and 89 as non-sepsis based on blood culture results. The optimal cutoff values for NLR and PLR were 2.75 and 11.73. Using those cutoff values, NLR and PLR could predict neonatal sepsis with sensitivities of 52.1% and 47.9%, specificities of 50.6% and 47.2%, area under the curve (AUC) of 0.46 and 0.47, with p=0.525 and p=0.662, respectively. Further investigation is warranted to refine the NLR and PLR utility and enhance diagnostic accuracy in clinical practices.

Neonatal bacterial sepsis

Neonatal sepsis remains one of the key challenges of neonatal medicine, and together with preterm birth, causes almost 50% of all deaths globally for children younger than 5 years. Compared with advances achieved for other serious neonatal and early childhood conditions globally, progress in reducing neonatal sepsis has been much slower, especially in low-resource settings that have the highest burden of neonatal sepsis morbidity and mortality. By contrast to sepsis in older patients, there is no universally accepted neonatal sepsis definition. This poses substantial challenges in clinical practice, research, and health-care management, and has direct practical implications, such as diagnostic inconsistency, heterogeneous data collection and surveillance, and inappropriate treatment, health-resource allocation, and education. As the clinical manifestation of neonatal sepsis is frequently non-specific and the current diagnostic standard blood culture has performance limitations, new improved diagnostic techniques are required to guide appropriate and warranted antimicrobial treatment. Although antimicrobial therapy and supportive care continue as principal components of neonatal sepsis therapy, refining basic neonatal care to prevent sepsis through education and quality improvement initiatives remains paramount.

Enhancing sepsis biomarker development: key considerations from public and private perspectives

Implementation of biomarkers in sepsis and septic shock in emergency situations, remains highly challenging. This viewpoint arose from a public-private 3-day workshop aiming to facilitate the transition of sepsis biomarkers into clinical practice. The authors consist of international academic researchers and clinician-scientists and industry experts who gathered (i) to identify current obstacles impeding biomarker research in sepsis, (ii) to outline the important milestones of the critical path of biomarker development and (iii) to discuss novel avenues in biomarker discovery and implementation. To define more appropriately the potential place of biomarkers in sepsis, a better understanding of sepsis pathophysiology is mandatory, in particular the sepsis patient's trajectory from the early inflammatory onset to the late persisting immunosuppression phase. This time-varying host response urges to develop time-resolved test to characterize persistence of immunological dysfunctions. Furthermore, age-related difference has to be considered between adult and paediatric septic patients. In this context, numerous barriers to biomarker adoption in practice, such as lack of consensus about diagnostic performances, the absence of strict recommendations for sepsis biomarker development, cost and resources implications, methodological validation challenges or limited awareness and education have been identified. Biomarker-guided interventions for sepsis to identify patients that would benefit more from therapy, such as sTREM-1-guided Nangibotide treatment or Adrenomedullin-guided Enibarcimab treatment, appear promising but require further evaluation. Artificial intelligence also has great potential in the sepsis biomarker discovery field through capability to analyse high volume complex data and identify complex multiparametric patient endotypes or trajectories. To conclude, biomarker development in sepsis requires (i) a comprehensive and multidisciplinary approach employing the most advanced analytical tools, (ii) the creation of a platform that collaboratively merges scientific and commercial needs and (iii) the support of an expedited regulatory approval process.

Comparative Analysis of C-reactive Protein and Procalcitonin as Biomarkers for Prognostic Assessment in Pediatric Sepsis

Background Sepsis poses a critical medical challenge due to its profound systemic inflammatory response, which frequently results in organ dysfunction and high mortality rates, especially in pediatric patients. The condition requires prompt recognition and aggressive management to mitigate its severe outcomes. Methods This prospective study enrolled 248 pediatric patients admitted with sepsis to the pediatric intensive care unit (PICU) at our tertiary care center. Patients were randomly assigned to either the C-reactive protein (CRP) or procalcitonin (PCT) groups, with biomarker levels measured upon admission (hour zero) and again at 72 hours post-admission. Clinical parameters such as the need for ionotropic support, use of steroids, incidence of acute kidney injury (AKI), requirement for invasive ventilation, patient outcomes, and changes in antibiotic management were assessed based on these biomarker levels. Results Procalcitonin-positive sepsis cases demonstrated notable clinical severity compared to their C-reactive protein counterparts, showing significantly lower systolic blood pressure (p = 0.012), heightened need for ionotropic support (p < 0.0001), and more pronounced liver and renal dysfunction as indicated by elevated serum bilirubin (p = 0.001) and creatinine levels (p = 0.0058). The incidence of AKI was also higher in procalcitonin-positive cases. Despite these severe clinical parameters, there were no significant differences in the length of the PICU stay or in patient outcomes concerning discharge and mortality rates. Procalcitonin levels effectively guided antibiotic management, resulting in therapy adjustments in a substantial proportion of cases, with 67 (54%) experiencing downgrades and 33 (27%) requiring upgrades based on procalcitonin levels measured 72 hours post-admission. Conclusion Procalcitonin proves to be a valuable biomarker in assessing the severity and management of sepsis in pediatric patients. It correlates significantly with clinical parameters such as blood pressure, the need for ionotropic support, and markers of organ dysfunction.

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Factors Associated with Post-rewarming Procalcitonin Levels in Newborns with Hypoxic Ischemic Encephalopathy

To determine the factors associated with the procalcitonin levels in newborns with hypoxic-ischemic encephalopathy (HIE) who received therapeutic hypothermia (TH). The neonates, who had moderate/severe HIE and were treated with TH, were included. The neonates were arranged into 2 groups by procalcitonin (PCT) level after rewarming was completed. The neonates who had a procalcitonin level of < 2.5 ng/ml constituted Group 1 and the ones who had a procalcitonin level of ≥ 2.5 ng/ml constituted Group 2. Univariate and multivariate logistic regression was used to assess the factors related with PCT level. The first group included 123 (87.9%) neonates and the second group included 17 (12.1%) neonates. The median gestational age was 38 (36-39) weeks and the mean birth weight was 3081.7 ± 552.8 grams. In group 2, the rates for severe HIE, cesarean section, antibiotic switch, convulsion, inotrope use and mortality were higher, and duration of hospitalization was longer, whereas Apgar scores were lower (P < .05). The risk of a high procalcitonin level was found to be 6-fold (95% CI 1.9-19.1) higher in severe HIE and 5.2-fold higher (95% CI 1.7-16) in cesarean delivery. In neonates with HIE/TH, high post-rewarming procalcitonin levels were related with severe HIE and cesarean delivery. Some other clinical and laboratory findings, which may reflect worse clinical status, were also associated with high procalcitonin levels.

Optimizing Newborn Outcomes in Cesarean Sections: A Comparative Analysis of Stress Indicators under General and Spinal Anesthesia

BACKGROUND AND OBJECTIVES

The moment of birth represents a complex physiological process that is followed by adaptive changes in the vital systems of the newborn. Such reactions have their positive but also negative effects. The aim of this research was to determine the difference in laboratory values of stress indicators in newborn children delivered by cesarean section (CS) with general and spinal anesthesia. We attempted to make a recommendation about the optimal type of anesthesia based on our results.

MATERIALS AND METHODS

The study was performed on 150 healthy term newborns delivered by urgent or planned CS. Samples for adrenocorticotropic hormone (ACTH), cortisol, triglycerides, and interleukin-6 (IL-6) were analyzed.

RESULTS

Leukocyte numbers, triglycerides, and blood sugar values were normal for the newborns' age, with statistically significantly lower values of blood sugar and triglycerides in newborns delivered by CS in spinal anesthesia (p < 0.005) compared to general anesthesia. There were no significant differences in ACTH, cortisol, and IL-6 levels between those newborns delivered via CS after spinal or general anesthesia.

CONCLUSIONS

In cases where vaginal delivery is not possible, when CS is indicated, the use of well-controlled spinal anesthesia is followed by lower degrees of metabolic, inflammatory, and stress responses and better vitality of the baby upon birth.

Effects of serum inflammatory factors, health index and disease activity scores on ankylosing spondylitis patients with sleep disorder

BACKGROUND

Patients with ankylosing spondylitis (AS) frequently suffer from comorbid sleep disorders, exacerbating the burden of the disease and affecting their quality of life.

AIM

To investigate the clinical significance of serum inflammatory factors, health index and disease activity scores in patients with AS complicated by sleep disorders.

METHODS

A total of 106 AS patients with comorbid sleep disorders were included in the study. The patients were grouped into the desirable and undesirable prognosis groups in accordance with their clinical outcomes. The serum levels of inflammatory factors, including C-reactive protein, erythrocyte sedimentation rate, interleukin (IL)-6, tumour necrosis factor-α and IL-1β, were measured. Disease activity scores, such as the Bath AS functional index, Bath AS disease activity index, Bath AS metrology index and AS disease activity score, were assessed. The health index was obtained through the Short Form-36 questionnaire.

RESULTS

The study found significant associations amongst serum inflammatory factors, health index and disease activity scores in AS patients with comorbid sleep disorders. Positive correlations were found between serum inflammatory factors and disease activity scores, indicating the influence of heightened systemic inflammation on disease severity and functional impairment. Conversely, negative correlations were found between disease activity scores and health index parameters, highlighting the effect of disease activity on various aspects of health-related quality of life. Logistic regression analysis further confirmed the predictive value of these factors on patient outcomes, underscoring their potential utility in risk assessment and prognostication.

CONCLUSION

The findings demonstrate the intricate interplay amongst disease activity, systemic inflammation and patient-reported health outcomes in AS patients complicated by sleep disorders. The results emphasise the need for comprehensive care strategies that address the diverse needs and challenges faced by these patients and underscore the potential relevance of serum inflammatory factors, health index and disease activity scores as prognostic markers in this patient population.

Epidemiology and Outcomes of Neonatal Sepsis: Experience from a Tertiary Australian NICU

INTRODUCTION

Neonatal sepsis is associated with significant mortality and morbidity. Low-middle-income countries are disproportionately affected, but late-onset sepsis (LOS) still occurs in up to 20% of infants <28 weeks in high-income countries. Understanding site-specific data is vital to guide management.

METHODS

A retrospective cohort study was conducted at King Edward Memorial Hospital (KEMH), Perth. Infants admitted between January 2012 and June 2022 were included. Data were extracted from routine electronic databases. Incidence and aetiology of sepsis were determined and the association of sepsis with neonatal outcomes analysed.

RESULTS

During the study period, 23,395 newborns were admitted with a median gestation of 37 weeks and birth weight of 2,800 g. There were 370 sepsis episodes in 350 infants; 102 were early-onset sepsis (EOS) (1.6 per 1,000 live births), predominantly Streptococcus agalactiae (35, 34.3%) and Escherichia coli (27, 26.5%); 268 were LOS (0.9 per 1,000 inpatient days), predominantly coagulase-negative staphylococci (CONS) (156, 57.6%) and E. coli (30, 11.1%). The incidence of LOS declined from 2012 to 2022 (p = 0.002). Infants with EOS had increased brain injury (25.7% vs. 4.1%; p = 0.002) and mortality (18.8% vs. 1.6%; p < 0.001). Those with LOS had increased hospital stay (median 95 vs. 15 days; p < 0.001), mortality (15.3% vs. 1.6%; p = 0.018), necrotising enterocolitis (NEC) (7.4% vs. 0.5%; p < 0.001), and chronic lung disease (CLD) (58.1% vs. 5.9%; p = 0.005). Infants <28 weeks with sepsis were at increased risk of neurodevelopmental impairment compared to those without infection (43.2% vs. 30.9%, p = 0.027).

CONCLUSIONS

While we observed a reduction in LOS incidence, sepsis remains associated with higher mortality, and in survivors with longer hospital stay and increased risk of brain injury, NEC, CLD, and neurodevelopmental impairment.

EARLY FLUID PLUS NOREPINEPHRINE RESUSCITATION DIMINISHES KIDNEY HYPOPERFUSION AND INFLAMMATION IN SEPTIC NEWBORN PIGS

ABSTRACT

Sepsis is the most frequent risk factor for acute kidney injury (AKI) in critically ill infants. Sepsis-induced dysregulation of kidney microcirculation in newborns is unresolved. The objective of this study was to use the translational swine model to evaluate changes in kidney function during the early phase of sepsis in newborns and the impact of fluid plus norepinephrine resuscitation. Newborn pigs (3-7-day-old) were allocated randomly to three groups: 1) sham, 2) sepsis (cecal ligation and puncture) without subsequent resuscitation, and 3) sepsis with lactated Ringer plus norepinephrine resuscitation. All animals underwent standard anesthesia and mechanical ventilation. Cardiac output and glomerular filtration rate were measured noninvasively. Mean arterial pressure, total renal blood flow, cortical perfusion, medullary perfusion, and medullary tissue oxygen tension (mtPO 2 ) were determined for 12 h. Cecal ligation and puncture decreased mean arterial pressure and cardiac output by more than 50%, with a proportional increase in renal vascular resistance and a 60-80% reduction in renal blood flow, cortical perfusion, medullary perfusion, and mtPO 2 compared to sham. Cecal ligation and puncture also decreased glomerular filtration rate by ~79% and increased AKI biomarkers. Isolated foci of tubular necrosis were observed in the septic piglets. Except for mtPO 2 , changes in all these parameters were ameliorated in resuscitated piglets. Resuscitation also attenuated sepsis-induced increases in the levels of plasma C-reactive protein, proinflammatory cytokines, lactate dehydrogenase, alanine transaminase, aspartate aminotransferase, and renal NLRP3 inflammasome. These data suggest that newborn pigs subjected to cecal ligation and puncture develop hypodynamic septic AKI. Early implementation of resuscitation lessens the degree of inflammation, AKI, and liver injury.

Antimicrobial peptide LL37 and regulatory T cell associated with late-onset sepsis in very preterm infants

Stem cell therapy may prevent late-onset sepsis (LOS) via antimicrobial peptide LL37 secretion and regulatory T cell (Treg) regulation. The early prediction of LOS is still a challenge. This study evaluated whether immunological state of LL37 or Tregs precedes LOS. We firstly analyzed the LL37 level, Treg proportion, and LOS incidence in very preterm infants treated with autologous cord blood mononuclear cells (ACBMNCs) in our previous trial. Then, we constructed a prediction model and built validation cohort. We found ACBMNC intervention reduced the incidence of LOS from 27.3% to 6.9% (p = 0.021). LL37 and Treg abundances were higher in the ACBMNCs group. The nomogram demonstrated that early-life Treg and LL37 characteristics were closely associated with LOS (area under the curve, AUC 0.936), with implications for early prediction and timely clinical management. This composite model was also helpful to evaluate the beneficial effect of ACBMNCs intervention on LOS, thus promoting translational research.

Maternal biomarkers in predicting neonatal sepsis after preterm premature rupture of membranes in preterm infants

AIM

This retrospective cohort study aimed to assess the utility of maternal C-reactive protein (CRP) and leukocyte levels in predicting neonatal sepsis after preterm premature rupture of membranes (pPROM).

METHODS

We conducted a retrospective cohort study (2009-2021), encompassing preterm infants born ≤29 + 6 weeks of gestation following pPROM. The primary outcome was early-onset neonatal sepsis within the initial 72 h of life.

RESULTS

We analysed data from 706 patients with a median gestational age at pPROM of 25.1 weeks and a median gestational age at birth of 26.4 weeks. Overall survival rate was 86.1%, with 65.7% survival without severe morbidities. These rates were significantly worse in preterm infants with sepsis. Maternal CRP and leukocyte levels correlated significantly with neonatal infection markers and sepsis. However, their predictive values, correlation coefficients, and area under the curve values were generally low. Using maternal CRP ≥2 mg/dL to predict neonatal sepsis yielded a positive predictive value of 18.5%, negative predictive value of 91.5%, AUC of 0.589, 45.5% sensitivity, and 74.5% specificity.

CONCLUSION

Maternal CRP and leukocyte levels were ineffective as a tool for predicting early-onset neonatal sepsis following early pPROM. Consequently, these biomarkers lack the reliability required for clinical decision-making in this context.

A decade of neonatal sepsis in Stockholm, Sweden: Gram-positive pathogens were four times as common as Gram-negatives

PURPOSE

To assess Gram-positive bacterial (GPB) bloodstream infection (BSI) in neonates, covering incidence, morbidity, mortality, antimicrobial resistance patterns and biomarkers in Region Stockholm, Sweden between 2006 and 2016.

METHODS

A population-based retrospective epidemiological study including infants with GPB-BSI, admitted to the neonatal units at Karolinska University Hospital (KUH). Data were collected from patient records, the Swedish Neonatal Quality Register, the microbiological laboratory at KUH and the Swedish Public Health Agency.

RESULTS

We identified 357 infants with GPB-BSI, representing an incidence of 1.47/1000 live births (LB). Group B streptococcus (GBS) was the most common pathogen causing BSI in full-term infants and early-onset sepsis (EOS) (0.20/1000 LB), while coagulase-negative staphylococci (CoNS) were predominant in infants born very preterm and in late-onset sepsis (LOS) (0.79/1000 LB). There were no fatal GBS BSI cases, but 10.2% developed meningitis. The GPB case fatality rate was 9.5% and the sepsis fatality rate 2.8%. In GPB-BSI, 1/10 did not have an elevated C-reactive protein level. Staphylococcus aureus (S. aureus) BSI increased during the study period, but no methicillin or vancomycin resistant strains were found. The antimicrobial resistance (AMR) rate was highest in CoNS isolates.

CONCLUSION

GPB-BSI was four times more common than Gram-negative BSI in neonates but resulted in lower mortality rate. GBS was the most common pathogen in full-term infants and in EOS. CoNS was the most common pathogen in LOS and infants born very preterm, and the AMR rate was high in these isolates. The increasing trend of S. aureus BSI indicates a need of further investigation.

Predictive Value of Neutrophil-to-Monocyte Ratio, Lymphocyte-to-Monocyte Ratio, C-Reactive Protein, Procalcitonin, and Tumor Necrosis Factor Alpha for Neurological Complications in Mechanically Ventilated Neonates Born after 35 Weeks of Gestation

This prospective study investigated the association between elevated neutrophil-to-monocyte ratio (NMR), lymphocyte-to-monocyte ratio (LMR), C-reactive protein (CRP), procalcitonin, and tumor necrosis factor-alpha (TNF-alpha) and the risk of developing neurological complications in mechanically ventilated neonates. The aim was to evaluate these biomarkers' predictive value for neurological complications. Within a one-year period from January to December 2022, this research encompassed neonates born at ≥35 weeks of gestational age who required mechanical ventilation in the neonatal intensive care unit (NICU) from the first day of life. Biomarkers were measured within the first 24 h and at 72 h. Sensitivity, specificity, and area under the curve (AUC) values were calculated for each biomarker to establish the best cutoff values for predicting neurological complications. The final analysis included a total of 85 newborns, of which 26 developed neurological complications and 59 without such complications. Among the studied biomarkers, TNF-alpha at >12.8 pg/mL in the first 24 h demonstrated the highest predictive value for neurological complications, with a sensitivity of 82%, specificity of 69%, and the highest AUC (0.574, p = 0.005). At 72 h, TNF-alpha levels greater than 14.3 pg/mL showed further increased predictive accuracy (sensitivity of 87%, specificity of 72%, AUC of 0.593, p < 0.001). The NMR also emerged as a significant predictor, with a cutoff value of >5.3 yielding a sensitivity of 78% and specificity of 67% (AUC of 0.562, p = 0.029) at 24 h, and a cutoff of >6.1 showing a sensitivity of 76% and specificity of 68% (AUC of 0.567, p = 0.025) at 72 h. Conversely, CRP and procalcitonin showed limited predictive value at both time points. This study identifies TNF-alpha and NMR as robust early predictors of neurological complications in mechanically ventilated neonates, underscoring their potential utility in guiding early intervention strategies. These findings highlight the importance of incorporating specific biomarker monitoring in the clinical management of at-risk neonates to mitigate the incidence of neurological complications.

Salivary C-reactive protein and mean platelet volume as possible diagnostic markers for late-onset neonatal pneumonia

BACKGROUND

Neonatal sepsis, a formidable threat to newborns, is a leading cause of neonatal mortality, with late-onset sepsis manifesting after 72 hours post-birth being particularly concerning. Pneumonia, a prevalent sepsis presentation, poses a significant risk, especially during the neonatal phase when lung defenses are compromised. Accurate diagnosis of pneumonia is imperative for timely and effective interventions. Saliva, a minimally invasive diagnostic medium, holds great promise for evaluating infections, especially in infants.

AIM

To investigate the potential of serum C-reactive protein (CRP), salivary CRP (sCRP), and mean platelet volume (MPV) as diagnostic markers for late-onset neonatal pneumonia (LONP).

METHODS

Eighty full-term neonates were systematically examined, considering anthropometric measurements, clinical manifestations, radiology findings, and essential biomarkers, including serum CRP, sCRP, and MPV.

RESULTS

The study reveals noteworthy distinctions in serum CRP levels, MPV, and the serum CRP/MPV ratio between neonates with LONP and healthy controls. MPV exhibited a robust discriminatory ability [area under the curve (AUC) = 0.87] with high sensitivity and specificity at a cutoff value of > 8.8. Correlations between serum CRP, sCRP, and MPV were also identified. Notably, sCRP demonstrated excellent predictive value for serum CRP levels (AUC = 0.89), underscoring its potential as a diagnostic tool.

CONCLUSION

This study underscores the diagnostic promise of salivary and serum biomarkers, specifically MPV and CRP, in identifying and predicting LONP among neonates. These findings advocate for further research to validate their clinical utility in larger neonatal cohorts.

Salivary C-reactive protein and mean platelet volume as possible diagnostic markers for late-onset neonatal pneumonia

BACKGROUND

Neonatal sepsis, a formidable threat to newborns, is a leading cause of neonatal mortality, with late-onset sepsis manifesting after 72 hours post-birth being particularly concerning. Pneumonia, a prevalent sepsis presentation, poses a significant risk, especially during the neonatal phase when lung defenses are compromised. Accurate diagnosis of pneumonia is imperative for timely and effective interventions. Saliva, a minimally invasive diagnostic medium, holds great promise for evaluating infections, especially in infants.

AIM

To investigate the potential of serum C-reactive protein (CRP), salivary CRP (sCRP), and mean platelet volume (MPV) as diagnostic markers for late-onset neonatal pneumonia (LONP).

METHODS

Eighty full-term neonates were systematically examined, considering anthropometric measurements, clinical manifestations, radiology findings, and essential biomarkers, including serum CRP, sCRP, and MPV.

RESULTS

The study reveals noteworthy distinctions in serum CRP levels, MPV, and the serum CRP/MPV ratio between neonates with LONP and healthy controls. MPV exhibited a robust discriminatory ability [area under the curve (AUC) = 0.87] with high sensitivity and specificity at a cutoff value of > 8.8. Correlations between serum CRP, sCRP, and MPV were also identified. Notably, sCRP demonstrated excellent predictive value for serum CRP levels (AUC = 0.89), underscoring its potential as a diagnostic tool.

CONCLUSION

This study underscores the diagnostic promise of salivary and serum biomarkers, specifically MPV and CRP, in identifying and predicting LONP among neonates. These findings advocate for further research to validate their clinical utility in larger neonatal cohorts.

Nanomaterial-based methods for sepsis management

Sepsis is a serious disease caused by an impaired host immune response to infection, resulting in organ dysfunction, tissue damage and is responsible for high in-hospital mortality (approximately 20%). Recently, WHO documented sepsis as a global health priority. Nevertheless, there is still no effective and specific therapy for clinically detecting sepsis. Nanomaterial-based approaches have appeared as promising tools for identifying bacterial infections. In this review, recent biosensors are introduced and summarized as nanomaterial-based platforms for sepsis management and severe complications. Biosensors can be used as tools for the diagnosis and treatment of sepsis and as nanocarriers for drug delivery. In general, diagnostic methods for sepsis-associated bacteria, biosensors developed for this purpose are presented in detail, and their strengths and weaknesses are discussed. In other words, readers of this article will gain a comprehensive understanding of biosensors and their applications in sepsis management.

Investigating the Association between Serum and Hematological Biomarkers and Neonatal Sepsis in Newborns with Premature Rupture of Membranes: A Retrospective Study

(1) Background: Neonatal early-onset sepsis (EOS) is associated with important mortality and morbidity. The aims of this study were to evaluate the association between serum and hematological biomarkers with early onset neonatal sepsis in a cohort of patients with prolonged rupture of membranes (PROM) and to calculate their diagnostic accuracy. (2) Methods: A retrospective cohort study was conducted on 1355 newborns with PROM admitted between January 2017 and March 2020, who were divided into two groups: group A, with PROM ≥ 18 h, and group B, with ROM < 18 h. Both groups were further split into subgroups: proven sepsis, presumed sepsis, and no sepsis. Descriptive statistics, analysis of variance (ANOVA) and a Random Effects Generalized Least Squares (GLS) regression were used to evaluate the data. (3) Results: The statistically significant predictors of neonatal sepsis were the high white blood cell count from the first (p = 0.005) and third day (p = 0.028), and high C-reactive protein (CRP) values from the first day (p = 0.004). Procalcitonin (area under the curve-AUC = 0.78) and CRP (AUC = 0.76) measured on the first day had the best predictive performance for early-onset neonatal sepsis. (4) Conclusions: Our results outline the feasibility of using procalcitonin and CRP measured on the first day taken individually in order to increase the detection rate of early-onset neonatal sepsis, in the absence of positive blood culture.

Identifying immune signatures of sepsis to increase diagnostic accuracy in very preterm babies

Bacterial infections are a major cause of mortality in preterm babies, yet our understanding of early-life disease-associated immune dysregulation remains limited. Here, we combine multi-parameter flow cytometry, single-cell RNA sequencing and plasma analysis to longitudinally profile blood from very preterm babies (<32 weeks gestation) across episodes of invasive bacterial infection (sepsis). We identify a dynamically changing blood immune signature of sepsis, including lymphopenia, reduced dendritic cell frequencies and myeloid cell HLA-DR expression, which characterizes sepsis even when the common clinical marker of inflammation, C-reactive protein, is not elevated. Furthermore, single-cell RNA sequencing identifies upregulation of amphiregulin in leukocyte populations during sepsis, which we validate as a plasma analyte that correlates with clinical signs of disease, even when C-reactive protein is normal. This study provides insights into immune pathways associated with early-life sepsis and identifies immune analytes as potential diagnostic adjuncts to standard tests to guide targeted antibiotic prescribing.

Pro-Inflammatory and Anti-Inflammatory Interleukins in Infectious Diseases: A Comprehensive Review

Interleukins (ILs) are signaling molecules that are crucial in regulating immune responses during infectious diseases. Pro-inflammatory ILs contribute to the activation and recruitment of immune cells, whereas anti-inflammatory ILs help to suppress excessive inflammation and promote tissue repair. Here, we provide a comprehensive overview of the role of pro-inflammatory and anti-inflammatory ILs in infectious diseases, with a focus on the mechanisms underlying their effects, their diagnostic and therapeutic potential, and emerging trends in IL-based therapies.

Viscoelastic coagulation testing in Neonatal Intensive Care Units: advantages and pitfalls in clinical practice

The expression "developmental hemostasis" indicates the age-related physiological changes occurring during the maturational process of the hemostatic system. Despite the quantitative and qualitative alterations, the neonatal hemostatic system is competent and well-balanced. Conventional coagulation tests do not provide reliable information as they only explore the procoagulants during the neonatal period. In contrast, viscoelastic coagulation tests (VCTs), such as viscoelastic coagulation monitoring (VCM), thromboelastography (TEG or ClotPro), and rotational thromboelastometry (ROTEM), are point-of-care assays that provide a quick, dynamic and global view of the hemostatic process, allowing prompt and individualized therapeutic intervention when necessary. Their use in neonatal care is on the increase and they could help monitor patients at risk of hemostatic derangement. In addition, they are crucial for anticoagulation monitoring during extracorporeal membrane oxygenation. Moreover, implementing VCT-based monitoring could optimize blood product use.

Role of interleukins in the detection of neonatal sepsis: a network meta-analysis

Objectives

The purpose of the network meta-analysis was to make a more comprehensive comparison of different interleukins in the detection of neonatal sepsis and to pose clues in the field of clinical practice.

Methods

Electronic databases of PubMed, Web of Science and Embase were systematically searched. Eligible studies included diagnostic tests utilizing interleukins to detect neonatal sepsis. We calculated pooled sensitivity, specificity, positive Likelihood Ratio (PLR) and negative Likelihood Ratio (NLR), diagnostic odds ratio (DOR), and superiority index.

Results

Fifteen studies including 1,369 neonates diagnosed of sepsis were included in this meta-analysis. For the detection of early-onset sepsis in neonates, the pooled sensitivity was 0.91 (95% CI: 0.81, 0.97; I2 = 0%, p = 0.946) and the pooled specificity was 0.98 (95% CI: 0.87, 0.97; I2 = 46.3%, p = 0.172) for IL-8. For the detection of late-onset sepsis in neonates. the sensitivity was 0.96 (95% CI: 0.85, 1.00; I2 = NA, p = NA) and the pooled specificity was 1.00 (95% CI: 0.92, 1.00; I2 = NA, p = NA) for IL-27. Results of ANOVA model revealed that the superiority index of IL-6, IL-8, IL-10, and IL-27 were 1.20 (0.14, 5.00), 5.14 (0.33, 7.00), 0.75 (0.14, 5.00), and 1.31 (0.14, 5.00) in the detection of early-onset neonatal sepsis. Superiority index of IL-8, IL-10, and IL-27 were 1.84 (0.20, 5.00), 1.04 (0.20, 5.00), and 2.21 (0.20, 5.00) in the detection of late-onset neonatal sepsis.

Conclusions

Findings of this network meta-analysis suggest that interleukins including IL-6, IL-8, IL-10, and IL-27 may have favorable performance in the detection of neonatal sepsis. IL-8 was more accurate in the detection of early-onset sepsis in neonates. IL-27 was more accurate in the detection of late-onset neonatal sepsis.

Fetal and neonatal alloimmune thrombocytopenia: No evidence of systemic inflammation as a modulator of disease severity. Could placental inflammation be key?

In fetal/neonatal alloimmune thrombocytopenia (FNAIT), maternal alloantibodies against paternal human platelet antigens (HPA) cross the placenta and lead to platelet destruction. The extent of thrombocytopenia varies among neonates, and inflammation may constitute an important trigger. A set of stable inflammatory markers was measured in serum samples from neonates with low platelet counts, of which n = 50 were diagnosed with FNAIT due to anti-HPA-1a antibodies and n = 50 were thrombocytopenic without detectable maternal HPA antibodies. Concentrations of C-reactive protein, soluble CD14, procalcitonin, and sFlt-1 did not differ between the two cohorts. There was no correlation between C-reactive protein or soluble CD14 and the platelet count, but a negative correlation between procalcitonin concentrations and the neonatal platelet count in both cohorts. sFlt-1 concentration and the platelet count were correlated in FNAIT cases exclusively. None of the inflammatory markers was statistically different between cases with and without intracranial haemorrhage. We were unable to identify systemic inflammation as a relevant factor for thrombocytopenia in FNAIT. The antiangiogenic enzyme sFlt-1, released by the placenta, did correlate with the platelet count in FNAIT cases. Our findings may give rise to the hypothesis that placental inflammation rather than systemic inflammation modulates disease severity in FNAIT.

A Global Assessment of Coagulation Profile and a Novel Insight into Adamts-13 Implication in Neonatal Sepsis

Neonatal sepsis is a life-threatening condition associated with significant morbidity and mortality. Sepsis-induced coagulopathy is a well-recognized entity, signifying the strong cross-talk between inflammation and coagulation. The aim of the present study was to compare the coagulation profile between the acute phase of sepsis and recovery in term and preterm neonates. Additional comparisons to healthy neonates were undertaken. Levels of clotting, anti-clotting factors and ADAMTS-13 (A disintegrin and metalloprotease with thrombospondin type-1 motives), the cleaving protein of von Willebrand factor (VWF), were measured in 16 term and preterm neonates in the acute phase of infection and following recovery, as well as in 18 healthy neonates. Clotting times were prolonged, while levels of particular clotting factors were lower in the acute phase of infection compared to controls and recovery. On the other hand, levels of fibrinogen, factor VIII (FVIII) and VWF were significantly higher in the acute phase in comparison to controls and recovery, while they remained persistently higher in the infection group compared to controls. In regard to the anticlotting mechanism, a clear suppression was observed in septic neonates. ADAMTS-13 levels were significantly lower in the acute phase of infection in comparison to controls and recovery (p = 0.015 and 0.004, respectively), while a trend toward superimposed normalization was demonstrated post infection, as higher ADAMTS-13 levels were measured in recovered neonates compared to controls (p = 0.002). The coagulation profile is considerably deranged in neonatal sepsis. ADAMTS-13 deficiency in septic neonates is a novel finding with promising future implications, as ADAMTS-13 substitution may serve as a useful therapeutic option in neonatal sepsis, prompting further investigation in future studies.

C-reactive protein-to-albumin ratio as a biomarker in patients with sepsis: a novel LASSO-COX based prognostic nomogram

To develop a C-reactive protein-to-albumin ratio (CAR)-based nomogram for predicting the risk of in-hospital death in sepsis patients. Sepsis patients were selected from the MIMIC-IV database. Independent predictors were determined by multiple Cox analysis and then integrated to predict survival. The performance of the model was evaluated using the concordance index (C-index), receiver operating characteristic curve (ROC) analysis, and calibration curve. The risk stratifications analysis and subgroup analysis of the model in overall survival (OS) were assessed by Kaplan-Meier (K-M) curves. A total of 6414 sepsis patients were included. C-index of the CAR-based model was 0.917 [standard error (SE): 0.112] for the training set and 0.935 (SE: 0.010) for the validation set. The ROC curve analysis showed that the area under the curve (AUC) of the nomogram was 0.881 in the training set and 0.801 in the validation set. And the calibration curve showed that the nomogram performs well in both the training and validation sets. K-M curves indicated that patients with high CAR had significantly higher in-hospital mortality than those with low CAR. The CAR-based model has considerably high accuracy for predicting the OS of sepsis patients.

Insight Into Neonatal Sepsis: An Overview

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.

Inflammatory Biomarker Profiles in Very Preterm Infants within the Context of Preeclampsia, Chorioamnionitis, and Clinically Diagnosed Postnatal Infection

Preterm delivery can be precipitated by preeclampsia or infection, and preterm infants are at heightened risk of postnatal infection. Little is known about the ontogeny of inflammatory biomarkers in extremely preterm infants. We hypothesized that suspected prenatal infection (clinical chorioamnionitis or spontaneous preterm labor) and clinically diagnosed postnatal infection would be associated with unique biomarker signatures, and those patterns would be influenced by the degree of prematurity. Venous blood was collected daily for the first week and weekly for up to 14 additional weeks from 142 neonates born at 22-32 weeks gestation. A custom array was utilized to measure monocyte chemoattractant protein-1 (MCP-1) and interleukin-6 (IL-6). C-reactive protein (CRP) levels were obtained from the electronic medical record. Independent of gestational age, MCP-1 was significantly increased (p < 0.001) in association with maternal preeclampsia, but MCP-1 was decreased (p < 0.01), and CRP was increased (p < 0.01) in the presence of chorioamnionitis with funisitis. IL-6 and CRP were both increased in infants diagnosed with postnatal infection, with peak levels observed on days 2 and 3, respectively. In conclusion, suspected prenatal and postnatal infections and non-infectious complications of pregnancy are associated with unique biomarker profiles, independent of gestational age, including over a 2-fold increase in MCP-1 among newborns of mothers with preeclampsia. Further, in those clinically diagnosed with a postnatal infection in the absence of antenatal infection concerns, IL-6 increases before CRP, emphasizing a potential role for expanded biomarker screening if antibiotics are initially avoided in infants delivered for maternal indications.

Increased Expression of Anaphylatoxin C5a-Receptor-1 in Neutrophils and Natural Killer Cells of Preterm Infants

Preterm infants are susceptible to infection and their defense against pathogens relies largely on innate immunity. The role of the complement system for the immunological vulnerability of preterm infants is less understood. Anaphylatoxin C5a and its receptors C5aR1 and -2 are known to be involved in sepsis pathogenesis, with C5aR1 mainly exerting pro-inflammatory effects. Our explorative study aimed to determine age-dependent changes in the expression of C5aR1 and C5aR2 in neonatal immune cell subsets. Via flow cytometry, we analyzed the expression pattern of C5a receptors on immune cells isolated from peripheral blood of preterm infants (n = 32) compared to those of their mothers (n = 25). Term infants and healthy adults served as controls. Preterm infants had a higher intracellular expression of C5aR1 on neutrophils than control individuals. We also found a higher expression of C5aR1 on NK cells, particularly on the cytotoxic CD56^dim subset and the CD56^- subset. Immune phenotyping of other leukocyte subpopulations revealed no gestational-age-related differences for the expression of and C5aR2. Elevated expression of C5aR1 on neutrophils and NK cells in preterm infants may contribute to the phenomenon of "immunoparalysis" caused by complement activation or to sustained hyper-inflammatory states. Further functional analyses are needed to elucidate the underlying mechanisms.

A Prospective Analysis of the Retinopathy of Prematurity Correlated with the Inflammatory Status of the Extremely Premature and Very Premature Neonates

Retinopathy of Prematurity (ROP) is a major cause of blindness in premature infants. This study aimed to evaluate the association between inflammatory markers and ROP development in extremely premature and very premature neonates and identify potential inflammatory biomarkers for ROP risk prediction. This prospective study was conducted from January 2021 to January 2023 in two clinical hospitals associated with the "Victor Babes" University of Medicine and Pharmacy Timisoara. The study population comprised neonates with a gestational age of less than 32 weeks. Various inflammatory markers, including total white blood cell count, polymorphonuclear leukocytes, C-reactive protein, interleukin-6, and lactate dehydrogenase, were analyzed from blood samples collected at birth and three days postnatally. ROP was diagnosed and classified following the International Classification of Retinopathy of Prematurity. The study included 48 neonates, 12 Extremely Premature Infants (EPI), and 36 Very Premature Infants (VPI). The EPI group had significantly higher mean interleukin-6 and lactate dehydrogenase levels at birth and three days postnatally than the VPI group. C-reactive protein levels at three days were significantly higher in the VPI group. Umbilical cord inflammation and ROP severity were found to have a statistically significant positive correlation. Half of the EPIs had moderate to severe ROP, significantly more than in the VPI group. The duration of oxygen supplementation, mechanical ventilation, Continuous Positive Airway Pressure (CPAP), gestational age less than 28 weeks, and umbilical cord inflammation at or above stage 3 were significant risk factors for developing ROP stage 2 or above. Elevated CRP and IL-6 were also significantly associated with an increased risk of developing ROP stage 2 or above, highlighting their potential as biomarkers for ROP risk prediction. This study suggests a significant association between inflammatory markers and ROP development in extremely premature and very premature neonates. These findings could contribute to the identification of potential inflammatory biomarkers for ROP risk prediction, improving early diagnosis and intervention strategies for this condition.

Performance of 11 Host Biomarkers Alone or in Combination in the Diagnosis of Late-Onset Sepsis in Hospitalized Neonates: The Prospective EMERAUDE Study

Despite the high prevalence of late-onset sepsis (LOS) in neonatal intensive care units, a reliable diagnosis remains difficult. This prospective, multicenter cohort study aimed to identify biomarkers early to rule out the diagnosis of LOS in 230 neonates ≥7 days of life with signs of suspected LOS. Blood levels of eleven protein biomarkers (PCT, IL-10, IL-6, NGAL, IP-10, PTX3, CD14, LBP, IL-27, gelsolin, and calprotectin) were measured. Patients received standard of care blinded to biomarker results, and an independent adjudication committee blinded to biomarker results assigned each patient to either infected, not infected, or unclassified groups. Performances of biomarkers were assessed considering a sensitivity of at least 0.898. The adjudication committee classified 22% of patients as infected and all of these received antibiotics. A total of 27% of the not infected group also received antibiotics. The best biomarkers alone were IL-6, IL-10, and NGAL with an area under the curve (95% confidence interval) of 0.864 (0.798-0.929), 0.845 (0.777-0.914), and 0.829 (0.760-0.898), respectively. The best combinations of up to four biomarkers were PCT/IL-10, PTX3/NGAL, and PTX3/NGAL/gelsolin. The best models of biomarkers could have identified not infected patients early on and avoided up to 64% of unjustified antibiotics. At the onset of clinical suspicion of LOS, additional biomarkers could help the clinician in identifying non-infected patients.

Point-of-care diagnostics for sepsis using clinical biomarkers and microfluidic technology

Sepsis is a life-threatening immune response which is caused by a wide variety of sources and is a leading cause of mortality globally. Rapid diagnosis and appropriate antibiotic treatment are critical for successful patient outcomes; however, current molecular diagnostic techniques are time-consuming, costly and require trained personnel. Additionally, there is a lack of rapid point-of-care (POC) devices available for sepsis detection despite the urgent requirements in emergency departments and low-resource areas. Recent advances have been made toward developing a POC test for early sepsis detection that will be more rapid and accurate compared to conventional techniques. Within this context, this review discusses the use of current and novel biomarkers for early sepsis diagnosis using microfluidics devices for POC testing.

A Study of the Prediction of Mortality in a Tertiary Care Hospital Using the Modified Sick Neonatal Score (MSNS): An Observational Cross-Sectional Study

PURPOSE

India is a major contributor to neonatal deaths worldwide. There is a paucity of amenities for the management of neonatal health issues in rural areas of our country. Hence, there is a need to invent a reliable scoring system for the analysis of neonatal mortality.

AIM

The aim of the study is to evaluate the Modified Sick Neonatal Score (MSNS) as a predictor of mortality in neonatal care units in resource-limited settings.

MATERIALS AND METHODS

This cross-sectional observational study was performed in the intensive care unit of our hospital. All the data were collected and analyzed using IBM Corp.'s Statistical Package for Social Sciences (SPSS) software.

RESULTS

Overall, 71 participants were considered for the present study. The common clinical diagnoses noticed in our participants were meconium aspiration, malformation, and jaundice. The MSNS score compared between expired and discharged participants is found to be statistically significant with p<0.05.

CONCLUSION

The MSNS scoring system is considered an ideal scoring system for detecting early mortality in neonates.

Essential Fatty Acid Supplementation and Early Inflammation in Preterm Infants: Secondary Analysis of a Randomized Clinical Trial

INTRODUCTION

Postnatal inflammation is associated with increased mortality and adverse outcomes in preterm infants. The essential fatty acids arachidonic acid (ARA) and docosahexaenoic acid (DHA) are precursors of lipid mediators with a key role in resolving inflammation. Our aim was to investigate the effect of ARA and DHA supplementation on systemic inflammation in very preterm infants and to identify clinical factors associated with early inflammation.

METHODS

Secondary analysis of data from a randomized clinical trial (ImNuT study). Infants with gestational age (GA) less than 29 weeks were randomized to receive a daily enteral supplement with ARA 100 mg/kg and DHA 50 mg/kg (ARA:DHA group) or MCT oil (control group) from the second day of life to 36 weeks postmenstrual age. ARA, DHA, and four proinflammatory cytokines (IL-1β, IL-6, IL-8, and TNF-α) were analyzed in repeated dried blood samples from birth to day 28 and the area under the curve (AUC) for each variable was calculated.

RESULTS

The intention to treat population included 120 infants with mean (SD) GA 26.4 (1.7). The ARA:DHA group had significantly lower IL-6 levels from day 3 to day 28 compared to the control group, mean difference AUC log10 (95% CI): 0.16 (0.03-0.30) pg/mL, p = 0.018. There was no correlation between ARA or DHA blood concentrations and cytokine levels. Having a low gestational age was independently associated with increased levels of all cytokines during the first 4 weeks of life.

CONCLUSIONS

Enhanced supplementation with ARA and DHA may modulate inflammation in very preterm infants.

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

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

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

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

Group B Streptococcus Early-Onset Disease: New Preventive and Diagnostic Tools to Decrease the Burden of Antibiotic Use

The difficulty in recognizing early-onset neonatal sepsis (EONS) in a timely manner due to non-specific symptoms and the limitations of diagnostic tests, combined with the risk of serious consequences if EONS is not treated in a timely manner, has resulted in a low threshold for starting empirical antibiotic treatment. New guideline strategies, such as the neonatal sepsis calculator, have been proven to reduce the antibiotic burden related to EONS, but lack sensitivity for detecting EONS. In this review, the potential of novel, targeted preventive and diagnostic methods for EONS is discussed from three different perspectives: maternal, umbilical cord and newborn perspectives. Promising strategies from the maternal perspective include Group B Streptococcus (GBS) prevention, exploring the virulence factors of GBS, maternal immunization and antepartum biomarkers. The diagnostic methods obtained from the umbilical cord are preliminary but promising. Finally, promising fields from the newborn perspective include biomarkers, new microbiological techniques and clinical prediction and monitoring strategies. Consensus on the definition of EONS and the standardization of research on novel diagnostic biomarkers are crucial for future implementation and to reduce current antibiotic overexposure in newborns.

Dual inhibition of complement C5 and CD14 attenuates inflammation in a cord blood model

BACKGROUND

Escherichia coli and Group B streptococci (GBS) are the main causes of neonatal early-onset sepsis (EOS). Despite antibiotic therapy, EOS is associated with high morbidity and mortality. Dual inhibition of complement C5 and the Toll-like receptor co-factor CD14 has in animal studies been a promising novel therapy for sepsis.

METHODS

Whole blood was collected from the umbilical cord after caesarean section (n = 30). Blood was anti-coagulated with lepirudin. C5 inhibitor (eculizumab) and anti-CD14 was added 8 min prior to, or 15 and 30 min after adding E. coli or GBS. Total bacterial incubation time was 120 min (n = 16) and 240 min (n = 14). Cytokines and the terminal complement complex (TCC) were measured using multiplex technology and ELISA.

RESULTS

Dual inhibition significantly attenuated TCC formation by 25-79% when adding inhibitors with up to 30 min delay in both E. coli- and GBS-induced inflammation. TNF, IL-6 and IL-8 plasma concentration were significantly reduced by 28-87% in E. coli-induced inflammation when adding inhibitors with up to 30 min delay. The dual inhibition did not significantly reduce TNF, IL-6 and IL-8 plasma concentration in GBS-induced inflammation.

CONCLUSION

Dual inhibition of C5 and CD14 holds promise as a potential future treatment for severe neonatal EOS.

IMPACT

Neonatal sepsis can cause severe host inflammation with high morbidity and mortality, but there are still no effective adjunctive immunologic interventions available. Adding CD14 and complement C5 inhibitors up to 30 min after incubation of E. coli or Group B streptococci in a human umbilical cord blood model significantly reduced complement activation and cytokine release. Dual inhibition of C5 and CD14 is a potential future therapy to modulate systemic inflammation in severe cases of neonatal sepsis.

Early-Onset Neonatal Sepsis: Inflammatory Biomarkers and MicroRNA as Potential Diagnostic Tools in Preterm Newborns

Mortality and morbidity of newborns with sepsis can be improved by early and accurate diagnosis and targeted therapy. To evaluate the early molecular events associated with inflammation and infection, we evaluated markers of endothelial activation and injury and circulating plasma miRNAs in preterm newborns with sepsis. The study group consisted of newborns with gestational age ≤ 32 weeks, with culture-positive early-onset neonatal sepsis (sepsis group, N = 8), and as a control group, we enrolled newborns without sepsis (control group, N = 12). Soluble markers of inflammation were measured using Luminex-based multiplex assay. Platelet-free plasma RNA was used to construct the library for miRNA sequencing analysis. Normalized counts were calculated and used to measure differential expression of individual detected miRNAs. We found a significant increase of interleukin 18 (IL-18) in the cord blood of the sepsis group (mean ± SEM, 104.7 ± 30.4 pg/ml vs 52.7 ± 5.6 pg/ml, P = 0.02). In peripheral blood of sepsis group patients, we found a significant increase of VEGF-A compared to controls (196.0 ± 70.5 pg/ml vs 59.6 ± 8.5 pg/ml, P = 0.02). In the cord blood plasma, eight miRNAs had significantly differential expression (P < 0.05), four miRNAs were up-regulated and four miRNAs down-regulated. In peripheral blood plasma, all nine miRNAs with significant differential expression were up-regulated. In conclusion, in early-onset neonatal sepsis, IL-18 and VEGF-A might be considered in diagnostic workup. Early-onset sepsis in preterm newborns is associated with significant changes in the circulating miRNA pattern.

Systematic review and meta-analysis of the diagnostic value of four biomarkers in detecting neonatal sepsis in low- and middle-income countries

BACKGROUND

Biomarkers may enhance diagnostic capability for common paediatric infections, especially in low- and middle-income countries (LMICs) where standard diagnostic modalities are frequently unavailable, but disease burden is high. A comprehensive understanding of the diagnostic capability of commonly available biomarkers for neonatal sepsis in LMICs is lacking. Our objective was to systematically review evidence on biomarkers to understand their diagnostic performance for neonatal sepsis in LMICs.

METHODS

We conducted a systematic review and meta-analysis of studies published in English, Spanish, French, German, Dutch, and Arabic reporting the diagnostic performance of C reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC) and procalcitonin (PCT) for neonatal sepsis. We calculated pooled test characteristics and the area under the curve (AUC) for each biomarker compared with the reference standards blood culture or clinical sepsis defined by each article.

RESULTS

Of 6570 studies related to biomarkers in children, 134 met inclusion criteria and included 23 179 neonates. There were 80 (59.7%) studies conducted in LMICs. CRP of ≥60 mg/L (AUC 0.87, 95% CI 0.76 to 0.91) among 1339 neonates and PCT of ≥0.5 ng/mL (AUC 0.87, 95% CI 0.70 to 0.92) among 617 neonates demonstrated the greatest discriminatory value for the diagnosis of neonatal sepsis using blood culture as the reference standard in LMICs.

CONCLUSIONS

PCT and CRP had good discriminatory value for neonatal sepsis in LMICs. ESR and WBC demonstrated poor discrimination for neonatal sepsis in LMICs. Future studies may incorporate biomarkers into clinical evaluation in LMICs to diagnose neonatal sepsis more accurately.

PROSPERO REGISTRATION NUMBER

CRD42020188680.

Mean Platelet Volume in Neonatal Sepsis: Meta-Analysis of Observational Studies

Introduction: Early onset neonatal sepsis (EONS), particularly in preterm sepsis, is a potentially fatal issue. Evaluation of mean platelet volume (MPV) as an EONS predictor was the goal. Methods: Four databases were used to conduct a systematic evaluation of cohort and case−control studies. Up till the end of October 2022, 137 articles were found utilizing the search method. Following the review, 12 studies were included. Leukocytes, MPV, platelets, gender, birth weight, gestational age, mortality, and C-reactive protein (CRP) were all taken into account while analyzing the prediction of EONS. Inverse-variance methodology and the random-effects model were used. Using GRADE, the evidence’s quality was evaluated. Results: Neonatal patients with sepsis had significantly higher MPV levels than do neonates without sepsis (MD 1.26; 95% CI 0.89−1.63; p < 0.001). An increased MPV during the first 24 h postpartum was associated with high CRP values and high risk of neonatal mortality. In the investigations, the MPV cutoff for sepsis patients was 9.95 (SD 0.843). Overall certainty of the evidence was very low. Conclusions: The increased MPV during the first 24 h postpartum may be predictive of EONS and mortality. Future studies are warranted.

Automated Complete Blood Cell Count Using Sysmex XN-9000® in the Diagnosis of Newborn Infection

The early identification of septically infected newborn infants is important for ensuring good outcomes. Blood cell differentiations are helpful, but they are often time consuming and inaccurate. In this study, we evaluated the use of automatic white blood cell differentiations by flow cytometry for the diagnosis of neonatal sepsis. Episodes of suspected infection in neonates were retrospectively classified into two groups, unlikely infection (UI, levels of Interleukin-6 < 400 pg/mL or CRP within 48 h < 10 mg/L), n = 101 and probable infection (PI, Interleukin-6 ≥ 400 pg/mL or CRP within 48 h ≥ 10 mg/L), n = 98. Complete blood cell counts were performed by Sysmex XN-9000® using flow cytometry. Relative and absolute proportions of immature granulocytes were evaluated. Unexpectedly, the absolute count of immature granulocytes was significantly lower in the group of PI compared to UI neonates. Similar results were found when analysing the relative proportion of immature granulocytes among all neutrophil granulocytes. On the other hand, manually counted immature to total (I/T) ratios of granulocytes were higher in PI than in UI infants. Therefore, we conclude that differentiations of granulocytes by Sysmex XN-9000® can be used to distinguish between infected and uninfected neonates if the results are interpreted according to our findings. A low count of immature granulocytes as determined by Sysmex XN-9000® may indicate neonatal infection.