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Hue-Bigé A, François-Garret B, Casagrande F, Oertel J, Mayerus M, Eleni Dit Trolli S. Early procalcitonin assays may reduce antibiotic exposure in premature newborn infants. Acta Paediatr 2024; 113:939-946. [PMID: 38314886 DOI: 10.1111/apa.17137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/07/2024]
Abstract
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.
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Affiliation(s)
- Amandine Hue-Bigé
- Neonatal Intensive Care Unit, Nice University Hospital, Nice, France
| | | | | | - Julie Oertel
- Neonatal Intensive Care Unit, Nice University Hospital, Nice, France
| | - Mathilde Mayerus
- Neonatal Intensive Care Unit, Nice University Hospital, Nice, France
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Wang Y, Chen Q, Xu S, Chao S. Obstetric Risk Factors and Serological Characteristics of Early-Onset Neonates Bacterial Infections. Front Surg 2022; 9:899795. [PMID: 35795229 PMCID: PMC9251195 DOI: 10.3389/fsurg.2022.899795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To analyze the obstetric high-risk factors and serological characteristics of early-onset neonatal bacterial infections (EONBI). Methods 119 neonates with early-onset bacterial infection who were admitted to the neonatal ward of our hospital from October 2020 to December 2021 were recorded as the study group, and 100 neonates without bacterial infection who were admitted during the same period were used as the reference group. Comparative analysis of obstetric high-risk factors and serological characteristics of EONBI. Results There was no statistical difference between the two groups in terms of gender and age at admission (P > 0.05). The gestational age and birth weight of newborns in the study group were lower than those in the reference group (P < 0.001). Comparing the maternal factors of EONBI between the two groups, there was no statistical difference in age, number of obstetric inspections, whether to use antibiotics, and mode of delivery (P > 0.05). Univariate analysis showed that preterm birth, unexplained asphyxia, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h were significantly associated with EONBI (P < 0.05); while there was no significant difference between the two groups in the comparison between diabetic mother and child and maternal fever at delivery (P > 0.05). Multifactorial analysis showed that preterm birth, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h had a good multivariate dependence on EONBI (P < 0.05), while there was no significant association with unexplained asphyxia, diabetic mother and child, and maternal fever at delivery (P > 0.05). The incidence of neonatal temperature >37.9°C was higher in the study group than in the reference group (P < 0.05), and there were no statistical differences in the comparison of other clinical manifestations (P > 0.05). The CRP level of neonates in the study group (47.33 ± 4.14) mg/L was higher than that of the reference group (4.84 ± 1.03) mg/L (P < 0.001). The WBC level of neonates in the study group (5.64 ± 1.18) 109/L was higher than that of the reference group (0.28 ± 0.04) 109/L (P < 0.001). The PCT level of neonates in the study group (5.41 ± 0.85) µg/L was higher than that of the reference group (0.24 ± 0.07) µg/L (P < 0.001). Conclusion EONBI is closely associated with several obstetric high-risk factors, including preterm birth, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h; EONBI has no specific symptoms and signs, but serum CRP, WBC, and PCT levels are significantly higher than those of newborns without co-infection with bacteria.
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Affiliation(s)
- Yuejiao Wang
- Department of Pediatrics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Qi Chen
- Department of Neonatology, Shangrao Maternal and Child Healthcare Hospital of Jiangxi Province, Shangrao, China
| | - Shixia Xu
- Department of Neonatology, Shangrao Maternal and Child Healthcare Hospital of Jiangxi Province, Shangrao, China
| | - Shuang Chao
- Department of Pediatrics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Correspondence: Shuang Chao
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Liu Y, Sun X, Wang Y, Xing C, Li L, Zhou S. Evaluation of Associated Markers of Neonatal Pathological Jaundice Due to Bacterial Infection. IRANIAN JOURNAL OF PUBLIC HEALTH 2021; 50:333-340. [PMID: 33747997 PMCID: PMC7956093 DOI: 10.18502/ijph.v50i2.5394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background To evaluate changes of associated markers in neonatal pathological jaundice due to bacterial infection in newborns, to provide an experimental basis for early diagnosis and treatment of neonatal pathological jaundice. Methods A total of 126 newborns with neonatal pathological jaundice in the Pediatrics Department of Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University from Jan 2016 to Jun 2018 were enrolled. The patients were divided into bacterial infection group (76 cases with combined bacterial infection) and non-infection group (50 cases without bacterial infection). Peripheral blood was drawn from patients, and levels of inflammatory factors, levels of indexes of liver function and levels of cardiac markers were detected. Correlation between inflammatory factors and neonatal pathological jaundice was assessed. Results The levels of WBC, hs-CRP and PCT in the bacterial infection group were significantly higher than those in the non-infected group (P<0.05). The level of TRF in the bacterial infection group was significantly lower than that in the non-infection group (P<0.01). In the bacterial infection group, the levels of WBC, hs-CRP, PCT, and TRF were positively correlated with the levels of CK, CKMB, LDH, and α-HBDB, respectively (all P<0.05). The TRF level after treatment was significantly higher than that before treatment (P<0.01). Conclusion Markers such as WBC, hs-CRP, PCT, and TRF can be used as effective indicators in diagnosis of pathological jaundice due to bacterial infection in newborns. The combined testing of WBC, hs-CRP, PCT, and TRF was helpful for early diagnosis and early clinical intervention of neonatal pathological jaundice, which can lower the risk of clinical complications.
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Affiliation(s)
- Yanli Liu
- Department of Pediatrics, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao 266000, China
| | - Xiuhua Sun
- Property Management Section, Zhangqiu District People's Hospital, Jinan 250200, China
| | - Yaqiong Wang
- Department of Infectious Diseases, Qingdao Central Hospital, Qingdao University, Qingdao 266000, China
| | - Cuihong Xing
- Nursing Department, Zhangqiu District People's Hospital, Jinan 250200, China
| | - Li Li
- Department of Neurosurgery, Zhangqiu District People's Hospital, Jinan 250200, China
| | - Shiying Zhou
- Department of Pediatrics, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao 266000, China
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Bianco B, François-Garret B, Butin M, Dalmasso C, Casagrande F, Mokhtari M, Eleni Dit Trolli S. Procalcitonin in Preterm Neonates: A Different Threshold and Prolonged Interpretation. Front Pediatr 2021; 9:623043. [PMID: 34079778 PMCID: PMC8165309 DOI: 10.3389/fped.2021.623043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/21/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives: To evaluate the positive threshold of PCT for neonates of <32 weeks of gestation for the diagnosis of early-onset sepsis and to determine if the level of PCT collected within 6 h of life could be used. Design: Retrospective and bicentric study from May 2016 to April 2018. Setting: Two groups were established, neonates evaluated for PCT at birth (CordPCT) and within 6 h of life (delPCT). Patients: Two hundred and sixty neonates of <32 weeks of gestation born in Nice and South Paris (Bicêtre) University Hospitals, had been evaluated for PCT level. Main Outcomes Measures: The value of the PCT positive threshold was determined for the total population and each groups thanks ROC curves. Results: The threshold level of PCT for the total population was 0.98 ng/mL. The threshold value of cordPCT group was 1.00 vs. 0.98 ng/mL for delPCT group. The area under the Receiver Operating Characteristics curve for PCT sampled in delPCT group was significantly higher than in cordPCT group (0.94 compared to 0.75). Conclusions: The threshold level of PCT was higher in this cohort of neonates of <32 weeks of gestation compared to the value generally described for term neonates. The secondary sampling PCT level seems to be usable in screening algorithm for early-onset neonatal sepsis.
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Affiliation(s)
- Blandine Bianco
- Neonatal Intensive Care Unit, CHU de Nice, Archet 2 Hospital, Nice, France
| | | | - Marine Butin
- Neonatal Intensive Care Unit, Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant, Bron, France
| | - Cyril Dalmasso
- Laboratoire de Mathématiques et Modélisation d'Evry (LaMME), Université d'Evry Val d'Essonne, UMR CNRS 8071, Evry, France
| | | | - Mostafa Mokhtari
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Kremlin-Bicêtre Hospital, University Paris Sud, Kremlin-Bicêtre, France
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Dain C, Rozé JC, Caillon J, Flamant C, Muller JB, Boscher C, Launay E, Gras-Le Guen C. Epidemiology of invasive early-onset neonatal infection in a French administrative district: A 10-year population-based study. Arch Pediatr 2020; 27:356-361. [PMID: 32896455 DOI: 10.1016/j.arcped.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/26/2020] [Accepted: 07/30/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND In light of the pending update of the French guidelines for the management of neonatal infections, knowing the current epidemiology of early-onset neonatal infection (EONI) is essential. OBJECTIVES The aim of this study was to assess the current epidemiology of a French administrative district population of proven EONI, including umbilical cord blood procalcitonin levels. METHODS We conducted a retrospective population-based study in the Nantes metropolitan area. We included all infants treated for proven EONI in the maternity, neonatology, and intensive care wards between 1 January 2006 and 31 December 2015 in the Nantes University Hospital. RESULTS Among the 140,502 children born during the study period, 61 cases of EONI were documented. The overall incidence of confirmed EONI was 0.43/1000 live births, with 0.23/1000 GBS (group B streptococcus) infections and 0.08/1000 Escherichia coli infections. The majority of infected newborns were full-term or late-preterm infants (67% were≥34 weeks of gestation), 88% had symptoms of EONI in the first 24h of life, most of which were respiratory. The mortality rate was 8% (in premature infants). Available in 51% of the population, the cord blood PCT value could contribute to an earlier diagnostic screening in 10% of cases but with a very low sensitivity. CONCLUSIONS The incidence of confirmed EONI is low in this French district. The diagnostic value of PCT umbilical blood cord should be assessed based on further studies before confirming its value. We suggest that a national registry of these rare but serious cases of EONI could contribute to monitoring the epidemiological progression as well as to optimizing our diagnostic and therapeutic strategies.
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Affiliation(s)
- C Dain
- Department of perinatal medicine, Nantes University Hospital, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France.
| | - J-C Rozé
- Department of perinatal medicine, Nantes University Hospital, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - J Caillon
- Department of bacteriology, Nantes University Hospital, 8, boulevard Moncousu, 44093 Nantes cedex 1, France
| | - C Flamant
- Department of perinatal medicine, Nantes University Hospital, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - J-B Muller
- Department of perinatal medicine, Nantes University Hospital, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - C Boscher
- Department of perinatal medicine, Nantes University Hospital, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - E Launay
- Department of pediatry, Nantes University Hospital, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - C Gras-Le Guen
- Department of pediatry, Nantes University Hospital, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France.
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Unal C, Karatas E, Fadıloglu E, Portakal O, Beksac MS. Comparison of term and preterm labor procalcitonin and leukocyte cell volume, conductivity and light scatter (VCS) parameters in order to demonstrate the impact of inflammation on the triggering mechanisms of preterm uterin contractions. J Obstet Gynaecol Res 2020; 46:694-698. [DOI: 10.1111/jog.14216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/07/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Canan Unal
- Division of Perinatology, Department of Obstetrics and GynecologyHacettepe University Ankara Turkey
| | - Esra Karatas
- Division of Perinatology, Department of Obstetrics and GynecologyHacettepe University Ankara Turkey
| | - Erdem Fadıloglu
- Division of Perinatology, Department of Obstetrics and GynecologyHacettepe University Ankara Turkey
| | - Oytun Portakal
- Department of BiochemistryHacettepe University Ankara Turkey
| | - Mehmet Sinan Beksac
- Division of Perinatology, Department of Obstetrics and GynecologyHacettepe University Ankara Turkey
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Critères cliniques en faveur d’un portage de germe pathogène chez le nouveau-né à terme suspect d’infection néonatale bactérienne précoce. Arch Pediatr 2017; 24:934-941. [DOI: 10.1016/j.arcped.2017.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 06/15/2017] [Accepted: 07/12/2017] [Indexed: 10/18/2022]
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N'Guessan R, Jellimann JM, Hascoët JM, Vieux R, Tahar H. [Value of gastric fluid to start antibiotics in premature babies suspected of having early neonatal bacterial infection]. Arch Pediatr 2017; 24:811-816. [PMID: 28801118 DOI: 10.1016/j.arcped.2017.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 05/17/2017] [Accepted: 06/16/2017] [Indexed: 11/28/2022]
Abstract
The objective of this study was to evaluate the value of direct examination and culture of gastric fluid in the treatment of early neonatal bacterial infections (INBP) in pre-term infants. MATERIALS AND METHODS Observational study conducted over 6 months in a Type III center. All hospitalized premature babies who had routine gastric fluid sampling at birth during the period of the study were included. They were classified into two groups: premature infants with probable or suspected infection and treated as such (Group 1) and premature infants with no infection or only having colonization (Group 2). RESULTS AND DISCUSSION In total, 255 pre-term infants were included in the study. Group 1 consisted of 127 newborns and group 2 consisted of 128 newborns. The direct gastric fluid examination was positive in 51 newborns in Group 1 and in 46 newborns in group 2. The culture was positive in 25 newborns in group 1 and eight newborns in group 2. Direct examination of gastric fluid of the 255 children studied had low sensitivity (40.1%) and low specificity (64%) of INBP, with 52.6% positive predictive value (PPV) and 51.8% negative predictive value (NPV). The gastric fluid culture was specific (93.7%) of the INBP, sensitivity was low (19.6%), with PPV at 75.7% and NPV at 54%. CONCLUSION These results undermine the relevance of the direct examination of gastric fluid in the delicate diagnosis of INBP. This direct examination has a low PPV and NPV. It is advisable not to start or stop antibiotic therapy solely on this argument; however, it can guide the choice of antibiotic therapy and remains useful for this reason. The culture of gastric fluid has very good specificity (93.7%).
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Affiliation(s)
- R N'Guessan
- Service de néonatologie, maternité régionale de Nancy, 10, rue du Docteur-Heydenreich, 54035 Nancy cedex, France.
| | - J-M Jellimann
- Service de néonatologie, maternité régionale de Nancy, 10, rue du Docteur-Heydenreich, 54035 Nancy cedex, France
| | - J-M Hascoët
- Service de néonatologie, maternité régionale de Nancy, 10, rue du Docteur-Heydenreich, 54035 Nancy cedex, France
| | - R Vieux
- Service de néonatologie, maternité régionale de Nancy, 10, rue du Docteur-Heydenreich, 54035 Nancy cedex, France
| | - H Tahar
- Service de microbiologie du CHU de Nancy, 54035 Nancy cedex, France
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Çelik HT, Portakal O, Yiğit Ş, Hasçelik G, Korkmaz A, Yurdakök M. Efficacy of new leukocyte parameters versus serum C-reactive protein, procalcitonin, and interleukin-6 in the diagnosis of neonatal sepsis. Pediatr Int 2016; 58:119-25. [PMID: 26190096 DOI: 10.1111/ped.12754] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 06/10/2015] [Accepted: 07/10/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- H Tolga Çelik
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Oytun Portakal
- Department of Biochemistry, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Şule Yiğit
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gülşen Hasçelik
- Department of Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ayşe Korkmaz
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Murat Yurdakök
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Sikias P, Parmentier C, Imbert P, Rajguru M, Chavet MS, Coquery S, Foix-L’Hélias L, Boileau P. Infections néonatales bactériennes précoces : évaluation des pratiques professionnelles dans 14 maternités d’Île-de-France en 2013. Arch Pediatr 2015; 22:1021-6. [DOI: 10.1016/j.arcped.2015.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 06/03/2015] [Accepted: 07/03/2015] [Indexed: 10/23/2022]
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Jost C, Mariani-Kurkdjian P, Biran V, Boissinot C, Bonacorsi S. Intérêt des prélèvements périnataux dans la prise en charge des nouveau-nés suspects d’infections bactériennes précoces. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/s1773-035x(15)30032-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Du Pont-Thibodeau G, Joyal JS, Lacroix J. Management of neonatal sepsis in term newborns. F1000PRIME REPORTS 2014; 6:67. [PMID: 25165566 PMCID: PMC4126544 DOI: 10.12703/p6-67] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neonatal sepsis is a common and deadly disease. It is broadly defined as a systemic inflammatory response, occurring in the first four weeks of life, as a result of a suspected or proven infection. Yet, more reliable and consistently applied diagnostic criteria would help improve our knowledge of the disease epidemiology. Several therapeutic attempts to control systemic inflammation in sepsis were unsuccessful. Immediate empirical administration of broad-spectrum anti-microbials, aggressive fluid resuscitation, and vaso-active or inotropic support (or both) are the mainstays of the therapeutic management of neonatal sepsis.
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Affiliation(s)
- Geneviève Du Pont-Thibodeau
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal and Sainte-Justine Hospital3175 Cote Sainte-Catherine, MontrealCanada H3T1C5
| | - Jean-Sébastien Joyal
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal and Sainte-Justine Hospital3175 Cote Sainte-Catherine, MontrealCanada H3T1C5
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal and Sainte-Justine Hospital3175 Cote Sainte-Catherine, MontrealCanada H3T1C5
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