Laboratory aid to the diagnosis and therapy of infection in the neonate

Soluble TREM-1 is not a useful biomarker in the diagnosis of early-onset neonatal sepsis

Aim: Sepsis remains a significant cause of morbidity and mortality in neonates. We aimed to investigate the use and reliability of the soluble triggering receptor expressed on myeloid cells (sTREM-1) biomarker for suspected early onset of neonatal sepsis (EONS).Materials & methods: 52 patients with suspected EONS and 30 healthy newborns were analyzed for sTREM-1 and other biomarkers.Results: It revealed that elevated levels of C-reactive protein (CRP), neutrophil (%), red cell distribution width (RDW), neutrophil/lymphocyte ratio (NLR) and lactate, as well as decreased lymphocyte (%) were statistically significant for EONS. However, there was no statistically significant difference in sTREM-1 levels between the groups.Conclusion: Although no significant difference in sTREM-1 levels was found between the groups, further research involving repeated measurements and larger sample sizes is necessary to evaluate its practical utility in clinical settings.

Intrauterine gangrene of the right upper limb in a newborn baby: Case report

INTRODUCTION AND IMPORTANCE

Congenital gangrene of the limb in a newborn child is an extremely rare pathology with polyetiological causes that has not been fully studied. Therefore, each case of this pathology has its own characteristics of manifestations and allows you to get closer to solving this problem.

CASE PRESENTATION

We present a clinical case of congenital gangrene of the right upper limb in a newborn child. Analysis of the newborn baby's medical history indicated gestational hypertension and pyelonephritis during pregnancy in the mother, hemostasis disorders in the newborn. Computed tomography (CT) of the vessels of the right upper limb and thoracic segment confirmed brachial artery thrombosis. At the initial stage, conservative treatment was carried out, which included preventive antibacterial therapy and local care of the affected area. Only after a clear delineation of the dead tissue, the amputation of the segment of the right upper limb was performed. Amputation was performed with preservation of the proximal growth zone in order to provide an adequate stump for subsequent prosthetics.

CLINICAL DISCUSSION

Adverse factors during pregnancy can cause increased thrombosis. Through fetal communications, blood clots from the right atrium can enter the left atrium, the left ventricle and further into the large circulatory circle and cause thrombosis of the artery of the right upper limb. Another factor of increased thrombosis is congenital intrauterine infection of the newborn. Conservative treatment is carried out after diagnosis until the final determination of the boundaries of gangrene. When performing amputation, it is important to preserve the proximal bone growth zone in order to form an adequate stump for prosthetics.

CONCLUSION

Congenital gangrene of the limb in a newborn child is an extremely rare pathology. Irreversible changes in the upper limb in the child were caused by a combination of two factors: gestational hypertension and pyelonephritis in a pregnant woman and hemostasis disorders in a newborn due to intrauterine infection. Therefore, the preparation of women for pregnancy, examination for intrauterine infection and treatment of extragenital pathology are important in the prevention of this disease.

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.

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.

Tackling Neonatal Sepsis-Can It Be Predicted?

(1) Background: Early signs of sepsis in a neonate are often subtle and non-specific, the clinical course rapid and fulminant. The aim of our research was to analyse diagnostic markers for neonatal sepsis and build an application which could calculate its probability. (2) Methods: A retrospective clinical study was conducted on 497 neonates treated at the Clinical Department of Neonatology of the University Children's Hospital in Ljubljana from 2007 to 2021. The neonates with a diagnosis of sepsis were separated based on their blood cultures, clinical and laboratory markers. The influence of perinatal factors was also observed. We trained several machine-learning models for prognosticating neonatal sepsis and used the best-performing model in our application. (3) Results: Thirteen features showed highest diagnostic importance: serum concentrations of C-reactive protein and procalcitonin, age of onset, immature neutrophil and lymphocyte percentages, leukocyte and thrombocyte counts, birth weight, gestational age, 5-min Apgar score, gender, toxic changes in neutrophils, and childbirth delivery. The created online application predicts the probability of sepsis by combining the data values of these features. (4) Conclusions: Our application combines thirteen most significant features for neonatal sepsis development and predicts the probability of sepsis in a neonate.

The role of MBL, PCT, CRP, neutrophil-lymphocyte ratio, and platelet lymphocyte ratio in differentiating infections from flares in lupus

BACKGROUND

The distinction between infection and flare in systemic lupus erythematosus (SLE) has always been a dilemma for clinicians as the clinical and biochemical profiles overlap. The present study evaluated affordable biomarkers to distinguish infection from flare in an SLE cohort in a tertiary care center in eastern India.

METHODS

One hundred and fifty-two SLE patients were clinically evaluated and enrolled in the present study. Hematological, immunological, and biochemical profiles and various biomarkers such as C reactive protein (CRP), procalcitonin (PCT), and Mannose-binding lectin (MBL) were quantified.

RESULTS

One hundred and fifty-two patients (152) were enrolled in the present study and all had SLEDAI scores of more than 4. From which 70 had infection, and the common infections were urinary tract infection (34.28%) followed by pneumonia (27.14%). Neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP) were significantly elevated in SLE with infections (NLR: 5.84 ± 2.47; CRP: 30.56 ± 41.63) than those with flare (NLR: 3.87 ± 2.62; CRP: 8.73 ± 9.53). The receiver operating characteristic curve (ROC) analysis revealed CRP, PLR, and NLR as important markers for predicting infections (CRP: AUC = 0.682, p = 0.0001; PLR: AUC = 0.668, p = 0.0008; NLR: AUC = 0.742, p < 0.0001). The MBL and PCT levels were comparable among SLE flare and those with infections.

CONCLUSIONS

NLR and CRP levels are affordable biomarkers to distinguish infections from flares in SLE. MBL and PCT could not differentiate flare from an infection. Key Points • Biomarkers for the differentiation of infection and flare in SLE are limited. • NLR, PLR, and CRP are promising biomarkers to enable differentiation. • PCT and MBL are not ideal biomarkers to differentiate infection from flare.

2.5 Million Annual Deaths-Are Neonates in Low- and Middle-Income Countries Too Small to Be Seen? A Bottom-Up Overview on Neonatal Morbi-Mortality

(1) Background: Every year, 2.5 million neonates die, mostly in low- and middle-income countries (LMIC), in total disregard of their fundamental human rights. Many of these deaths are preventable. For decades, the leading causes of neonatal mortality (prematurity, perinatal hypoxia, and infection) have been known, so why does neonatal mortality fail to diminish effectively? A bottom-up understanding of neonatal morbi-mortality and neonatal rights is essential to achieve adequate progress, and so is increased visibility. (2) Methods: We performed an overview on the leading causes of neonatal morbi-mortality and analyzed the key interventions to reduce it with a bottom-up approach: from the clinician in the field to the policy maker. (3) Results and Conclusions: Overall, more than half of neonatal deaths in LMIC are avoidable through established and well-known cost-effective interventions, good quality antenatal and intrapartum care, neonatal resuscitation, thermal care, nasal CPAP, infection control and prevention, and antibiotic stewardship. Implementing these requires education and training, particularly at the bottom of the healthcare pyramid, and advocacy at the highest levels of government for health policies supporting better newborn care. Moreover, to plan and follow interventions, better-quality data are paramount. For healthcare developments and improvement, neonates must be acknowledged as humans entitled to rights and freedoms, as stipulated by international law. Most importantly, they deserve more respectful care.

Monocyte-to-HDL ratio and non-HDL cholesterol were predictors of septic shock in newborns

BACKGROUND

The association between lipoprotein levels and late-onset neonatal sepsis has shown controversial results. The aims are to assess lipid profile, cytokines, and Monocyte-to-HDL (M/H) ratio as diagnostic and prognostic markers for late-onset neonatal sepsis.

METHODS

This prospective study included 49 septic neonates and 17 controls. Cholesterol (CT), Triglyceride (TG), Very-Low-Density (VLDLc), Low-Density (LDLc), and High-Density Lipoproteins (HDLc) were measured at admission (D0) and on days 3, 7 and 10 to evaluate septic shock outcomes. Cytokines and monocytes were evaluated by flow cytometry.

RESULTS

Septic newborns showed higher IL-6 and IL-8 at D0 and CT levels on D7 and on D10, which also presented higher TG, VLDLc and non-HDL cholesterol concentrations than controls. The septic shock group (n = 22) revealed a higher number of male subjects, CRP, IL-6, IL-8 and IL-10 levels, while lower TG, HDLc, monocyte numbers and M/H ratio at admission compared to the non-shock group (n = 27). M/H ratio and non-HDL cholesterol on D0 were risk factors for septic shock (OR = 0.70, 0.49‒0.99; OR = 0.96, 0.92‒0.99, respectively). Decreasing levels from D0 to D3 of CT (OR = 0.96, 0.93‒0.99), VLDLc (OR = 0.91, 0.85‒0.98), and non-HDL cholesterol (OR = 0.92, 0.87‒0.98) were also predictors of septic shock.

CONCLUSIONS

Lower M/H ratios and non-HDL cholesterol at admission and decreasing levels of cholesterol, VLDLc and non-HDL cholesterol during a hospital stay are associated with the development of septic shock in newborns with late-onset neonatal sepsis.

Variations in Antibiotic Use and Sepsis Management in Neonatal Intensive Care Units: A European Survey

Management of neonatal sepsis and the use of antimicrobials have an important impact on morbidity and mortality. However, there is no recent background on which antibiotic regimens are used in different European neonatal intensive care units (NICUs). Our study aimed to describe the use of antibiotics and other aspects of early- and late-onset sepsis (EOS and LOS, respectively) management by European NICUs. We conducted an online survey among NICUs throughout Europe to collect information about antibiotic stewardship, antibiotic regimens, and general aspects of managing neonatal infections. NICUs from up to 38 European countries responded, with 271 valid responses. Most units had written clinical guidelines for EOS (92.2%) and LOS (81.1%) management. For EOS, ampicillin, penicillin, gentamicin, and amikacin were the most commonly used antibiotics. Analysis of the combinations of EOS regimens showed that the most frequently used was ampicillin plus gentamicin (54.6%). For LOS, the most frequently used antibiotics were vancomycin (52.4%), gentamicin (33.9%), cefotaxime (28%), and meropenem (15.5%). Other aspects of the general management of sepsis have also been analyzed. The management of neonatal sepsis in European NICUs is diverse. There was high self-reported adherence to the local clinical guidelines. There was homogeneity in the combination of antibiotics in EOS but less in LOS.

The Association of Laboratory Test Abnormalities With Mortality Risk in Pediatric Intensive Care

OBJECTIVES

To determine the bivariable associations between abnormalities of 28 common laboratory tests and hospital mortality and determine how mortality risks changes when the ranges are evaluated in the context of commonly used laboratory test panels.

DESIGN

A 2009-2016 cohort from the Health Facts (Cerner Corporation, Kansas City, MO) database.

SETTING

Hospitals caring for children in ICUs.

PATIENTS

Children cared for in ICUs with laboratory data.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 2,987,515 laboratory measurements in 71,563 children. The distribution of laboratory test values in 10 groups defined by population percentiles demonstrated the midrange of tests was within the normal range except for those measured predominantly when significant abnormalities are suspected. Logistic regression analysis at the patient level combined the population-based groups into ranges with nonoverlapping mortality odds ratios. The most deviant test ranges associated with increased mortality risk (mortality odds ratios > 5.0) included variables associated with acidosis, coagulation abnormalities and blood loss, immune function, liver function, nutritional status, and the basic metabolic profile. The test ranges most associated with survival included normal values for chloride, pH, and bicarbonate/total Co2. When the significant test ranges from bivariable analyses were combined in commonly used test panels, they generally remained significant but were reduced as risk was distributed among the tests.

CONCLUSIONS

The relative importance of laboratory test ranges vary widely, with some ranges strongly associated with mortality and others strongly associated with survival. When evaluated in the context of test panels rather than isolated tests, the mortality odds ratios for the test ranges decreased but generally remained significant as risk was distributed among the components of the test panels. These data are useful to develop critical values for children in ICUs, to identify risk factors previously underappreciated, for education and training, and for future risk score development.

A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan

Neonatal sepsis is one of the most critical illnesses in newborns with significant morbidity and mortality, particularly in developing countries. The present, cross-sectional, hospital-based, study was conducted to evaluate the association of red cell distribution width (RDW) with neonatal sepsis and its role as a predictive marker in the diagnosis of neonatal sepsis at Soba University Hospital, during the period July 2018 to April 2019. The study population was term neonates, aged 1-28 days, who were diagnosed with neonatal sepsis, with positive blood culture. A total of 111 full-term neonates had blood culture proven neonatal sepsis and the majority of them (100%, 90%) had positive C-reactive protein (CRP). The average RDW in this study was 19.3% and was elevated in 103 (92%) of the study participants with a significant association with positive blood culture. The majority (65%, 58.6%) of mothers of the studied neonates did not have an illness during pregnancy, 19 (17.1%) had diabetes mellitus, 9 (8.1%) had hypertension, in addition to other different conditions in 18 (16.2%). The common causes of admission of the studied newborns included respiratory distress (70%, 79%), jaundice (33%, 29.7%) and lethargy (28%, 25.2%). Staphylococcus aureus was the most common organism isolated from blood culture in 50 (45.0%) patients, and Escherichia coli was the least one, isolated in only one (0.9%) newborn. There is a significant association between positive blood culture, CRP and elevated RDW (p-value 0.01). RDW was found to be significantly elevated in the studied newborns with neonatal sepsis.

C-reactive protein as a predictor of meningitis in early onset neonatal sepsis: a single unit experience

Objectives To determine whether there is a cut off value of serum C-reactive protein (CRP) associated with a higher risk of meningitis in suspected early onset sepsis (EOS) (onset birth to 7 days of life). Methods A retrospective cohort study on neonates admitted in neonatal intensive care unit at McMaster Children's Hospital from January 2010 to 2017 and had lumbar puncture (LP) and CRP for workup of EOS. Included subjects had either (a) non-traumatic LP or (b) traumatic LP with cerebral spinal fluid (CSF) polymerase chain reaction or gram stain or culture-positive or had received antimicrobials for 21 days. Excluded were CSF done for metabolic errors, before cytomegalovirus (CMV) treatment; from ventriculo-peritoneal (VP) shunts; missing data and contamination. Neonates were classified into definite and probable meningitis and on the range of CRP. We calculated sensitivity, specificity, and likelihood ratios for CRP values; and area under the receiver operating characteristic (AUROC) curve. Results Out of 609 CSF samples, 184 were eligible (28 cases of definite or probable meningitis and 156 controls). Sensitivity, specificity, predictive values, likelihood ratios, and AUROC were too low to be of clinical significance to predict meningitis in EOS. Conclusions Serum CRP values have poor discriminatory power to distinguish between subjects with and without meningitis, in symptomatic EOS.

Precision Medicine for Neonatal Sepsis

Neonatal sepsis remains a significant cause of morbidity and mortality especially in the preterm infant population. The ability to promptly and accurately diagnose neonatal sepsis based on clinical evaluation and laboratory blood tests remains challenging. Advances in high-throughput molecular technologies have increased investigations into the utility of transcriptomic, proteomic and metabolomic approaches as diagnostic tools for neonatal sepsis. A systems-level understanding of neonatal sepsis, obtained by using omics-based technologies (at the transcriptome, proteome or metabolome level), may lead to new diagnostic tools for neonatal sepsis. In particular, recent omic-based studies have identified distinct transcriptional signatures and metabolic or proteomic biomarkers associated with sepsis. Despite the emerging need for a systems biology approach, future studies have to address the challenges of integrating multi-omic data with laboratory and clinical meta-data in order to translate outcomes into precision medicine for neonatal sepsis. Omics-based analytical approaches may advance diagnostic tools for neonatal sepsis. More research is needed to validate the recent systems biology findings in order to integrate multi-dimensional data (clinical, laboratory and multi-omic) for future translation into precision medicine for neonatal sepsis. This review will discuss the possible applications of omics-based analyses for identification of new biomarkers and diagnostic signatures for neonatal sepsis, focusing on the immune-compromised preterm infant and considerations for clinical translation.

Mean platelet volume in preterm: a predictor of early onset neonatal sepsis

Background: Early onset sepsis (EOS) is potentially life-threatening problem especially in preterm. EOS diagnosis is challenging due to its non-specific signs and laboratory tests. Mean platelet volume (MPV) has been used as predictor of many inflammatory diseases.Objectives: To assess the correlation between serial MPV measurement and EOS occurrence in preterm infants and to determine MPV effectiveness in combination with C reactive protein (CRP) to diagnose EOS and mortality prediction.Methods: The study was carried out on 95 preterm infants with antenatal risk factor for EOS. Blood samples were taken for complete blood count (CBC) including MPV evaluated at birth (cord blood) and at 72 h of life. CRP analyzed on days 1 and 3, subsequently patients were identified in two groups: sepsis (n = 28) and no-sepsis (n = 67).Results: MPV was significantly higher on both day 1 (10.23 ± 0.92) fl and day 3 (10.77 ± 1.16) fL in the sepsis group compared with no-sepsis (8.11 ± 0.29) fl and (8.53 ± 0.42) fl, respectively. MPV of 8.6 fL was identified as cut off value in patients probably resulting in sepsis with a sensitivity of 97.14% and a specificity of 100%. MPV of 10.4 fl was determined as cut off value in patients possibly resulting in death with a sensitivity of 70% and a specificity of 82.5%. The combination of both MPV and CRP on day 1 resulted in improving performance of MPV with higher negative predictive value (93.1%) and higher sensitivity (80%).Conclusion: High cord blood and day 3 MPV can be used as surrogate marker for prediction of EOS and associated mortality in preterm neonates.

The role of nCD64 in the diagnosis of neonatal sepsis in preterm newborns

BACKGROUND

Diagnosing neonatal sepsis is difficult, particularly in preterm newborns. A promising method appears to be evaluation of cell surface markers by flow cytometry.

METHODS

This prospective study investigated 217 newborns suspected of having early- or late-onset neonatal sepsis. In all, flow cytometry was used to determine the proportion of CD64-positive neutrophils (nCD64). Based on the clinical course and laboratory test results, newborns were categorized as having proven, possible, clinical or no neonatal sepsis. Subsequently, associations between the categories and nCD64 values were analyzed.

RESULTS

There were significant associations between nCD64 values and the development of sepsis in newborns with both early- or late-onset sepsis.

CONCLUSION

nCD64expression is significantly elevated in preterm newborn with early and late onset sepsis. The results show that nCD64 is a reliable marker for diagnosing neonatal sepsis.

Sepsis calculator implementation reduces empiric antibiotics for suspected early-onset sepsis

Significant overtreatment with antibiotics for suspected early onset sepsis (EOS) constitutes a persisting clinical problem, generating unnecessary risks, harms, and costs for many newborns. We aimed to study feasibility and impact of a sepsis calculator to help guide antibiotic for suspected EOS in a European setting. In this single-center study, the sepsis calculator was implemented as an addition to and in accordance with existing protocols. One thousand eight hundred seventy-seven newborns ≥ 35 weeks of gestational age were prospectively evaluated; an analogous retrospective control group (n = 2076) was used for impact analysis. We found that empirical treatment with intravenous antibiotics for suspected EOS was reduced from 4.8 to 2.7% after sepsis calculator implementation (relative risk reduction 44% (95% confidence interval 21.4-59.5%)). No evidence for changes in time to treatment start, treatment duration, or proven sepsis rates was found. Adherence to sepsis calculator recommendation was 91%.

CONCLUSION

Pragmatic and feasible implementation of the sepsis calculator yields a 44% reduction of empirical use of antibiotics for EOS, without signs of delay or prolongation of treatment. These findings warrant a multicenter, nation-wide, randomized study evaluating systematic use of the sepsis calculator prediction model and its effects in clinical practice outside of the USA. What is known: • Significant overtreatment with antibiotics for suspected early-onset sepsis results in unnecessary costs, risks, and harms. • Implementation of the sepsis calculator in the USA has resulted in a significant decrease in empirical antibiotic treatment, without apparent adverse events. What is new: • Implementation of the sepsis calculator in daily clinical decision-making in a Dutch teaching hospital is feasible in conjunction with existing protocols, with high adherence. • Antibiotic therapy for suspected early-onset sepsis was reduced by 44% following implementation of the calculator.

C reactive protein in healthy term newborns during the first 48 hours of life

BACKGROUND

Early-onset neonatal sepsis (EOS) is a serious and potentially life-threatening disease in newborns. C reactive protein (CRP) is the most used laboratory biomarker for the detection of EOS. Little is known about normal reference values of CRP during the perinatal period as several factors are able to influence it.

OBJECTIVES

To identify an appropriate range of CRP values in healthy term newborns during the first 48 hours of life.

DESIGN

CRP determination was performed in 859 term newborns at 12, 24 and 48 hours of life. Mode of delivery, maternal vaginal culture results, intrapartum antimicrobial prophylaxis (IAP) and other perinatal variables were recorded.

RESULTS

CRP mean values were significantly higher at 48 hours (4.10 mg/L) than at both 24 (2.30 mg/L) and 12 hours of life (0.80 mg/L). CRP levels were affected by a number of perinatal proinflammatory variables. In particular, CRP mean values were significantly higher in babies born by vaginal delivery (3.80 mg/L) and emergency caesarean section (3.60 mg/L) than in babies born by elective caesarean section (2.10 mg/L). Completed course of IAP led to lower CRP mean values (2.90 mg/L) than IAP not completed (3.80 mg/L) or not performed (4.70 mg/L).

CONCLUSIONS

Postnatal age and mode of delivery significantly influence CRP values. Reliable reference values are crucial in order to obtain an adequate diagnostic accuracy.

Salivary C-reactive protein, mean platelet volume and neutrophil lymphocyte ratio as diagnostic markers for neonatal sepsis

OBJECTIVE

To assess the applicability of salivary C-reactive protein, mean platelet volume, neutrophil-lymphocyte ratio, and platelet lymphocyte ratio in the diagnosis of neonatal sepsis.

METHODS

Prospective case-control study of 70 full-term neonates, 35 with sepsis (20 with proven sepsis and 15 with clinical sepsis) and 35 healthy controls. Serum and salivary C-reactive protein concentrations were measured by enzyme-linked immunosorbent assay while mean platelet volume, neutrophil-lymphocyte ratio, and platelet lymphocyte ratio were measured by automated blood cell counter.

RESULTS

This study showed statistically significant difference of mean salivary C-reactive protein between septic neonates and controls (12.0±4.6ng/L vs. 2.8±1.2ng/L) respectively. At a cut-off point of 3.48ng/L, salivary C-reactive protein showed 94.3% sensitivity and 80% specificity. Salivary C-reactive protein also showed good predictive accuracy for predicting elevated serum C-reactive protein values in septic neonates. Mean platelet volume and neutrophil-lymphocyte ratio showed significant difference between septic neonates and controls (10.2±1.2fL vs.8.0±0.5fL; 2.9±1.7 vs. 1.6±0.4, respectively). At a cut-off point of 10.2fL, mean platelet volume presented 80% sensitivity and specificity. At a cut-off point of 2.7, neutrophil-lymphocyte ratio presented 80% sensitivity and 57.1% specificity.

CONCLUSION

This study provides support for further studies on the usefulness of salivary C-reactive protein, mean platelet volume, and neutrophil-lymphocyte ratio as diagnostic markers for neonatal sepsis.

Hypothermia at neonatal intensive care unit admission was not associated with respiratory disease or death in very preterm infants

AIM

This study investigated the association between hypothermia and respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD) or death in very preterm infants admitted to a Danish neonatal intensive care unit (NICU).

METHODS

We studied 675 infants born at Aalborg University Hospital before 32 weeks and admitted to the NICU from April 1997 to December 2011. Hypothermia was defined as a core temperature of <36.5°C on admission. The primary outcome was severe RDS or death within the first three days of life, and the secondary outcome was BPD or death before 36 postmenstrual weeks. The multivariable logistic regression was adjusted for early-onset infection, gestational age, Apgar score, sex, treatment year and birth weight.

RESULTS

Infants with hypothermia had a twofold increase (OR) in the odds for RDS or death (2.03), but the adjusted OR was not statistically significant (1.36). They also demonstrated a twofold increase (OR) in the odds for BPD or death (2.28), but again the adjusted OR was not statistically significant (1.03).

CONCLUSION

After adjusting for confounders, we found that the association between hypothermia on admission to the NICU and RDS or death, or BPD or death was statistically insignificant.

Potential biomarkers for effective screening of neonatal sepsis infections: An overview

Neonatal sepsis, a clinical disorder developed by bacterial blood stream infections (BSI) in neonates, is one of the serious global public health problems that must be addressed. More than one million of the estimated global newborn deaths per year are occurred due to severe infections. The genesis of the infection is divided into early-onset sepsis (EOS) and late-onset sepsis (LOS) of the disease. The clinical complications of neonatal sepsis may be associated with bronchopulmonary dysplasia, ductus arteriosus and necrotizing enterocolitis. The clinical diagnosis and treatment of neonatal sepsis is highly complicated. Over the past few years distinct biomarkers have been identified. Most widely used biomarkers are C-reactive protein, Procalcitonin (PCT) and Serum amyloid A (SAA). Until recently, many potential biomarkers including Cell Surface antigens and Bacterial surface antigens and genetic biomarkers are being investigated. Protein biomarkers, cytokines and chemokines are getting much interest for identification of neonatal sepsis infection.

Flow cytometric white blood differential using CytoDiff™ in the diagnosis of neonatal early-onset infection

OBJECTIVE

Neonatal early-onset infection is a life-threatening disease, requiring early diagnosis and treatment. Newborns at risk are identified by a combination of risk factors, clinical signs of infection and laboratory parameters such as white blood cell count and C-reactive protein (CRP). This method is labor-intensive, time consuming and has a variable reproducibility. New reliable diagnostic markers are needed to identify neonatal infection. This study presents additional leukocyte differential parameters produced by the automated flow cytometry and processing software using CytoDiff™ reagent (Beckman Coulter) in newborns suspected for early-onset infection.

METHODS

An analytic prospective observational case-control study was performed in which 185 newborns were included and retrospectively allocated into two groups, "infection likely" and "infection unlikely". Leukocyte parameters of the CytoDiff™ technique were compared with microscopic slide differentiation and routine tests.

RESULTS

We showed significant lower numbers of monocytes, CD16(-) monocytes and lymphocytes (including T+/NK-lymphocytes) in neonates suspected for early-onset infection using CytoDiff™ technique. The manual counting did not demonstrate changes with respect to the number of monocytes in these neonates.

CONCLUSIONS

The automated routine CytoDiff™ leukocyte differential provides an interesting additional diagnostic tool, next to routine laboratory diagnostics, in the diagnosis of neonatal early-onset infection.

Efficacy of new leukocyte parameters versus serum C-reactive protein, procalcitonin, and interleukin-6 in the diagnosis of neonatal sepsis

BACKGROUND

The aim of this study was to investigate and compare the efficacy of the new leukocyte parameters mean neutrophil and monocyte volume (MNV, MMV), conductivity (MNC, MMC), scattering (MNS, MMS) and volume distribution width (NDW, MDW) with serum C-reactive protein (CRP), procalcitonin (PC) and interleukin (IL)-6 in the diagnosis of neonatal sepsis.

METHODS

A total of 227 newborns (132 boys, 95 girls) were analyzed. There were 116 infants in the sepsis group (proven sepsis, n = 40; clinical sepsis, n = 76) and 111 in the control group. Venous blood samples were collected from infants at the time of diagnosis and complete blood count, peripheral blood smear, blood cultures, CRP, PC, IL-6 and MNV, MMV, MNC, MMC, MNS, MMS, NDW, and MDW were analyzed.

RESULTS

MNV, NDW, MMV and, MDW were higher in infants with sepsis than in controls (P < 0.05 for all). MNS was lower in the patients with sepsis (P = 0.002). There was no significant difference between the sepsis and control groups in terms of MNC, MMC and MMS.

CONCLUSION

Although the predictive value of leukocyte parameters including neutrophil and monocyte volume, conductivity, scattering and volume distribution width in the diagnosis of neonatal sepsis was lower than that of CRP, PC and IL-6, some of these new parameters may be useful in the differential diagnosis of newborn sepsis, along with the other screening tools. In particular, MNV seems to be the most useful parameter with the highest specificity; also, the importance of PC in the diagnosis of early onset sepsis was confirmed.

Improvement in detecting bacterial infection in lower respiratory tract infections using the Intensive Care Infection Score (ICIS)

Immediate treatment of lower respiratory tract infections (LRTI) caused by bacteria is important to reduce pneumonia and other complications such as systemic inflammatory response syndrome and sepsis. Nowadays procalcitonin (PCT) is the gold standard to differentiate between bacterial and non-bacterial infections in LRTI. The aim of this study was to evaluate if the new Intensive Care Infection Score (ICIS) which is a combination of various cellular measurements made on hematology analyzers could be a potential method to differentiate between bacterial and non-bacterial infections in LRTI.

The ICIS is composed of five blood-cell derived parameters characterizing the early innate immune response; (1) mean fluorescence intensity of mature (segmented) neutrophils; (2) the difference in hemoglobin concentration between newly formed red blood cells and the mature ones; (3) absolute number of segmented neutrophils; (4) absolute count of antibody secreting lymphocytes and (5) absolute count of number of granulocytes.

The discriminative power of ICIS to differentiate between patients with LRTI of bacterial and non-bacterial origin is as good or even better as the commonly used infection biomarkers PCT, CRP and IL-6.

Beside PCT, CRP and IL-6, ICIS could be used as infection marker in LRTI.

Astragaloside IV prevents lipopolysaccharide-induced injury in H9C2 cardiomyocytes

This study aimed to investigate the protective effects of astragaloside IV (AS IV) on lipopolysaccharide (LPS)-induced injury in H9C2 cardiomyocytes. H9C2 Cardiomyocytes were cultured with LPS (10 μg·mL(-1)) for 4 h and treated with AS IV at 50, 100, and 150 μmol·L(-1) for various durations. Cell viability was determined by MTT. The content of released TNF-α and IL-6 from cardiomyocytes were evaluated by enzyme-linked immunosorbent assay (ELISA). The levels of superoxidase dismutase (SOD), malondialdehyde (MDA), lactate dehydrogenase (LDH), and creatine phosphate kinase (CK) were measured by using commercial available kits. The mRNA and protein expression levels of NF-κB p65 were measured by RT-PCR and Western blotting, respectively. And the NF-κB p65 activity was measured by ELISA. Our results demonstrated that AS IV at 50, 100, and 150 μmol·L(-1) markedly inhibited the release of TNF-α and IL-6 and decreased NF-κB expression, compared with the model group. Moreover, the improved SOD activity and decreased MDA, LDH and CK levels were detected after AS IV treatment. In summary, AS IV could increase the activities of antioxidant enzymes, inhibite lipid peroxidation, and down-regulate the inflammatory mediators involved in the inflammatory responses. These results demonstrated that AS IV could prevent LPS-induced injury in cardiomyocytes.

Markedly raised levels of C-reactive protein are associated with culture-proven sepsis or necrotising enterocolitis in extremely preterm neonates

AIM

A serious inflammatory process is suspected when C-reactive protein (CRP) is very high, and we established the causes and outcomes when CRP was >100 mg/L in neonates.

METHODS

We retrospectively reviewed all 277 episodes where CRP exceeded 100 mg/L between January 2007 and December 2011 at a tertiary neonatal unit.

RESULTS

Of the 6025 neonates admitted during the study period, 258 had CRP >100 mg/L at least once. The overall mortality rate was 44/258 (17%); 36 died within 7 days of CRP >100 mg/L, and 34 were extremely preterm infants. CRP exceeded 100 mg/L in 106 infants within the first 3 days of life - 74 term, 25 preterm and seven extremely preterm - with no infection identified in 81%. In contrast, infections were found in 87% of the 171 episodes from day four of life - 129 extremely preterm, 23 preterm and 19 term - predominantly coagulase-negative staphylococcus sepsis and necrotising enterocolitis.

CONCLUSION

Markedly elevated CRP in the first 3 days of life was most likely to affect term neonates (74/106) with no infectious cause (81%). However, CRP >100 mg/L from the fourth day of life was most likely to affect extremely preterm neonates (129/171) and have an infectious cause (87%).

Study on the usefulness of APR scores from the viewpoint of proinflammatory cytokines

Background. Delayed diagnosis and treatment of newborn infection adversely impact outcomes. Clinical laboratory parameters have aimed to obtain the most correct and prompt diagnosis and treatment of this disease. This study simultaneously observed changes over time in APR as well as proinflammatory cytokines and anti-proinflammatory cytokines and aims to clarify usefulness of APR scores. Methods. We evaluated the usefulness of acute phase reactants (APR) in 46 newborns whose serum up to age 7 days had been stored, with comparison of three types (Group I: infection 15, Group F: fetal inflammatory response syndrome 17, and Group C: control 14) of APR-based scores, those of C-reactive protein (CRP), alpha1-acid glycoprotein (AGP), and haptoglobin (Hp), with proinflammatory cytokine levels. APR scores for CRP, AGP, and Hp and the levels of the proinflammatory cytokines IL-1β, IL-6, IL-8, IL-10, and TNFα were determined. Results. The cytokine levels started to increase from age 0 days and then decreased rapidly. The three APR scores, CRP, AG, and Hp, were elevated at age 0 days and then gradually decreased in infection (Group I) and fetal inflammatory response syndrome (Group F). The duration of antibiotic administration according to APR scores was significantly shorter in Group F than in Group I. Conclusion. This study demonstrated APR scores to be more useful for deciding whether antibiotics should be discontinued than proinflammatory cytokine levels.

Use of early biomarkers in neonatal brain damage and sepsis: state of the art and future perspectives

The identification of early noninvasive biochemical markers of disease is a crucial issue of the current scientific research, particularly during the first period of life, since it could provide useful and precocious diagnostic information when clinical and radiological signs are still silent. The ideal biomarker should be practical and sensitive in the precocious identification of at risk patients. An earlier diagnosis may lead to a larger therapeutic window and improve neonatal outcome. Brain damage and sepsis are common causes of severe morbidity with poor outcome and mortality during the perinatal period. A large number of potential biomarkers, including neuroproteins, calcium binding proteins, enzymes, oxidative stress markers, vasoactive agents, and inflammatory mediators, have been so far investigated. The aim of the present review was to provide a brief overview of some of the more commonly investigated biomarkers used in case of neonatal brain damage and sepsis.

The Sex Differences of Morphology and Immunology of SIRS of Newborn Wistar Rats

The sex differences of infection and inflammatory diseases particularly appear at reproductive age and depend on the sex hormone level, varied between male and female. There are a few sets of data about the sex differences of infection and inflammatory diseases course, including systemic inflammatory response syndrome (SIRS) and sepsis, of newborns. The aim of our research was the estimation of morphological and immunological manifestation of SIRS of the newborn Wistar rats. Investigations were carried out on male and female two-day-old Wistar rats (10–12 g). SIRS was modeled by intraperitoneal injection of LPS (E. coli, O26: B6 strain, Sigma) in high dose—15 mg/kg. We did not find out any sex differences of the liver lesions severity between newborn males and females after LPS injection. The levels of endotoxin and estradiol in the serum, as the number of neutrophils in the intra-alveolar septa of the lungs, were higher in males than females with SIRS. Production of IL-2 and TNF-α by the spleen cells of males was higher than that in control group that reflects polarization predominantly on the Th1-type immune response. The secretion of IL-2, TNF-α, and IFN-γ by ConA activated spleen cells of females decreased that reflects the suppression of Th1-type immune response. We suppose that the LPS administration in the high dose causes the multidirectional reaction of the immune system of neonatal males and females Wistar rats.

Diagnostic utility of neutrophil CD64 as a marker for early-onset sepsis in preterm neonates

Introduction

Neutrophil CD64 has been proposed as an early marker of sepsis. This study aims to evaluate the diagnostic utility of neutrophil CD64 for identification of early-onset sepsis in preterm neonates.

Methods

The prospective study was conducted in a neonatal intensive care unit between November 2010 and June 2011. Preterm neonates in whom infection was suspected when they were <12 hours of age were enrolled. Complete blood count with differential, blood culture, neutrophil CD11b and CD64 measurement were performed. Receiver operating characteristic curve analysis was performed to evaluate the performance of neutrophil CD64 as biomarker of sepsis.

Results

A total of 158 preterm neonates was enrolled, 88 of whom were suspected infection. The suspected sepsis group was of lesser gestational age (P<0.001) and lower birth weight (P<0.001), compared with controls. The hematologic profiles of the suspected sepsis group were characterized by higher white blood cell count, neutrophil counts and C-reactive protein. The suspected sepsis neonates had significantly higher neutrophil CD64 expression compared with controls. Neutrophil CD64 had an area value under the curve of 0.869 with an optimal cutoff values of 1010 phycoerythrin molecules bound/cell and it had a high sensitivity (81.82%) and negative predictive value (77.4%). The level of neutrophil CD64 was independent of antibiotic therapy within 24 hours after the onset of sepsis in preterm neonates.

Conclusions

Neutrophil CD64 is a highly sensitive marker for suspected early-onset sepsis in preterm neonates. Our study suggests that neutrophil CD64 may be incorporated as a valuable marker to diagnose infection.

Diagnostic accuracy of neutrophil CD64 expression in neonatal infection: A meta-analysis

Objective

*Liu-Qun Jia and Yong-Chun Shen contributed equally to this work and are joint first authors. The aim of the present study was to establish the predictive values of neutrophil CD64 expression in diagnosing neonatal infection.

Methods

A comprehensive search of the PubMed and Embase® literature databases identified outcome data from published studies estimating the diagnostic accuracy of neutrophil CD64 expression for neonatal infection. Summary estimates for sensitivity, specificity, diagnostic odds ratios (DOR) and the area under the summary receiver operating characteristic curve (AUC) were calculated using a bivariate random-effects approach.

Results

Twelve studies including 1915 neonates were analysed. Summary estimates (95% confidence intervals) for CD64 expression in the diagnosis of neonatal infection were: sensitivity, 0.78 (0.75, 0.81); specificity, 0.81 (0.78, 0.83); DOR, 21.27 (11.71, 38.65); positive-likelihood ratio, 4.53 (3.22, 6.36); negative-likelihood ratio, 0.23 (0.14, 0.37); AUC, 0.89.

Conclusions

Neutrophil CD64 expression can be used as an additional test in the diagnosis of neonatal infection. Results of a CD64 assay should not be used alone to diagnose such infections, but should be interpreted in combination with other test results and clinical findings.

LPS induces cardiomyocyte injury through calcium-sensing receptor

Calcium-sensing receptor (CaSR) belongs to the family C of G-protein coupled receptors. We have previously demonstrated that CaSR could induce apoptosis of cultured neonatal rat ventricular cardiomyocytes in simulated ischemia/reperfusion. It remains unknown whether the CaSR has function in lipopolysaccharide (LPS)-induced myocardial injure. The aim of this study was to investigate whether the CaSR plays a role in LPS-induced myocardial injury. Cultured neonatal rat cardiomyocytes were treated with LPS, with or without pretreatment with the CaSR-specific agonist gadolinium chloride (GdCl3) or the CaSR-specific antagonist NPS2390. Release of TNF-α and IL-6 from cardiomyocytes was observed. Levels of malonaldehyde (MDA), lactate dehydrogenase (LDH), and activity of superoxide dismutase (SOD) were measured. In addition, apoptosis of the cardiomyocytes, [Ca(2+)]i and level of CaSR expression were determined. The results showed that LPS increased cardiomyocytes apoptosis, [Ca(2+)]i, MDA, LDH, TNF-α, IL-6 release, and CaSR protein expression. Compared with LPS treatment alone, pretreatment with GdCl3 further increased apoptosis of cardiomyocytes, MDA, LDH, TNF-α, IL-6 release, [Ca(2+)]i, and the expression of the CaSR protein. Conversely, pretreatment with NPS2390 decreased apoptosis of cardiomyocytes, MDA, LDH, TNF-α, IL-6 release, [Ca(2+)]i and the expression of the CaSR protein. These results demonstrate that LPS could induce cardiomyocyte injury. Moreover, LPS-induced cardiomyocyte injury was related to CaSR-mediated cardiomyocytes apoptosis, TNF-α, IL-6 release, and increase of intracellular calcium.