What is/are the earliest predictor(s) of neonatal sepsis ?
Early prediction of sepsis can help better management of patients and better prognosis. Our protocol for treating suspected neonatal sepsis is to start empirical broad spectrum antimicrobials and to send sepsis screen which consists of a battery of tests like total counts, platelets counts, immature neutrophils counts (Band cells), CRP, Micro ESR, and blood culture. If Sepsis Screen results are positive but blood culture negative, we stop antimicrobials after 5 days and if blood culture positive then we change antimicrobials accordingly and complete 14 days.
Shri Guru Ram Rai Institute of Medical and Health Sciences
Neonatal Sepsis is an emergency. Earliest clinical features includes refusal to feed, feed intolerance, hypothermia, excessive cry or lethargy, respiratory distress and increased CFT. In case of maternal risk factors such as foul smelling liquor, maternal fever, chorioamnitis we should treat them as probable sepsis and start empirical antibiotics as early as possible. Lab findings includes sepsis screen and blood culture. Lab findings are adjunct to clinical diagnosis.
In my opinion, the early predictive findings of sepsis are thrombocytopenia, increased D- dimer, increased serum insuline level and high serum IL-6 and CRP levels in addition to clinical findings related to septicemia such as agonia, hypotension, cutis marmaratus, peripheral collapse. Which one is more important for early diagnosis of sepsis? I don't know. But, I can speculate that thrombocyopenia, increased D-dimer and serum insulin level are more important than others for early diagnosis of sepsis.
Sepsis is an urgent disease. Gene studies and long-lasting protein analysis is a waste of time. İt is not pratical to study above mentioned laboratory tests such as PCR analysis, heparin-binding protein and gene expressions. Clinicians have to give right, acute and the best desicion for patient. This is especially true for sepsis.
There are no specific biomarkers that can specifically diagnose sepsis. The most commonly used markers are serum CRP and PCT levels, although these are not specific for sepsis as that can also be elevated in other inflammatory conditions and even trauma. The same holds true for cytokines such as TNF and IL-6. Bacterial culture has also been used but this relies on being able to culture the bacteria. In reality, a combination of predictive tests are probably needed but this has not been thoroughly tested.
The question should be asked more specifically. The age group will also determine the appropriate answer. In premature infants a recent tool in the HERO monitor which analyze the variation of heart rate continuously and provide a prediction. Hemogram and classification is the routine for pediatricians but the sensitivity and specificity are very poor (~25-30% depend on the threshold). Any so called the good indicator (IL-8 nephelometry, cytokine array, PCR) are either way too sensitive or too expensive and provide too many false alarms (detect the gene not necessary mean the patient is really septic). I have some colleague insist using CRP and ended up keeping a lot of healthy newborn babies in the nursery on antibiotics for two weeks (to the best of my knowledge none of the 20 treated babies had any positive culture). Some papers use 10-25 parameters to build an algorism to predict sepsis but they all become so hard to use so nobody really using them. To me a clinical judgement may be more important and everybody can do it. Treat when you suspect it then taper down if the culture come back negative in 48 hours maybe more useful to clinicians.
In my opinion the frist step to detect sepsis as this disease is an urgent case to initiate treatment, is drawing the blood sample and observe a slide with Gram stain.
if the rate of infection would be high then it can simply indicate either gram negative or gram positive bacteria. However in some conditions such as fastidious blood-born infection this situation will be different.
when you suspect to sepsis, measuring of some laboratory tests may be helpful which are not time-consuming such as CRP, ESR and CBC also you can check random blood sugar and plasma protein which can be decreased during septicemia. It is recommended during the suspicious case antibiotic therapy must be started.
Most of clinically significant blood born bacteria can be detected during 6-12 hours of sample collection by acridine orange stain, you can also consider it.
some companies produce commercially kits for rapid diagnosis of bacteraemia such as BACTEC and something like that.
4. evidence of decreased organ perfusion: oliguria/anuria, altered mental status (drowsiness, agitation, delirium, seizures)
These are also valid in pediatric patients and should alert you to impending septic shock. Assessing for skin color changes, petechiae etc may be helpful.
Blood analysis may show high leukocyte count and/or high levels of CRP, and taking blood cultures at first presentation is justified. Starting with empirical AB therapy is a good first step.
I also believe that the gram stain, which can be performed very quickly, is the most helpful and easy first step to do to assess for bacteremia. Results of subsequent cultures may then guide further AB choice, as well as the identified source of the sepsis. Repeat blood cultures if no response to AB, and consider further analysis for atypical micro-organisms or viruses. With suspected pneumonia, urine antigen testing for pneumococcal disease or legionella may be helpful.
It is unforgotten that clinical findings of sepsis in newborn such as hypotonia, tachypnea, hypoactivity, weak or no sucking, hypothermia, cutis marmaratus, convulsion are more important than laboratory findings. Although definitive diagnosis of sepsis is the growth of any microorganism in blood culture medium, it is time consuming. To start of the treatment of sepsis is urgent and treatment should be started as soon as possible when sepsis is suspected. Laboratory findings help the diagnosis of sepsis and these are valuable if laboratory findings support the diagnosis, as always.
Neonatal sepsis is life threatening and needs to be handled rather urgently. I high index of suspicion is necessary for early diagnosis and treatment. Clinical features such as poor feeding, excessive crying and fever should arouse the suspicion of sepsis in the newborn and warrant prompt diagnostic work up, including a pan-culture, complete blood counts with ESR, platelet counts, total white cell counts and I/T ratios.
Fever is everytime a diagnostic marker of neonatal sepsis because sometimes, hypothermi occurs in neonatal sepsis. Clinical findings are more important than laboratory findings of neonatal sepsis. Laboratory findings are important if they support to the clinical findings of neonatal sepsis. The most important and pratical laboratory findings are peripheral blood smear including vakuolization of neutrophils, toxic granulation, Dohle body, immatur/total neutrophils> 0.2, thrombocytopenia associated with increased D-dimer.
Golden rule in the diagnosis of NNS is high index of suspicion of NNS or when NNS is likely. It could be based on presence of maternal, fetal/neonatal or environmental risk factors including possibility of sepsis in the internal milieu or the inner house where the baby is coming from. Presence of any symptom especially reduced activity, reduced sucking, abdominal distension and respiratory distress makes the diagnosis more likely. Laboratory findings are adjunct in the diagnosis. Because of wide range of normality in the laboratory investigative values, many of the laboratory findings are non-specific. Many times, intervention may be coming too late if the diagnosis is based on CVS instability or an organ dysfunction. It is also important to know that because of fear of infection, unusual predisposition to infection in newborn period, progression and severity an infection may attain in newborn period, unnecessary use of antibiotics in the newborn is common especially in the developing countries where infection is commoner and screening facilities are limited. Therefore, to treat or not to treat a baby with suspected infection will be based on clinical status, close monitoring and follow up.
One of the major problems of neonatal medicine is the differentiation of complex congenital heart disease from severe lung disease. The neonatologist faces three potential diagnostic groups; 1. the critically ill child with a congenital cardiac lesion who requires early catheterisation and surgical intervention; 2. the child with complex congenital...
Background: Neonatal sepsis (NS) is a global health problem owing to its significant contribution to morbidity and mortality. We evaluated the significance of neutrophilic CD64 (nCD64) expression as an early marker for diagnosis of NS compared to CRP and assessed its relation to disease outcome. Methods: High sensitivity CRP (hs-CRP) and nCD64 were...