Neonatal sepsis: an old problem with new insights

Fetal chronic hypoxia does not affect urinary presepsin levels in newborns at birth

OBJECTIVES

Early sepsis detection and diagnosis still constitutes an open issue since the accuracy of standard-of care parameters is biased by a series of perinatal factors including hypoxia. Therefore, we aimed at investigating the effect of fetal chronic hypoxia insult on urine levels of a promising new marker of sepsis, namely presepsin (P-SEP).

METHODS

We conducted a prospective case-control study in 22 cases of early-intrauterine growth restriction (E-IUGR) compared with 22 small-for-gestational-age (SGA) newborns and 66 healthy controls. P-SEP urine samples were collected over the first 72 h from birth. Blood culture and C-reactive protein (CRP) blood levels were measured in E-IUGR and SGA infants. Perinatal standard monitoring parameters and main outcomes were also recorded.

RESULTS

No significant urinary P-SEP differences (p>0.05, for all) were observed among studied groups. Moreover, no significant correlations (p>0.05, for both) between urinary P-SEP and blood CRP levels in both E-IUGR and SGA groups (R=0.08; R=0.07, respectively) were observed.

CONCLUSIONS

The present results showing the lack of influence of fetal chronic hypoxia on urinary P-SEP levels offer additional data to hypothesize the possible use of urinary P-SEP measurement in neonates in daily clinical practice. Further multicenter prospective data are needed, including infants with early-onset sepsis.

***ECD*** maternal C-reactive protein as a predictor of neonatal sepsis

Systemic bacterial infection in the newborn has a significant impact on neonatal mortality and morbidity. Non-invasive prenatal markers of risk could be useful in the prediction and prevention of neonatal sepsis. We evaluated the association of maternal third-trimester serum level of C-Reactive Protein (CRP) with neonatal sepsis in a sample of infants in the JAKids pregnancy and birth cohort study. A population-based nested case-control design was used to identify cases and controls of neonatal sepsis from the subset of infants in the JAKids study whose mothers had serum archived in the early third trimester and who were admitted to newborn intensive care. Cases were 25 neonates with neonatal sepsis identified from hospital records. Controls were a random sample of 62 sepsis-free neonates matched to cases within three gestational age strata - ≤32 weeks, 33-36 weeks, and ≥37 weeks.Mothers of neonatal sepsis cases ≥37 weeks had significantly higher mean levels of maternal CRP protein than mothers of controls (11.0 mg/dL ± 3.0 vs. 8.7 mg/dL ± 5.9; p < .05). Differences in maternal CRP were not found in sepsis cases born ≤32 weeks (9.5 mg/dL ± 4.2 vs 5.8 mg/dL ± 4.0, p = .23) nor in sepsis cases born at 33-36 weeks (9.0 mg/dL ± 3.6 vs 11.9 mg/dL ± 7.8, p = .34). Maternal third-trimester C-reactive protein levels were elevated in mothers of term-born neonates with sepsis, but not in the mothers of preterm neonates with sepsis.

Early procalcitonin assays may reduce antibiotic exposure in premature newborn infants

AIM

The diagnosis of early-onset neonatal sepsis (EOS) remains difficult. The main aim was to study the effect of a new algorithm for EOS, which includes the level of procalcitonin in umbilical cord blood, on the exposure to antibiotic therapy of premature newborn infants.

METHODS

This was a monocentric, observational and retrospective study with before-and-after design. The duration and dose of antibiotic therapy provided as well as the morbidity and mortality were compared in two groups, one included 01 May 2015-30 November 2015 when procalcitonin was not used, and one after the change 01 November 2016-30 May 2017 when procalcitonin was used in a hospital setting in Nice, France.

RESULTS

Sixty newborn infants were included in the before group and 54 in the after group. Antibiotic therapy was stopped after 24 h for 18 newborn infants in the after group and four in the before group, and after 48 h for 26 newborn infants in the after group and 10 in the before group.

CONCLUSION

The implementation of a new decision-making algorithm including early procalcitonin assay of premature newborn infants significantly reduced exposure to antibiotics without modifying mortality or morbidity.

High prevalence of multidrug-resistant Enterobacterales carrying extended-spectrum beta-lactamase and AmpC genes isolated from neonatal sepsis in Ahvaz, Iran

OBJECTIVES

In the recent years, multidrug resistant (MDR) neonatal septicemia-causing Enterobacterales has been dramatically increased due to the extended-spectrum beta-lactamases (ESBLs) and AmpC enzymes. This study aimed to assess the antibiotic resistance pattern, prevalence of ESBLs/AmpC beta-lactamase genes, and Enterobacterial Repetitive Intergenic Consensus Polymerase Chain Reaction (ERIC-PCR) fingerprints in Enterobacterales isolated from neonatal sepsis.

RESULTS

In total, 59 Enterobacterales isolates including 41 (69.5%) Enterobacter species, 15 (25.4%) Klebsiella pneumoniae and 3 (5.1%) Escherichia coli were isolated respectively. Resistance to ceftazidime and cefotaxime was seen in all of isolates. Furthermore, all of them were multidrug-resistant (resistant to three different antibiotic categories). The phenotypic tests showed that 100% of isolates were ESBL-positive. Moreover, AmpC production was observed in 84.7% (n = 50/59) of isolates. Among 59 ESBL-positive isolates, the highest percentage belonged to blaCTX-M-15 gene (66.1%) followed by blaCTX-M (45.8%), blaCTX-M-14 (30.5%), blaSHV (28.8%), and blaTEM (13.6%). The frequency of blaDHA, blaEBC, blaMOX and blaCIT genes were 24%, 24%, 4%, and 2% respectively. ERIC-PCR analysis revealed that Enterobacterales isolates were genetically diverse. The remarkable prevalence of MDR Enterobacterales isolates carrying ESBL and AmpC beta-lactamase genes emphasizes that efficient surveillance measures are essential to avoid the more expansion of drug resistance amongst isolates.

Application of Advanced Molecular Methods to Study Early-Onset Neonatal Sepsis

Early-onset sepsis (EOS) is a global health issue, considered one of the primary causes of neonatal mortality. Diagnosis of EOS is challenging because its clinical signs are nonspecific, and blood culture, which is the current gold-standard diagnostic tool, has low sensitivity. Commonly used biomarkers for sepsis diagnosis, including C-reactive protein, procalcitonin, and interleukin-6, lack specificity for infection. Due to the disadvantages of blood culture and other common biomarkers, ongoing efforts are directed towards identifying innovative molecular approaches to diagnose neonates at risk of sepsis. This review aims to gather knowledge and recent research on these emerging molecular methods. PCR-based techniques and unrestricted techniques based on 16S rRNA sequencing and 16S-23S rRNA gene interspace region sequencing offer several advantages. Despite their potential, these approaches are not able to replace blood cultures due to several limitations; however, they may prove valuable as complementary tests in neonatal sepsis diagnosis. Several microRNAs have been evaluated and have been proposed as diagnostic biomarkers in EOS. T2 magnetic resonance and bioinformatic analysis have proposed potential biomarkers of neonatal sepsis, though further studies are essential to validate these findings.

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.

Neonatal early-onset sepsis calculator: Impact on antibiotic use in a level II neonatal unit in Western Australia

BACKGROUND

Overuse of empirical intravenous antibiotics in neonates in high-income countries (HICs) is well documented. The Kaiser Permanente neonatal early-onset sepsis (EOS) calculator is an evidence-based sepsis risk assessment tool that has demonstrated potential to reduce antibiotic usage in this population. The incidence of early-onset sepsis in most HICs is 0.4-0.8 per 1000 live births. The objective was to evaluate the calculator's impact on antibiotic rates and length of stay in a regional level II Special Care Nursery.

METHODS

A single-centre retrospective cohort study compared antibiotic administration rates in the first 72 h in neonates ≥35 weeks gestation born during two 6-month periods in 2019 (pre-EOS calculator) and 2021 (post-EOS calculator). Electronic and paper case records were accessed to capture data. Continuous data were summarised using mean and standard deviation, and categorical data were summarized using frequency distributions. There were 951 (2019) and 1129 (2021) infants born during the study periods.

RESULTS

Following implementation of the calculator, antibiotic exposure decreased from 13.7% to 4.7% of all neonates without reported negative outcomes. Mean length of stay for neonates born across the two periods decreased from 2.38 to 2.13 days. Indications for antibiotic use shifted more towards clinical condition and away from obstetric risk factors. There were no culture-proven cases of sepsis or readmissions with EOS in either period.

CONCLUSION

Implementation of the EOS calculator significantly reduced exposure to antibiotics, without adverse outcomes.

Association Between Hypoglycemia and the Occurrence of Early Onset Sepsis in Premature Infants

BACKGROUND

We examined the association between hypoglycemia and the occurrence of early onset sepsis (EOS) in premature infants admitted to the neonatal intensive care unit (NICU).

METHODS

We included infants discharged from 358 NICUs between 1997 and 2020 with gestational age <34 weeks, ≥1 culture collected in the first 3 days of life, and ≥1 serum glucose value recorded on the day of or day prior to culture collection. We used multivariable logistic regression and inverse probability weighting (IPW) and constructed models for three definitions of hypoglycemia: American Academy of Pediatrics (AAP), Pediatric Endocrine Society, and a definition based on neurodevelopmental studies. We performed subgroup analysis in EOS episodes caused by Gram-negative and Gram-positive organisms.

RESULTS

Of the 62,178 infants and 64,559 cultures that met study inclusion criteria, 739 (1%) cultures were positive. The median (25th, 75th percentile) glucose value was 75 mg/dL (50, 106) on the day of or day prior to a positive culture versus 70 mg/dL (50, 95) on the day of or day prior to a negative culture. We found that hypoglycemia was not associated with the occurrence of EOS for all organisms and Gram-positive organisms, whereas there was a small but significant association between the lower AAP glucose cutoff value and EOS due to Gram-negative organisms (logistic regression: risk difference [RD] 0.24% [95% CI, 0.01-0.47]; IPW: RD 0.22% [95% CI, 0.00-0.43]).

CONCLUSIONS

Hypoglycemia may be an early marker of EOS, particularly in episodes caused by Gram-negative organisms and when using a stricter definition of hypoglycemia.

Advancement in biomarker based effective diagnosis of neonatal sepsis

Neonatal sepsis is considered as alarming medical emergency and becomes the common global reason of neonatal mortality. Non-specific symptoms and limitations of conventional diagnostic methods for neonatal sepsis mandate fast and reliable method to diagnose disease for point of care application. Recently, disease specific biomarkers have gained interest for rapid diagnosis that led to the development of electrochemical biosensor with enhanced specificity, sensitivity, cost-effectiveness and user-friendliness. Other than conventional biomarker C-reactive protein to diagnose neonatal sepsis, several potential biomarkers including Procalcitonin (PCT), Serum amyloid A (SAA) and other candidates are extensively investigated. The present review provides insights on advancements and diagnostic abilities of protein and nucleotide based biomarkers with their incorporation in developing electrochemical biosensors by employing novel fabrication strategies. This review provides an overview of most promising biomarker and its capability for neonatal sepsis diagnosis to fulfil future demand to develop electrochemical biosensor for point-of-care applications.

Diagnostic Accuracy of Multiplex Polymerase Chain Reaction in Early Onset Neonatal Sepsis

Early onset neonatal sepsis is a significant contributor to neonatal morbidity and mortality. Although blood cultures remain the diagnostic gold standard, they detect pathogens in only a minority of suspected cases. This study compared the accuracy of blood cultures with a rapid multiplex PCR test. Newborns at risk of neonatal sepsis were prospectively screened as recommended per national guidelines. Evaluations included laboratory parameters (CrP, IL6, differential blood count), blood culture, and a molecular multiplex PCR test (ROCHE LightCycler SeptiFast®) identifying 20 common microbial agents. Blood samples were taken simultaneously from umbilical cord or venous sources on the first day of life. Of 229 infants included, 69% were born preterm. Blood culture and multiplex PCR sensitivity were 7.4% and 14.8%, respectively. Specificity, negative and positive predictive values between methods showed no significant variance, although multiplex PCR had more false positives due to contamination. The limited sensitivity of blood cultures for early onset neonatal sepsis is concerning. Despite quicker results, multiplex PCR does not enhance diagnostic accuracy or antibiotic therapy guidance, thus it cannot be recommended for this indication.

Early Diagnostic Markers of Late-Onset Neonatal Sepsis

OBJECTIVE

Early diagnosis of nosocomial infections in newborns is a great challenge, because in the initial phase of systemic infection, clinical symptoms are often non-specific, and routinely used hematological markers are not sufficiently informative. The aim of this study was to determine the potential of early inflammatory markers to diagnose late-onset neonatal sepsis-procalcitonin (PCT), interleukin 6 (IL-6), interleukin 8 (IL-8) and endocan (ESM-1).

MATERIAL AND METHODS

A prospective clinical-epidemiological study was conducted in a third-level NICU in Pleven, Bulgaria. Patients with suspected late-onset sepsis and healthy controls were tested. A sandwich ELISA method was used to measure the serum concentrations of biomarkers.

RESULTS

Sixty newborns were included, of which 35% symptomatic and infected, 33.3% symptomatic but uninfected and 31.7% asymptomatic controls. The mean values of PCT, IL-6, I/T index and PLT differ significantly in the three groups. For ESM-1, IL-8 and CRP, the difference was statistically insignificant. The best sensitivity (78%) and negative predictive value (84%) was found for IL-6. The combinations of PCT + IL-6 and PCT + IL-6+ I/T+ PLT showed very good diagnostic potential.

CONCLUSION

The introduction into the routine practice of indicators such as PCT and IL-6 may provide an opportunity to promptly optimize the diagnostic and therapeutic approach to LOS.

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.

Potential of Molecular Culture in Early Onset Neonatal Sepsis Diagnosis: A Proof of Principle Study

Delay in the time-to-positivity of a peripheral blood culture (PBC), the gold standard for early onset neonatal sepsis (EOS) diagnosis, has resulted in excessive use of antibiotics. In this study, we evaluate the potential of the rapid Molecular Culture (MC) assay for quick EOS diagnosis. In the first part of this study, known positive and spiked blood samples were used to assess the performance of MC. In the in vivo clinical study, the second part of this study, all infants receiving antibiotics for suspicion of EOS were included. At initial EOS suspicion, a blood sample was collected for PBC and MC. MC was able to detect bacteria present in the spiked samples even when the bacterial load was low. In the clinical study, MC was positive in one infant with clinical EOS (Enterococcus faecalis) that was not detected by PBC. Additionally, MC was positive in two infants without clinical sepsis (Streptococcus mitis and multiple species), referred to as contamination. The other 37 samples were negative both by MC and PBC. MC seems to be able to detect bacteria even when the bacterial load is low. The majority of MC and PBC results were comparable and the risk for contamination and false positive MC results seems to be limited. Since MC can generate results within 4 h following sampling compared with 36-72 h in PBC, MC may have the potential to replace conventional PBC in EOS diagnostics in order to guide clinicians on when to discontinue antibiotic therapy several hours after birth.

Can Presepsin Be Valuable in Reducing Unnecessary Antibiotic Exposure after Birth?

Background: Due to a lack of rapid, accurate diagnostic tools for early-onset neonatal sepsis (EOS) at the initial suspicion, infants are often unnecessarily given antibiotics directly after birth. We aimed to determine the diagnostic accuracy of presepsin for EOS before antibiotic initiation and to investigate whether presepsin can be used to guide clinicians’ decisions on whether to start antibiotics. Methods: In this multicenter prospective observational cohort study, all infants who started on antibiotics for EOS suspicion were consecutively included. Presepsin concentrations were determined in blood samples collected at the initial EOS suspicion (t = 0). In addition to this, samples were collected at 3, 6, 12 and 24 h after the initial EOS suspicion and from the umbilical cord directly after birth. The diagnostic accuracy of presepsin was calculated. Results: A total of 333 infants were included, of whom 169 were born preterm. We included 65 term and 15 preterm EOS cases. At the initial EOS suspicion, the area under the curve (AUC) was 0.60 (95% confidence interval (CI) 0.50–0.70) in the term-born infants compared to 0.84 (95% CI 0.73–0.95) in the preterm infants. A cut-off value of 645 pg/mL resulted in a sensitivity of 100% and a specificity of 54% in the preterm infants. The presepsin concentrations in cord blood and at other time points did not differ significantly from the concentrations at the initial EOS suspicion. Conclusions: Presepsin is a biomarker with an acceptable diagnostic accuracy for EOS (culture-proven and clinical EOS) in preterm infants and might be of value in reducing antibiotic exposure after birth when appended to current EOS guidelines. However, the small number of EOS cases prevents us from drawing firm conclusions. Further research should be performed to evaluate whether appending a presepsin-guided step to current EOS guidelines leads to a safe decrease in antibiotic overtreatment and antibiotic-related morbidity.

Vaginal and neonatal microbiota in pregnant women with preterm premature rupture of membranes and consecutive early onset neonatal sepsis

BACKGROUND

Preterm premature rupture of membranes (PPROM), which is associated with vaginal dysbiosis, is responsible for up to one-third of all preterm births. Consecutive ascending colonization, infection, and inflammation may lead to relevant neonatal morbidity including early-onset neonatal sepsis (EONS). The present study aims to assess the vaginal microbial composition of PPROM patients and its development under standard antibiotic therapy and to evaluate the usefulness of the vaginal microbiota for the prediction of EONS. It moreover aims to decipher neonatal microbiota at birth as possible mirror of the in utero microbiota.

METHODS

As part of the PEONS prospective multicenter cohort study, 78 women with PPROM and their 89 neonates were recruited. Maternal vaginal and neonatal pharyngeal, rectal, umbilical cord blood, and meconium microbiota were analyzed by 16S rRNA gene sequencing. Significant differences between the sample groups were evaluated using permutational multivariate analysis of variance and differently distributed taxa by the Mann-Whitney test. Potential biomarkers for the prediction of EONS were analyzed using the MetaboAnalyst platform.

RESULTS

Vaginal microbiota at admission after PPROM were dominated by Lactobacillus spp. Standard antibiotic treatment triggers significant changes in microbial community (relative depletion of Lactobacillus spp. and relative enrichment of Ureaplasma parvum) accompanied by an increase in bacterial diversity, evenness and richness. The neonatal microbiota showed a heterogeneous microbial composition where meconium samples were characterized by specific taxa enriched in this niche. The vaginal microbiota at birth was shown to have the potential to predict EONS with Escherichia/Shigella and Facklamia as risk taxa and Anaerococcus obesiensis and Campylobacter ureolyticus as protective taxa. EONS cases could also be predicted at a reasonable rate from neonatal meconium communities with the protective taxa Bifidobacterium longum, Agathobacter rectale, and S. epidermidis as features.

CONCLUSIONS

Vaginal and neonatal microbiota analysis by 16S rRNA gene sequencing after PPROM may form the basis of individualized risk assessment for consecutive EONS. Further studies on extended cohorts are necessary to evaluate how far this technique may in future close a diagnostic gap to optimize and personalize the clinical management of PPROM patients.

TRIAL REGISTRATION

NCT03819192, ClinicalTrials.gov. Registered on January 28, 2019.

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.

Economic and Diagnostic Biomarker Tests of Neonatal Sepsis: A Prospective Study from a Tertiary Care Hospital in a Low-Income Country

Background. Neonatal sepsis is a leading cause of morbidity and mortality in low-and middle-income countries (LMICs). There are several sophisticated biomarkers; however, they are still insufficient in precision. In this perspective, our study aims to search for a pragmatic diagnostic biomarker in the age category. Methods. A cross-sectional study was conducted over six months(April-September 2018). All neonates with a diagnosis of probable sepsis were included. Logistic regression analysis of demographic variables was done to elucidate any association with confirmed sepsis cases. The median with interquartile range (IQR)] and mean with standard deviation (SD) were calculated, and then compared. The area under the receiver operating characteristic curve (AUROC) of the commonly opted biomarker tests [distribution width of red blood cells (RDW) and platelets(PDW), mean platelet volume(MPV), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR)] was compared to the culture-confirmed case. Results. Of the 171 suspected sepsis subjects, we discovered a significant burden of newborn sepsis, with 18.7% of cases being culture-confirmed. 66 Early-onset sepsis(EOS) and 105 Late-onset sepsis(LOS) probable sepsis cases were enrolled. A higher incidence was revealed among male infants 24(14%) compared to females 8(4.7%). On logistic regression analysis, preterm birth [odds ratio (OR): 10.9, 95% confidence interval (CI): 4.5-26.9] and low birth weight (OR: 6.5, 95% CI: 2.4-17.9) were significantly associated. Coagulase-negative Staphylococcus aureus (CoNS) (n =6) among gram-positive, and Pseudomonas aeruginosa (n =6) was among gram-negative, were the leading etiologies. Escherichia coli (n =3) was the predominant bacteria in EOS subjects, while Pseudomonas aeruginosa (n =6) among LOS. Median interquartile range(IQR): platelet count 144.5(99-192), red cell distribution width 18(16.9-20), CRP 6(3-18.3); and mean ± SD: MPV (11.7 ± 1.7); PDW (15.2 ± 3.5) were attained, among confirmed cases. The AUROC, of biomarker tests was attained in the order: PDW(0.86) > MPV(0.81) > RDW(0.76) > CRP(0.67) > ESR(0.59); similarly, the cut-off order was >11.2, >10.4, >16.8, >2.9, >4.5, respectively. Conclusions. Our finding shows an increment in the width and volume of RBCand platelet: RDW, MPV, and PDW have a diagnostic role in neonatal sepsis.

Amino acids for the prevention of mortality and morbidity in preterm infants: a systematic review and network meta-analysis

To determine the effectiveness and safety of amino acids in preventing the mortality and morbidity among preterm infants. We conducted a systematic review and network meta-analysis. We searched MEDLINE, EMBASE, Web of Science, CINAHL, Scopus, Cochrane, and Google Scholar, and grey literature, from databases inception to January 2021. We included randomized trials that evaluated any amino acids on preterm or low-birth weight infants. We performed frequentist pairwise and network meta-analyses and used the GRADE methodology to assess the certainty of the evidence and provide a summary of the results.We included 18 trials (3702 infants). Low certainty evidence showed that there seems to be no benefit for arginine, glutamine, or N-acetylcysteine in reducing all-cause mortality. Oral arginine likely results in reduction of necrotizin enterocolitis (NEC) stage ≥ II (OR 0.48; 95% CI 0.26-0.90; moderate certainty). Oral glutamine may reduce the likelihood of developing late-onset sepsis (LOS) compared to placebo (OR 0.62; 95% CI 0.47-0.82; low certainty); and likely reduces time to reach full enteral feeding (MD = - 2.63 days; 95% CI - 4.99 to - 0.27; moderate certainty). Amino acids may have no effect on mortality. Oral arginine may reduce severe NEC, and oral glutamine may reduce LOS and the time to reach full feeding.Systematic review registration: PROSPERO registration number: CRD4201603873.

Knowledge of nurses on neonatal sepsis: a tertiary teaching hospital-based study

Neonatal sepsis is a significant cause of morbidity and mortality in hospitalized newborns and premature infants. Therefore, knowledge of essential newborn Care (ENC) is important for a newborn's survival, growth and development. The aim of this study was to assess the knowledge of nurses regarding essential newborn care in our Special Care Neonatal Unit (SCNU). Methods: A descriptive cross-sectional study was conducted between 1st September 2021 and 30th November 2021 among the nurses working in SNCU of Government Medical College and Hospital (GMC), Doda, Jammu and Kashmir, India. Data were was collected using a pre-tested questionnaire by purposive sample. Collected data were checked, and coding was done and analyzed using SPSS 20 software. Results: 72.0 % of nurses were of the age group of 21–30 years. The majority (74 %) were females, 78 % had completed B Sc Nursing, and 66 % had experience of 2 to 4 years. Most of the nurses had good knowledge about ENC, about basic equipment’s used in SNCU, and about advanced equipment’s or procedures had less knowledge. All nurses answered bacteria correctly as a causative organism of neonatal sepsis. Conclusions: Most of the nurses working in the SCNU of GMC Doda had good knowledge regarding ENC. The knowledge appeared irrespective of their age, gender, religion, educational status, working place and special courses/training in neonatology.

Clinical Utility of A Model-based Amoxicillin Dosage Regimen in Neonates with Early-Onset Sepsis

Early-onset sepsis (EOS) is one of the most significant causes of morbidity and mortality in neonates. Currently, amoxicillin is empirically used to treat neonates with EOS. However, data on its effectiveness in neonates with EOS are still limited. Therefore, we aimed to evaluate the pharmacodynamics (PD) target attainment and effectiveness of a model-based amoxicillin dosage regimen in these neonates. We used a previously developed model and collected additional clinical data from the EOS neonates who used the model-based dosage regimen (25 mg/kg q12h). The primary outcomes were PD target attainment (free drug concentration above MIC during 70% of the dosing interval) and treatment failure rate. The secondary endpoints were length of amoxicillin treatment, duration of hospitalization, etc. Seventy-five neonates (postmenstrual age 28.4-41.6 weeks) were enrolled. A total of 70 (93.3%) neonates reached their PD target using 1 mg/L as the MIC breakpoint. The treatment failure rate was 10.7%.

Umbilical cord blood culture in neonatal early-onset sepsis: a systematic review and meta-analysis

BACKGROUND

Peripheral blood culture (PBC) is considered the gold standard for diagnosis of neonatal early-onset sepsis (EOS), but its diagnostic value can be questioned. We aimed to systematically asses the diagnostic test accuracy (DTA) of umbilical cord blood culture (UCBC) for EOS.

METHODS

A systematic literature search was performed in PubMed, Embase, Web of Science, and the Cochrane Library. Studies performing UCBC for the diagnosis of EOS were included.

RESULTS

A total of 1908 articles were screened of which 17 were included. Incidences of positive PBC and UCBC were low in all studies. There was a large heterogeneity in the consistency between positive PBC and UCBC outcomes. PBC had a pooled sensitivity of 20.4% (95% CI 0.0-40.9) and specificity of 100.0% (95% CI 100.0-100.0) compared to 42.6% (95% CI 12.7-72.4%) and 97.8% (95% CI 93.1-100.0) of UCBC for clinical EOS, defined as clinical sepsis regardless of PBC outcomes.

CONCLUSIONS

This systematic review shows that, compared to PBC, UCBC has higher sensitivity and comparable specificity for clinical EOS and might be considered as diagnostic test for EOS. Due to the limited number of studies, low incidences of EOS cases, and the imperfect reference standards for EOS, results should be interpreted cautiously.

IMPACT

This is the first systematic review and meta-analysis investigating the diagnostic test accuracy of umbilical cord blood culture for neonatal early-onset sepsis. Peripheral blood culture is considered the gold standard for diagnosis of neonatal early-onset sepsis, but its value for this specific diagnosis can be questioned. Umbilical cord blood culture has higher sensitivity and comparable specificity for diagnosis of neonatal early-onset sepsis compared to peripheral blood culture, circumventing the risk for iatrogenic anemia and consequently might be used as a diagnostic tool for early-onset sepsis. Quality of evidence was regarded as low due to imperfect diagnostic methods of neonatal early-onset sepsis.

Time to recovery of neonatal sepsis and determinant factors among neonates admitted in Public Hospitals of Central Gondar Zone, Northwest Ethiopia, 2021

Background

Neonatal sepsis is a leading cause of neonatal morbidity and mortality, particularly in developing countries. Time to recovery is an indicator of the severity of sepsis, and risk factors varied significantly according to study population and settings. Moreover, published literature regarding the time to recovery of neonatal sepsis is scarce.

Objective

The aim of this study was to assess the time to recovery of neonatal sepsis and determinant factors among neonates admitted in the Public Hospitals of Central Gondar Zone, Northwest Ethiopia.

Methods

An institution-based prospective follow-up study design was conducted among 631 neonates with sepsis. A structured, pre-tested, interviewer-administered questionnaire was used. The median time to recovery, life-table, the Kaplan Meier curve, and the log-rank test were computed. Both bi-variable and multivariable Cox regression models were applied to analyze the data.

Results

Of all septic neonates, 511 successfully recovered. They were followed for a total of 4,740-neonate day’s observation and the median time to recovery was 7 days (IQR = 5–10 days). After adjusting for covariates, intrapartum fever (AHR = 0.69, 95%CI: 0.49, 0.99), induced onset of labor (AHR = 0.68, 95%CI: 0.49, 0.94), chest indrawing (AHR = 0.67, 95%CI: 0.46, 0.99), late onset sepsis (AHR = 0.55, 95%CI: 0.40, 0.75), non-oral enteral feeding (AHR = 0.38, 95%CI: 0.29, 0.50), assisted with bag and mask (AHR = 0.72, 95%CI: 0.56, 0.93), normal birth weight (AHR = 1.42, 95%CI: 1.03, 1.94), gestational age of 37–42 weeks (AHR = 1.93, 95%CI: 1.32, 2.84), septic shock (AHR = 0.08, 95%CI: 0.02, 0.39), infectious complications (AHR = 0.42, 95%CI: 0.29, 0.61), being in critical conditions (AHR = 0.68, 95%CI: 0.52, 0.89), and early recognition of illness (AHR = 1.83, 95%CI: 1.27, 2.63) were independently associated with the time to recovery of neonatal sepsis.

Conclusions and recommendations

The time to recovery of this study was moderately acceptable as compared to the previous studies. The above-mentioned factors could be used for the early identification of neonates with sepsis at risk for protracted illness and it could guide prompt referral to higher centers in primary health sectors. This also will provide prognostic information to clinicians and families as longer recovery time has economic and social implications in our country.

Predictive Scores for Late-Onset Neonatal Sepsis as an Early Diagnostic and Antimicrobial Stewardship Tool: What Have We Done So Far?

Background: Late-onset neonatal sepsis (LOS) represents a significant cause of morbidity and mortality worldwide, and early diagnosis remains a challenge. Various ‘sepsis scores’ have been developed to improve early identification. The aim of the current review is to summarize the current knowledge on the utility of predictive scores in LOS as a tool for early sepsis recognition, as well as an antimicrobial stewardship tool. Methods: The following research question was developed: Can we diagnose LOS with accuracy in neonates using a predictive score? A systematic search was performed in the PubMed database from 1982 (first predictive score published) to December 2021. Results: Some (1352) articles were identified—out of which, 16 were included in the review. Eight were original scores, five were validations of already existing scores and two were mixed. Predictive models were developed by combining a variety of clinical, laboratory and other variables. The majority were found to assist in early diagnosis, but almost all had a limited diagnostic accuracy. Conclusions: There is an increasing need worldwide for a simple and accurate score to promptly predict LOS. Combinations of the selected parameters may be helpful, but until now, a single score has not been proven to be comprehensive.

Admission Outcome and Antimicrobial Resistance Pattern of Bacterial Isolates among Neonates with Suspected Sepsis in Neonatal Intensive Care Unit at Dessie Comprehensive Specialized Hospital, Dessie, Northeastern Ethiopia

Background

Neonatal sepsis is a major cause of morbidity and mortality globally. The aim of this study was to assess admission outcome and antimicrobial susceptibility pattern of bacterial isolates among neonates with suspected sepsis at the Dessie Comprehensive specialized Hospital (DCSH), Northeastern Ethiopia.

Method

Cross-sectional study was conducted from August 2017 to March 2018. Two hundred forty-six neonates were recruited, and each patient's blood specimen was collected aseptically using bottle containing Brain Heart Infusion for blood culture. Both clinical and laboratory data such as bacterial culture growth and antimicrobial susceptibility pattern were collected from the neonate; clinical data from the mothers were also included. Antimicrobial susceptibility testing was performed using Kirby-Bauer disk diffusion method. The data were analyzed using SPSS version 20.

Results

Bacteria were identified from 67 (27.2%) blood cultures. The predominant pathogen was Escherichia coli (35.8%) followed by Staphylococcus aureus (26.8%), and Coagulase Negative Staphylococcus (CoNS) (19.4%). The isolated bacteria showed resistance to Ampicillin 55 (82%), third-generation Cephalosporins 21 (58.3%) and other tested antimicrobials. Overall, 68.6% bacterial isolates demonstrated Multidrug resistance (MDR) and total registered mortality rate was 12/246 (4.8%). Both neonatal factors such as neonatal temperature, septic umbilicus and utilization of indwelling medical device during delivery; and maternal factors such as age, antenatal urinary tract infection (UTI), mode of delivery and prolonged rupture of membrane (PROM) had shown statistically significant association with bacterial sepsis.

Conclusion

The rate of bacterial growth was found to be high; E. coli and S. aureus were the predominant organisms. Both maternal and neonatal related data were strong predictors for bacterial infection of the neonate. Therefore, improving infrastructures for screening of bacteremia as well as active surveillance in clinical setting needed to ensure proper empirical therapy.

External Validation of a Vancomycin Population Pharmacokinetic Model and Developing a New Dosage Regimen in Neonates

BACKGROUND AND OBJECTIVE

Vancomycin is the drug of choice in the treatment of MRSA infections. In a published vancomycin population pharmacokinetic study on neonates in Singapore healthcare institutions, it was found that vancomycin clearance was predicted by weight, postmenstrual age, and serum creatinine. The aim of this study was to externally validate the vancomycin population pharmacokinetic model to develop a new dosage regimen in neonates, and to compare this regimen with the existing institutional and NeoFax^® dosage regimens.

METHODS

A retrospective chart review of neonates who received vancomycin therapy and therapeutic drug monitoring was conducted. The median prediction error percentage was calculated to assess bias, while the median absolute prediction error percentage and the root mean squared error percentage were calculated to assess precision. The new dosage regimen was developed using Monte Carlo simulation.

RESULTS

A total of 20 neonates were included in the external validation dataset. Eighteen of them were premature, with a median gestational age of 27.7 (25.9-31.5) weeks and postmenstrual age of 30.5 (27.3-34.3) weeks at the point of vancomycin initiation. No apparent systematic bias was found in the predictions of the model. The external validation performed in the current study found the model to be generally unbiased. Our new vancomycin dosage regimen was able to achieve target trough concentrations and area under the curve (AUC₂₄) at a greater proportion as compared to existing institutional and NeoFax^® dosage regimens.

CONCLUSION

The pharmacokinetic model built in the previous study can be used to conduct reliable population simulations of our Asian neonatal population in Singapore. The new dosage regimen was able to achieve target trough concentrations and AUC₂₄ better than existing institutional and NeoFax^® dosage regimens.

Perinatal presepsin assessment: a new sepsis diagnostic tool?

Perinatal sepsis constitutes a medical emergency and is still one of the major causes of mortality and morbidity. The possibility of an early diagnosis of sepsis is still debated and controversial. In particular, clinical symptoms can be hidden by the association of sepsis with other perinatal diseases and/or by therapeutic strategies performed. In this context, there is evidence that the accuracy of standard of care diagnostic parameters (i.e. blood culture, C-reactive protein, procalcitonin) can be biased by additional confounding factors (gestational age, birth-weight, acute-chronic hypoxia). Therefore, the inclusion in clinical daily practice of new biomarkers of sepsis is of utmost importance. Of a panel of biomarkers, Presepsin (P-SEP) plays an important role in the development and response of the immune system and as an early marker of sepsis both in adult and pediatric patients. Therefore, in the present review we aim to offer an overview of the role of P-SEP in the early detection of perinatal sepsis as a trustworthy marker according to actual statements of official international institutions. Future perspectives regard the possibility of a longitudinal non-invasive biological fluids P-SEP assessment thus limiting the sample stress in high risk newborns.

Risk factors and predictive markers for early and late-onset neonatal bacteremic sepsis in preterm and term infants

BACKGROUND

The early detection and prediction of bacteremic sepsis in preterm and term neonates remains a challenging task because of their nonspecific clinical presentations. We aimed to investigate the risk factors associated with bacteremia and find the cutoff values of predictive markers to achieve accurate diagnosis of neonatal bacteremic sepsis.

METHODS

Not-doing-well preterm and term neonates with suspected sepsis were retrospectively enrolled between January 2015 and December 2017 in Taipei Veterans General Hospital. Blood culture, hemogram, serum procalcitonin (PCT), and C-reactive protein (CRP) were drawn at the onset of clinical signs and symptoms. All cases were divided to either early-onset or late-onset groups according to postpartum age. Nonparametric statistic, logistic regression, and receiver operating characteristic analysis were performed to evaluate the risk factors and cutoff values for predicting bacteremia.

RESULTS

A total of 169 suspected sepsis episodes were analyzed, 68.0% of which had cardiopulmonary dysfunction and 19.5% had perinatal stress. The early-onset group had 123 (72.8%) patients, 4 of which had bacteremia and 119 had nonbacteremia conditions. The late-onset group had 46 (27.2%) patients, 8 of which had bacteremia and 38 had nonbacteremia conditions. Gestational age, birth body weight, Apgar score at 5 minutes, serum PCT, CRP, and platelet (PLT) count in the early-onset group and white blood cell (WBC) count in the late-onset group were substantially different between the patients with bacteremia and nonbacteremia conditions. PCT greater than 27 µg/L (adjusted odd ratio [aOR], 21.6; 95% CI, 1.1-435.1) and thrombocytopenia less than 100 × 109/L (aOR, 38.6; 95% CI, 1.4-1030.3) were predictive markers for bacteremia in the early-onset group.

CONCLUSION

Early- and late-onset neonatal sepsis had different risk factors and predictive markers of bacteremia. PCT and PLT count in the early-onset group and WBC count in the late-onset group were accurate diagnostic serum markers for neonatal bacteremic sepsis.

Biomarkers of Neonatal Sepsis: From Being Mere Numbers to Becoming Guiding Diagnostics

Neonatal sepsis is a common cause of neonatal morbidity and mortality. The diagnosis of newborn sepsis is still difficult. Different early objective diagnostic tests or specific signs and symptoms, particularly in preterm infants, make it difficult to diagnose neonatal sepsis. This review article describes biomarkers and their role in the early diagnosis, treatment, and prognosis of neonatal sepsis. It also explores the possible advances and future prospects of these biomarkers. An ideal sepsis biomarker will not only help in the guidance of the use of antibiotics when not needed but also the duration of the course of antibiotics if sepsis is proven. It should also have high sensitivity, specificity, positive predictive value, and negative predictive value. These biomarkers hold a promising position in the management of neonatal sepsis and translate into use in clinical settings. Metabolomics, a diagnostic method based on detecting metabolites found in biological fluids, may open new possibilities in the management of critically ill newborns.

Exploring functional metabolites in preterm infants

AIM

Metabolomics is the study of small molecules that represent the functional end points of cellular reactions that can impact health. Necrotising enterocolitis (NEC) and late onset sepsis (LOS) are the main cause of death in preterm infants surviving the initial days of life.

METHODS

This review will explore and summarise the current literature exploring metabolomics in preterm infants.

RESULTS

There are a relatively limited number of studies investigating metabolomics in preterm infants with NEC and/or LOS and matched controls. Nonetheless, it is evident across longitudinally age-related metabolomic studies that there are significant changes in metabolite profiles post-partum and over the first year of life. Existing studies have reported associations between the metabolite profiles of serum, urine and stool in health and disease in preterm infants. Although some studies have found selected metabolites are associated with disease, the specific metabolites vary from study to study, and larger studies are required. Excitingly, recent work has also begun to untangle how microbially produced metabolites can impact immunoregulation of the infant.

CONCLUSION

Metabolic exploration is an emerging research area with huge potential for developing novel biomarkers and better understanding disease processes in preterm infants.

Investigation of salivary C-reactive protein and interleukin-18 for the diagnosis of neonatal sepsis

BACKGROUND

Neonatal sepsis is a leading cause of death in neonates worldwide. The investigation of biomarkers for the early diagnosis of neonatal sepsis is in progress with controversial outcomes. The current report aims to evaluate the values of salivary C-reactive protein (CRP) and interleukin-18 (IL-18) for the diagnosis of neonatal sepsis.

MATERIALS AND METHODS

In this cross-sectional study, 89 neonates, including 49 neonatal septic case and 40 healthy group admitted at the neonatal intensive care unit, were evaluated. The salivary samples of IL-18 and CRP were measured before the antibiotic therapy initiation, as soon as blood samplings. Sepsis diagnosis was confirmed by the positive blood culture. The diagnostic values of the biomarkers were determined using the receiver operating characteristic curve (ROC curve) analysis. Besides, the sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) positive likelihood ratio (LR+), negative likelihood ratio (LR-), and diagnostic accuracy were measured.

RESULTS

Salivary CRP level was remarkably higher in septic case than healthy group (5.2 ± 4.61 vs. 3.5 ± 1.7; P = 0.02), while salivary IL-18 was not different between the groups (0.1 ± 0.29 vs. 0.04 ± 0.19; P = 0.25). The ROC curve for IL-18 showed insignificant values (P = 0.37). The ROC curve of salivary CRP showed area under the curve of 0.63 (95% confidence interval: 0.51-0.74; P = 0.03) with the sensitivity, specificity, PPV, NPV, LR+, LR - and diagnostic accuracy of 44.9% (31.8-58.7), 80% (65.2-89.5), 73.3% (55.5-85.82), 54.2% (41.6-66.3), 60.6% (50.29-70.18), 2.24 (1.57-3.2), and 0.68 (0.63-0.75) at the cutoff of 4.55 ng/L, respectively.

CONCLUSION

Based on the findings of the current study, salivary CRP can be considered a biomarker for the early diagnosis of neonatal sepsis, while no statistical values for salivary IL-18 were detected. Due to the significance of neonatal sepsis, further evaluations are strongly recommended.

Experience in the diagnosis of group B Streptococcus infections in pregnant women and newborns in a perinatal center

Serogroup B streptococci (Streptococcus agalactiae) are one of the main etiological agents responsible for the occurrence of severe perinatal infections in both postpartum women and newborns. The experience of microbiological diagnostics of infections caused by streptococcus serogroup B (GBS) according to the data of the microbiological laboratory of the perinatal center is generalized. In the study of biomaterial from patients, the proportion of positive cultures of Streptococcus agalactiae was 2.2% in cervical samples, 8.8% in vaginal contents, 6.6%; 2.8% and 0.7% in amniotic fluid, placenta and urine, respectively. In 57% of cases, GBS was released at a concentration of more than 5 lg / ml and in 73% of cases as part of polymicrobial associations with other opportunistic microorganisms. In the biomaterial from newborns, GBS was found in 2.5% of positive findings in blood samples, 4.6% in tracheobronchial lavages and 2.7% in detachable skin of the armpit when taking material immediately after childbirth and 1, 1% and 0.7%, respectively, during examination in the second stage of nursing. 5 cases of GBS isolation in newborns ended in early neonatal mortality with definitive diagnoses of congenital pneumonia and IUI of newborns, while there was only partial coincidence of the results of microbiological studies of the genital tract of the mother and biomaterials from the newborn. Relatively frequent findings of GBS in newborns of the high-risk group in intensive care unit indicate intrauterine infection with this pathogen. The examination of smears from the cervical canal is not informative in relation toGBS infection in comparison with the examination of the vaginal contents and recto-vaginal smears. The results of the introduction of microbiological screening and its effectiveness in real practice to prevent the development of early and late forms of GBS infections in newborns require further analysis.

A Prospective Study on Neonatal Sepsis in a Tertiary Hospital, Nepal

About 20 % of neonates develop sepsis and among them approximately 1% die due to sepsis-related causes. Bacterial pathogens are the commonest cause of neonatal sepsis which is either early-onset (<72 hours of age) or late-onset (>72 hours). Little is known about the epidemiology and antimicrobial susceptibility pattern of sepsis causing bacterial pathogens in Nepal. A prospective study was carried out among neonates suspected to have sepsis and admitted to Tribhuwan University Teaching Hospital from January to December 2016. Clinical suspicion of sepsis was made based on clinical findings and laboratory parameters, later confirmed by isolation of organisms in blood culture. Drug resistance pattern of Gram-positive and Gram-negative bacteria were studied by standard methods. Meropenem resistant Gram-negative bacteria were processed for the detection of β-lactamases and resistant genes were detected by X-pert Carba-R (Cepheid) Assays. Of 372 neonates with clinically suspected sepsis, 132 (35.4%) had blood culture positivity, with 47% early-onset and 53% late-onset sepsis. Coagulase-negative Staphylococcus aureus (CONS) was the most common (37.9%) etiological agent followed by Klebsiella pneumoniae (12.9%). Of all 132 isolates, 81 (61.3%) were Gram-positive of which 22 (27.2%) were multi-drug resistant (MDR), three (3.7%) were methicillin-resistant S. aureus (MRSA), and 14 (17.2%) were methicillin-resistant CoNS; and 50 (37.8%) were Gram-negative of which 26 (52%) were MDR and 29 (58%) were resistant to β-lactamases. The blaKPC gene was detected in four isolates of K. pneumoniae, two of E. coli, one ABC (Acinetobacter baumanii complex), and one Enterobacter aerogenes whereas blaNDM gene was detected in one isolate of K. pneumoniae, two of E. coli, two Pseudomonas aeruginosa, one Acinetobacter baumanii complex, and one Enterobacter aerogenes. Overall mortality due to sepsis-related causes was 7.6% (10 of 132). One-third of clinically suspected neonatal sepsis cases were culture positive. Late-onset sepsis was more common than early onset. CoNS was the predominant bacterial isolate followed by Klebsiella pneumoniae, with high rates of multi-drug resistance.

Clinical and immunological aspects of microRNAs in neonatal sepsis

Neonatal sepsis constitutes a highly relevant public health challenge and is the most common cause of infant morbidity and mortality worldwide. Recent studies have demonstrated that during infection epigenetic changes may occur leading to reprogramming of gene expression. Post-transcriptional regulation by short non-coding RNAs (e.g., microRNAs) have recently acquired special relevance because of their role in the regulation of the pathophysiology of sepsis and their potential clinical use as biomarkers. ~22-nucleotide of microRNAs are not only involved in regulating multiple relevant cellular and molecular functions, such as immune cell function and inflammatory response, but have also been proposed as good candidates as biomarkers in sepsis. Nevertheless, establishing clinical practice guidelines based on microRNA patterns as biomarkers for diagnosis and prognosis in neonatal sepsis has yet to be achieved. Given their differential expression across tissues in neonates, the release of specific microRNAs to blood and their expression pattern can differ compared to sepsis in adult patients. Further in-depth research is necessary to fully understand the biological relevance of microRNAs and assess their potential use in clinical settings. This review provides a general overview of microRNAs, their structure, function and biogenesis before exploring their potential clinical interest as diagnostic and prognostic biomarkers of neonatal sepsis. An important part of the review is focused on immune and inflammatory aspects of selected microRNAs that may become biomarkers for clinical use and therapeutic intervention.

The Emerging Role of Presepsin (P-SEP) in the Diagnosis of Sepsis in the Critically Ill Infant: A Literature Review

Sepsis causes high rates of morbidity and mortality in NICUs. The estimated incidence varies between 5 and 170 per 1000 births, depending on the social context. In very low birth-weight neonates, the level of mortality increases with the duration of hospitalization, reaching 36% among infants aged 8-14 days and 52% among infants aged 15-28 days. Early diagnosis is the only tool to improve the poor prognosis of neonatal sepsis. Blood culture, the gold standard for diagnosis, is time-consuming and poorly sensitive. C-reactive protein and procalcitonin, currently used as sepsis biomarkers, are influenced by several maternal and fetal pro-inflammatory conditions in the perinatal age. Presepsin is the N-terminal fragment of soluble CD14 subtype (sCD14-ST): it is released in the bloodstream by monocytes and macrophages, in response to bacterial invasion. Presepsin seems to be a new, promising biomarker for the early diagnosis of sepsis in neonates as it is not modified by perinatal confounding inflammatory factors. The aim of the present review is to collect current knowledge about the role of presepsin in critically ill neonates.

Evaluation of the Molecular Mechanisms of Sepsis Using Proteomics

Sepsis is a complex syndrome promoted by pathogenic and host factors; it is characterized by dysregulated host responses and multiple organ dysfunction, which can lead to death. However, its underlying molecular mechanisms remain unknown. Proteomics, as a biotechnology research area in the post-genomic era, paves the way for large-scale protein characterization. With the rapid development of proteomics technology, various approaches can be used to monitor proteome changes and identify differentially expressed proteins in sepsis, which may help to understand the pathophysiological process of sepsis. Although previous reports have summarized proteomics-related data on the diagnosis of sepsis and sepsis-related biomarkers, the present review aims to comprehensively summarize the available literature concerning “sepsis”, “proteomics”, “cecal ligation and puncture”, “lipopolysaccharide”, and “post-translational modifications” in relation to proteomics research to provide novel insights into the molecular mechanisms of sepsis.

Comparing the Diagnostic Accuracy of Procalcitonin and C-Reactive Protein in Neonatal Sepsis: A Systematic Review

Neonatal sepsis remains a significant diagnostic challenge in newborn care. It has the potential to be disastrous, but precise diagnosis is difficult. No biomarker has yet demonstrated sufficient diagnostic accuracy to rule out sepsis when clinical suspicion exists. As a result, neonates with suspected sepsis are treated with empiric antibiotics. These unnecessary antibiotics promote bacterial antibiotic resistance, raise economic costs, and alter the composition of the gut microbiota. This study aimed to determine the diagnostic accuracy of procalcitonin in the prompt diagnosis of neonatal sepsis. Articles were systematically screened in PubMed/MEDLINE, PubMed Central (PMC), and ScienceDirect, using keywords and Medical Subject Heading (MeSH) terms to identify the relevant articles. Additionally, one article from the Indian Journal of Applied Research was also used. Inclusion/exclusion criteria were applied post article screening via title and abstracts. Quality appraisal check was done using the Scale for the Assessment of Narrative Review Articles (SANRA) checklist, A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist, and Newcastle-Ottawa checklist. Six related articles were strictly reviewed. Procalcitonin is a useful biomarker in the early diagnosis of neonatal sepsis. Because procalcitonin has a better correlation with proven sepsis and is an early biomarker in diagnosing neonatal sepsis, it should be included in the overall sepsis evaluation. Future clinical trials on optimal cut-off levels of procalcitonin with shifting neonatal ages and its use in the post-op setting are needed.

Gut Dysbiosis, Bacterial Colonization and Translocation, and Neonatal Sepsis in Very-Low-Birth-Weight Preterm Infants

Gut dysbiosis may precede neonatal sepsis, but the association is still not well-understood. The goal of this study is to investigate the association between gut microbiota and neonatal sepsis, and to seek the evidence of colonization of pathogenic bacteria in the gut before evolving into an invasive infection. A prospective cohort study examined fecal microbiota composition in preterm infants with and without sepsis. Thirty-two very-low-birth-weight (VLBW) preterm infants and 10 healthy term infants as controls were enrolled. The fecal samples collected from the participants at the first, fourth, and seventh weeks of life underwent 16S rRNA amplicon sequencing for measurement of the diversity and composition of the microbiota. The bacterial isolates causing neonatal sepsis were genome sequenced. PCR was performed to confirm the translocation of the bacteria from the gut to the blood. The results showed that VLBW preterm infants with sepsis had lower microbial diversity in the gut at birth compared to preterm infants without sepsis and term infants. The composition of gut microbiome in preterm infants was similar to healthy terms at birth but evolved toward dysbiosis with increasing Proteobacteria and decreasing Firmicutes weeks later. The strain-specific PCR confirmed the presence of causative pathogens in the gut in 4 (40%) out of 10 VLBW preterms with sepsis before or at onset of sepsis, and persistence of the colonization for weeks after antibiotic treatment. The same bacterial strain could horizontally spread to cause infection in other infants. Prolonged antibiotic exposure significantly reduced beneficial Bifidobacterium and Lactobacillus in the gut. In conclusion, preterm infants with gut dysbiosis are at risk for neonatal sepsis, and the causative pathogens may be from the gut and persist to spread horizontally. The association of increased Proteobacteria abundance and decrease in microbiome diversity suggests the need for interventions targeting the gut microbiome to prevent dysbiosis and sepsis in VLBW preterm infants.

Methicillin and multidrug resistant pathogenic Staphylococcus aureus associated sepsis in hospitalized neonatal infections and antibiotic susceptibility

BACKGROUND

Neonatal infection is infection of the newborn or neonate acquired in first four weeks of life or during prenatal development. Microorganism associated neonatal infections caused severe mortality in recent years. It is developed either prenatally or within 28 days of neonatal period. This infection is mainly transmitted from mother to child through placenta. It has been well associated with the premature rupture of membranes which markedly enhances the risk of neonatal sepsis.

METHODS

The present experiment was designed to analyze bacteria, their antibiotic resistance pattern and possible risk factors among neonatal patients with sepsis. The neonates specimen was subjected for the isolation of bacteria and antibiotic susceptibility test. Neonates were analyzed with previous clinical history such as, previous admission in hospitals, mode of delivery, birth weight, and feeding type in accordance with questionnaire.

RESULTS

Gram-positive bacteria isolates were found to be high (79 strains, 64.22%) than the Gram-negative bacteria (44 strains, 32.5%). Staphylococcus aureus (33 strains, 26.9%) was the major Gram-positive groups of bacteria. Multidrug resistance analysis accounted more S. aureus (26.9%) and 5 strains (15.15%) showed methicillin resistance, whereas 84.9% were found to be sensitive to methicillin.

CONCLUSION

In this study, S. aureus and K. pneumoniae were the highest frequency of isolates. The overall percentage of multidrug resistant isolates was high in this study. Highest degree of resistance was observed in ampicillin against all isolates. Hence much attention is required while diagnosing sepsis among neonates. To analyze the risk for neonatal sepsis, it is not preferable for caesarian mode of delivery. Moreover, frequent screening of mother, suitable prenatal care of newborns with proper clinical interventions isthe key elements to control sepsis.

Tocolysis in the management of preterm prelabor rupture of membranes at 22-33 weeks of gestation: study protocol for a multicenter, double-blind, randomized controlled trial comparing nifedipine with placebo (TOCOPROM)

Background

Preterm prelabor rupture of membranes (PPROM) before 34 weeks of gestation complicates 1% of pregnancies and accounts for one-third of preterm births. International guidelines recommend expectant management, along with antenatal steroids before 34 weeks and antibiotics. Up-to-date evidence about the risks and benefits of administering tocolysis after PPROM, however, is lacking. In theory, reducing uterine contractility could delay delivery and reduce the risks of prematurity and its adverse short- and long-term consequences, but it might also prolong fetal exposure to inflammation, infection, and acute obstetric complications, potentially associated with neonatal death or long-term sequelae. The primary objective of this study is to assess whether short-term (48 h) tocolysis reduces perinatal mortality/morbidity in PPROM at 22 to 33 completed weeks of gestation.

Methods

A randomized, double-blind, placebo-controlled, superiority trial will be performed in 29 French maternity units. Women with PPROM between 22^0/7 and 33^6/7 weeks of gestation, a singleton pregnancy, and no condition contraindicating expectant management will be randomized to receive a 48-hour oral treatment by either nifedipine or placebo (1:1 ratio). The primary outcome will be the occurrence of perinatal mortality/morbidity, a composite outcome including fetal death, neonatal death, or severe neonatal morbidity before discharge. If we assume an alpha-risk of 0.05 and beta-risk of 0.20 (i.e., a statistical power of 80%), 702 women (351 per arm) are required to show a reduction of the primary endpoint from 35% (placebo group) to 25% (nifedipine group). We plan to increase the required number of subjects by 20%, to replace any patients who leave the study early. The total number of subjects required is thus 850. Data will be analyzed by the intention-to-treat principle.

Discussion

This trial will inform practices and policies worldwide. Optimized prenatal management to improve the prognosis of infants born preterm could benefit about 50,000 women in the European Union and 40,000 in the United States each year.

Trial registration

ClinicalTrials.gov identifier: NCT03976063 (registration date June 5, 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04047-2.

The potential value of plasma receptor interacting protein 3 in neonates with culture-positive late-onset sepsis

Background

Late-onset sepsis (LOS) is a systemic inflammatory response syndrome in neonates, and the molecular mechanism of LOS is incompletely characterized. The purpose of this study was to explore the potential value of receptor interacting protein 3 (RIP3) in LOS.

Methods

63 neonates with LOS supported by positive culture and 79 neonates without sepsis were enrolled in this study from September 2019 to March 2021. Plasma RIP3 was detected by enzyme-linked immunosorbent assay (ELISA) and assessed along with the whole blood hypersensitive C-reactive protein (hs-CRP) level and platelet count (PLT). Differences in RIP3, hs-CRP and PLT between the two groups were compared. Changes in the three indicators in sepsis were also observed after treatment. The diagnostic value of indicators for LOS was evaluated by receiver operating characteristic (ROC) curve analysis.

Results

In the sepsis group, RIP3 and hs-CRP levels were significantly higher than those in the control group (RIP3, p < 0.0001; hs-CRP, p < 0.0001), and PLT was significantly lower than that in the control group (p < 0.0001). After treatment, RIP3 and hs-CRP levels among septic survivors were significantly decreased (p < 0.0001) and PLT significantly improved (p = 0.0216). With RIP3 > 15,845.19 pg/mL, hs-CRP > 5.00 mg/L, and PLT < 204.00 × 10⁹/L as the positive criteria, the sensitivity values of the three indicators in the diagnosis of LOS were 69.8%, 60.3%, 60.3%, respectively, and the specificity values were 92.4%, 96.2%, 79.8%, respectively. The combination of RIP3, hs-CRP and PLT had a sensitivity of 77.8% and specificity of 97.5%.

Conclusions

RIP3 may contribute to the early diagnosis of LOS and monitoring of treatment effect. The combined detection of RIP3, hs-CRP and PLT may be more effective than individual detection in the diagnosis of LOS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06636-0.

Can EEG accurately predict 2-year neurodevelopmental outcome for preterm infants?

OBJECTIVE

Establish if serial, multichannel video electroencephalography (EEG) in preterm infants can accurately predict 2-year neurodevelopmental outcome.

DESIGN AND PATIENTS

EEGs were recorded at three time points over the neonatal course for infants <32 weeks' gestational age (GA). Monitoring commenced soon after birth and continued over the first 3 days. EEGs were repeated at approximately 32 and 35 weeks' postmenstrual age (PMA). EEG scores were based on an age-specific grading scheme. Clinical score of neonatal morbidity risk and cranial ultrasound imaging were completed.

SETTING

Neonatal intensive care unit at Cork University Maternity Hospital, Ireland.

MAIN OUTCOME MEASURES

Bayley Scales of Infant Development III at 2 years' corrected age.

RESULTS

Sixty-seven infants were prospectively enrolled in the study and 57 had follow-up available (median GA 28.9 weeks (IQR 26.5-30.4)). Forty had normal outcome, 17 had abnormal outcome/died. All EEG time points were individually predictive of abnormal outcome; however, the 35-week EEG performed best. The area under the receiver operating characteristic curve (AUC) for this time point was 0.91 (95% CI 0.83 to 1), p<0.001. Comparatively, the clinical course AUC was 0.68 (95% CI 0.54 to 0.80, p=0.015), while abnormal cranial ultrasound was 0.58 (95% CI 0.41 to 0.75, p=0.342).

CONCLUSION

Multichannel EEG is a strong predictor of 2-year outcome in preterm infants particularly when recorded around 35 weeks' PMA. Infants at high risk of brain injury may benefit from early postnatal EEG recording which, if normal, is reassuring. Postnatal clinical complications can contribute to poor outcome; therefore, we state that a later EEG around 35 weeks has a role to play in prognostication.

Metabolic responses in neonatal sepsis-A systematic review of human metabolomic studies

AIM

To systematically review human metabolomic studies investigating metabolic responses in septic neonates.

METHODS

A systematic literature search was performed in the databases MEDLINE, EMBASE and Cochrane library up to the 1st of January 2021. We included studies that assessed neonatal sepsis and the following outcomes; (1) change in the metabolism compared to healthy neonates and/or (2) metabolomics compared to traditional diagnostic tools of neonatal sepsis. The screened abstracts were independently considered for eligibility by two researchers.

PROSPERO ID

CRD42020164454.

RESULTS

The search identified in total 762 articles. Fifteen articles were assessed for eligibility. Four studies were included, with totally 78 neonates. The studies used different diagnostic criteria and had between 1 and 16 sepsis cases. All studies with bacterial sepsis found alterations in the glucose and lactate metabolism, reflecting possible redistribution of glucose consumption from mitochondrial oxidative phosphorylation to the lactate and pentose phosphate pathway. We also found signs of increased oxidative stress and fatty acid oxidation in sepsis cases.

CONCLUSION

We found signs of metabolomic signatures in neonatal sepsis. This may lead to better understanding of sepsis pathophysiology and detection of new candidate biomarkers. Results should be validated in large-scale multicentre studies.

A Systemic Review and Meta-analysis of the Leading Pathogens Causing Neonatal Sepsis in Developing Countries

Background

Neonatal sepsis is one of the major public health problems globally, particularly, in developing countries. Klebsiella, Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli are the common pathogens for neonatal sepsis in developing countries. However, the pooled estimate of common pathogens causing neonatal sepsis in developing countries is still unknown. Therefore, this study is aimed at computing the pooled proportion of the leading cause of pathogens for neonatal sepsis in developing countries.

Methods

We strictly followed the Preferred Reporting Items for Systemic Reviews and Meta-analysis guidelines to report this systematic review and meta-analysis. PubMed, Cochrane Library, Web of Science, CINAHL, Science Direct, and other search engines such as Google Scholar, Africa Journals Online, and Hinari were used to obtain studies related to the leading cause of pathogens for neonatal sepsis in developing countries. The search was done from October 1 to December 30, 2018, by considering both published and gray literature. Studies were evaluated based on the PRISMA guideline checklist by using their titles, abstracts, and full texts. Studies were extracted using Microsoft Excel spreadsheets, and STATA software version 14 was used to analyze data. Heterogeneity between studies was checked based on Cochran's Q-test and the corresponding I² statistic test.

Results

The pooled prevalence of the leading cause of pathogens of neonatal sepsis in developing countries were Klebsiella (26.36%), Staphylococcus aureus (23.22%), Coagulase-negative Staphylococcus (23.22%), and Escherichia coli (15.30%). Common pathogens were varied across regions; for instance, pooled isolated Coagulase-negative Staphylococcus was 25.98% in Africa, 16.62% in Asia, and 36.71% in Latin America, and Klebsiella was 29.80% in Africa, 23.21% in Asia, and 22.00% in Latin America. Also, Staphylococcus aureus was 27.87% in Africa and 18.28% in Asia, and Escherichia coli was 22.97% in Asia and 9.43% in Africa.

Conclusions

This study highlights that the more prevalent common isolated pathogens in developing countries were Klebsiella, Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli, Klebsiella, and Staphylococcus aureus pathogens were predominantly high in Africa as compared to other Asian and Latin American countries. At the same time, Coagulase-negative Staphylococcus was more prevalent in Latin America compared to other regions. Escherichia coli is more dominant in Asia as compared to Africa and Latin America.

Identification of Potential Biomarkers in Neonatal Sepsis by Establishing a Competitive Endogenous RNA Network

BACKGROUND

Neonatal sepsis is a serious and difficult-to-diagnose systemic infectious disease occurring during the neonatal period.

OBJECTIVE

This study aimed to identify potential biomarkers of neonatal sepsis and explore its underlying mechanisms.

METHODS

We downloaded the neonatal sepsis-related gene profile GSE25504 from the NCBI Gene Expression Omnibus (GEO) database. The differentially expressed RNAs (DERs) were screened and identified using LIMMA. Then, the functions of the DERs were evaluated using Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. Finally, a competing endogenous RNA (ceRNA) network was constructed and functional analyses were performed.

RESULTS

The initial screening identified 444 differentially expressed (DE)-mRNAs and 45 DElncRNAs. GO analysis showed that these DE-mRNAs were involved in immune response, defense response, and positive regulation of immune system process. KEGG analysis showed that these DE-mRNAs were enriched in 30 activated pathways and 6 suppressed pathways, and those with the highest scores were the IL-17 signaling pathway and ribosome. Next, 722 miRNAs associated with the identified lncRNAs were predicted using miRWalk. A ceRNA network was constructed that included 6 lncRNAs, 11 mRNAs, and 55 miRNAs. In this network, HCP5, LINC00638, XIST and TP53TG1 were hub nodes. Functional analysis of this network identified some essential immune functions, hematopoietic functions, osteoclast differentiation, and primary immunodeficiency as associated with neonatal sepsis.

CONCLUSION

HCP5, LINC00638, TP53TG1, ST20-AS1, and SERPINB9P1 may be potential biomarkers of neonatal sepsis and may be useful for rapid diagnosis; the biological process of the immune response was related to neonatal sepsis.