Diagnostics for neonatal sepsis: current approaches and future directions

Point-of-Care Serum Amyloid A as a Diagnostic Marker for Neonatal Sepsis

OBJECTIVES

To evaluate diagnostic accuracy of point-of-care Serum Amyloid A (POC-SAA) and its comparison with procalcitonin for diagnosis of neonatal sepsis.

METHODS

The present diagnostic accuracy study consecutively recruited neonates with suspected sepsis. Blood samples for sepsis screen, culture, high sensitivity C-reactive protein (CRP) (hs-CRP, as a part of sepsis screen), procalcitonin and POC-SAA were collected before starting antibiotics. The optimum cut-off level of biomarkers (POC-SAA and procalcitonin) was determined by receiver-operating-characteristics curve (ROC) analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of POC-SAA and procalcitonin were derived for 'clinical sepsis (neonates with suspected sepsis and either positive sepsis screen and/or blood culture)' and 'culture positive sepsis' (neonates with suspected sepsis and positive blood culture).

RESULTS

Seventy-four neonates with mean±SD gestational age of 32.8±3.7 wk were evaluated for suspected sepsis, of which the proportion of 'clinical sepsis' and 'culture positive sepsis' was 37.8% had 16.2%, respectively. At a cut-off of 25.4 mg/L, POC-SAA had sensitivity, specificity, PPV and NPV of 53.6%, 80.4%, 62.5% and 74.0%, respectively for diagnosis of clinical sepsis. The sensitivity, specificity, PPV and NPV of POC-SAA for detection of culture positive sepsis were 83.3%, 61.3%, 29.4% and 95.0%, respectively at a cut-off of 10.3 mg/L. There was no significant difference in the diagnostic accuracy of biomarkers for detection of culture positive sepsis (area under the curve, AUC of POC-SAA vs. procalcitonin vs. hs-CRP: 0.72 vs. 0.85 vs. 0.85; p = 0.21).

CONCLUSIONS

POC-SAA is comparable to procalcitonin and hs-CRP for diagnosis of neonatal sepsis.

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.

Umbilical cord blood hematological parameters in predicting early onset neonatal sepsis (EOS) - a prospective cohort study

OBJECTIVES

In low and middle income countries, there is a need for affordable and accurate biomarkers to identify neonates at risk of early onset neonatal sepsis (EOS). Cord blood hematological parameters if reliable and accurate for the detection of EOS are cost effective and can reduce the need for repeated venipuncture in the neonate.

METHODS

In this prospective cohort study, the umbilical cord parameters of newborns with gestational age >34 weeks were collected. These neonates were followed up for 72 h and septic screen was employed in those babies who had risk factors or developed clinical features of sepsis. The cord blood parameters of the normal newborn and those who had sepsis were analyzed.

RESULTS

A total of 513 neonates were enrolled for the study, 32 required septic screening of whom 13 neonates were found to meet the criteria for sepsis: either blood culture positive or sepsis screen positive with clinical features. Cord blood parameters were analyzed using independent t test. Red cell distribution width (RDW) and band cells were statistically significant (p 0.007 and 0.009 respectively) between the septic and normal neonates. Increased RDW had a sensitivity of 61.54 %, specificity of 54.60 %. Increased band cells with a cut off of >15 cells had a sensitivity of 7.7 % with specificity of 100 % with higher numbers in septic neonates. Increased RDW and band cells in combination had sensitivity of 61.54 % and specificity of 54.6 %.

CONCLUSIONS

RDW and band cell can be potential markers of EOS in cord blood but require further study in a larger population.

Clinical value of procalcitonin-to-albumin ratio for identifying sepsis in neonates with pneumonia

BACKGROUND

It is possible that neonates with pneumonia also have unrecognized sepsis. Identifying sepsis in neonates with pneumonia may cause some trouble for clinicians. This study aimed to evaluate the clinical value of the procalcitonin-to-albumin ratio (PAR) in identifying sepsis in neonates with pneumonia.

METHODS

We retrospectively included 912 neonates with pneumonia from January 2016 to July 2021. Clinical and laboratory data were collected from electronic medical records. Among neonates with pneumonia, 561 neonates were diagnosed with sepsis, according to the International Pediatric Sepsis Consensus. Neonates were divided into a sepsis group and a pneumonia group. A multivariate logistic regression analysis was used to evaluate whether PAR was a potential independent indicator for identifying sepsis in neonates with pneumonia. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic value of PAR in sepsis.

RESULTS

Neonates with sepsis have a higher PAR (p < 0.001). Correlation analysis showed that PAR was positively correlated with the level of C-reactive protein (r = 0.446, p < 0.001). Multiple logistic regression analysis showed that PAR was an independent predictor of the presence of sepsis in neonates with pneumonia. ROC curve analysis revealed that PAR had good power in identifying sepsis in neonates with pneumonia (area under curve (AUC) = 0.72, 95% confidence interval (CI), 0.68-0.75, p < 0.001).

CONCLUSION

PAR can be used as a new biomarker to identify sepsis in neonates with pneumonia.

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.

Clinical Value of Laboratory Biomarkers for the Diagnosis and Early Identification of Culture-Positive Sepsis in Neonates

Background

Neonatal sepsis (NS) is an important cause of mortality and morbidity in newborn infants. However, early diagnosis of proven sepsis (culture-positive sepsis) is difficult. We aimed to define the best combination of biomarkers to diagnose the onset of neonatal sepsis, distinguish culture-positive neonatal sepsis and predict the time of confirmation of neonatal sepsis.

Methods

This retrospective cohort study was conducted from January 2016 to December 2020. Clinical characteristics and laboratory results were collected from the electronic medical records. Hematology profiles and biochemical indices were obtained upon hospital admission. Multivariate logistic regression analysis was used to evaluate the risk factors and construct a nomogram. The performance of the nomogram was evaluated by receiver operating characteristic (ROC) curve and decision curve analysis (DCA). Multivariable linear regression was used to identify the association between admission-to-diagnosis interval (ADI) and correlated variables.

Results

Overall, 148 infants with neonatal sepsis (67 culture positive sepsis and 81 culture negative sepsis) and 150 controls were included. C-reactive protein (CRP) (p<0.001), platelets (PLT) (p=0.011), urea nitrogen (BUN) (p=0.001) and conjugated bilirubin (BC) (p=0.007) were independent risk factors for neonatal sepsis. The diagnostic nomogram based on CRP, PLT, BUN and BC showed excellent diagnostic accuracy for neonatal sepsis (AUC=0.928). The nomogram based on red blood cell distribution width (RDW) and mean platelet volume (MPV) was efficient in distinguishing proven neonatal sepsis from clinical sepsis, with an AUC of 0.700 in the training group and 0.689 in the validation group. Decision curve analysis (DCA) showed that the nomogram had good clinical utility. Multivariable analysis revealed gestational age, CRP, and MPV were significantly associated with admission-to-diagnosis interval in culture-positive sepsis (p < 0.001).

Conclusion

Different combinations biomarkers were performant to diagnose the onset of neonatal sepsis, distinguish culture-positive neonatal sepsis, predict the time of confirmation, and aid in individual therapy.

Possible Rates of Detection of Neonatal Sepsis Pathogens in the Context of Microbiological Diagnostics in Mothers - Real World Data

Objective

The aim of this study was to identify the rate of detection of neonatal sepsis pathogens in maternal microbiological smears.

Study Design

This is a retrospective study conducted at a Level 1 perinatal center in the context of routine care from 2014 to 2019. For all premature infants and neonates with neonatal sepsis, the neonatal and maternal microbiological findings were examined to see if there was a match.

Results

During the study period, a total of 948 premature or newborn infants were identified as having a neonatal infection. Among all of the premature or newborn infants, 209 (22%) met the diagnostic criteria for neonatal sepsis; of these, 157 were premature births and 52 were full-term births. We evaluated the microbiological findings for these 209 mother and child pairs. No pathogens were detected in 27 out of 157 mothers of premature infants (17.1%) and in 31 out of 52 mothers of full-term infants (59.6%). In the premature infant group there were pairs with matching pathogens in 30 out of 130 cases (23.1%, 95% CI: 16.1-31.3), and in the full-term infant group there was a match in 4 out of 21 cases (19%, 95% CI: 5.4-41.9). The number needed to test to have a 90% probability of success for pathogen detection varies between 9 and 11 in the most favorable case and 26 and 32 in the least favorable case, depending on the evaluation method.

Conclusion

In cases of neonatal sepsis, the sepsis-causing pathogen was successfully detected through prior analysis of a maternal smear in 7% of full-term infants and in 19% of premature infants. The number needed to test was relatively high in all groups. The value of maternal smears for identifying neonatal sepsis-causing pathogens needs to be critically questioned.

Fibrinogen-to-Albumin Ratio in Neonatal Sepsis

Background

Previous studies have established an association between fibrinogen-to-albumin ratio (FAR) and cancer, cardiovascular disease, and coronavirus disease 2019. However, no studies have investigated the relationship between FAR and neonatal sepsis. This study aims to evaluate the association of fibrinogen-to-albumin ratio with the presence and severity of sepsis in neonates.

Methods

A total of 1292 neonates with suspected sepsis were enrolled in this study. Clinical and laboratory data were collected from electronic medical records. Neonates with final diagnosis with sepsis were divided into the sepsis group, The remaining neonates were divided into the control group. Neonates with sepsis were further categorized into mild (n = 312) and severe (n = 425) groups based on the severity of their condition. FAR was determined by dividing the plasma fibrinogen concentration (g/L) by the serum albumin concentration (g/L). The statistical analyses were conducted using the SPSS 26.0 statistical software package, as deemed appropriate.

Results

FAR levels were significantly higher in neonates with sepsis compared to the control group. Additionally, a significant gradual increase in FAR was observed in the control, mild sepsis, and severe sepsis groups (P < 0.001). Correlation analysis showed that FAR had a positive correlation with PCT, CRP, and the length of hospital stay. Multiple logistic regression analysis showed that FAR was independently associated with the presence and severity of neonatal sepsis. Specifically, FAR was identified as an independent risk factor for both the presence of sepsis (OR = 8.641, 95% CI 5.708-13.080, P < 0.001) and severe sepsis (OR = 2.817, 95% CI 1.701-4.666, P < 0.001).

Conclusion

FAR is significantly increased in neonates with sepsis and had a correlation with the severity of sepsis. Increased FAR was an independent predictor for the presence and severity of neonatal sepsis.

Clinical Features and Antibiotic Treatment of Neonatal Listeriosis: A Hospital-Based Study

Purpose

To determine the clinical features, laboratory findings, antibiotic treatment, and outcomes of neonatal listeriosis in a specialized tertiary hospital in Wuhan, China.

Patients and Methods

We retrospectively analyzed the medical records of patients diagnosed with neonatal listeriosis at Maternal and Child Health Hospital of Hubei Province from January 2015 to December 2022. Listeriosis was indicated by positive culture for Listeria monocytogenes (LM).

Results

A total of 11 cases were included in our study. The incidence rate of neonatal listeriosis was 2.06 per 100,000 live births. Seventy-three percent of the cases were born prematurely, caused early onset sepsis. Respiratory distress (100%) was the most common and earliest symptom, followed by fever (64%) and rashes (27%). The levels of C-reactive protein (CRP) and procalcitonin (PCT) were elevated in 100% of the cases. The median time-to-positivity (TTP) of the culture was 15 hours (range 9-28hours). Of the 11 neonates, 6 were cured, 2 showed improvement, and 3 died, with a mortality rate of 27%. There were statistically significant differences in Apgar score at 5 minutes (p=0.037) and CRP (p=0.025) between the survival group and fatality group. Ampicillin was sensitive to LM isolates and effective for therapy if initiated early.

Conclusion

Neonatal listeriosis is a rare but severe infection with a high mortality rate. Early identification and appropriate use of effective antibiotics are particularly critical for achieving positive outcomes. Apgar score and CRP are relevant indices for prognosis. Ampicillin is the first-line therapy and can be empirically administered to neonates suspected of having listeriosis.

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.

Lymphocyte to C-Reactive Protein Ratio as an Early Biomarker to Distinguish Sepsis from Pneumonia in Neonates

Background

Neonatal sepsis is an acute and severe disease that seriously threatens the life and health of newborns. Neonates with pneumonia may also have unrecognized neonatal sepsis. Early diagnosis of neonatal sepsis is beneficial for early treatment. This study aimed to evaluate the clinical significance of the lymphocyte-to-C-reactive protein ratio (LCR) as an early biomarker to distinguish sepsis from pneumonia.

Methods

This retrospective study enrolled 1635 neonates with pneumonia from February 2016 to March 2022. Among them, 182 cases were diagnosed with sepsis based on the positive blood culture results. Clinical and laboratory data were extracted from the electronic medical records. LCR was calculated as the ratio of the total lymphocyte count (×109 cells/L) to the C-reactive protein level (mg/L). Binary logistic regression analysis was conducted to evaluate the clinical significance of LCR as an early biomarker in distinguishing sepsis from pneumonia. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic value of LPCR in sepsis cases. All statistical analyses were conducted using Statistical Product and Service Solutions, version 24.0.

Results

The neonates with pneumonia combined with sepsis had a lower LCR than that of the neonates with pneumonia. Further analysis showed that the prevalence of neonatal pneumonia combined with sepsis was significantly higher in the low-LCR group than in the high-LCR group (20.7% vs 5.5%, P < 001). Binary logistic regression revealed that LCR was an independent risk factor for identifying pneumonia combined with sepsis. The ROC curve analysis revealed that LCR had better power than the lymphocyte count and CRP level individually in diagnosing neonatal pneumonia combined with sepsis (0.72 vs 0.65 vs 0.66, P < 0.001), with 62% sensitivity and 72% specificity.

Conclusion

LCR can be a potential early biomarker in distinguishing neonates with sepsis from those with pneumonia.

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

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

Diagnosing early-onset neonatal sepsis in low-resource settings: development of a multivariable prediction model

OBJECTIVE

To develop a clinical prediction model to diagnose neonatal sepsis in low-resource settings.

DESIGN

Secondary analysis of data collected by the Neotree digital health system from 1 February 2019 to 31 March 2020. We used multivariable logistic regression with candidate predictors identified from expert opinion and literature review. Missing data were imputed using multivariate imputation and model performance was evaluated in the derivation cohort.

SETTING

A tertiary neonatal unit at Sally Mugabe Central Hospital, Zimbabwe.

PATIENTS

We included 2628 neonates aged <72 hours, gestation ≥32+0 weeks and birth weight ≥1500 g.

INTERVENTIONS

Participants received standard care as no specific interventions were dictated by the study protocol.

MAIN OUTCOME MEASURES

Clinical early-onset neonatal sepsis (within the first 72 hours of life), defined by the treating consultant neonatologist.

RESULTS

Clinical early-onset sepsis was diagnosed in 297 neonates (11%). The optimal model included eight predictors: maternal fever, offensive liquor, prolonged rupture of membranes, neonatal temperature, respiratory rate, activity, chest retractions and grunting. Receiver operating characteristic analysis gave an area under the curve of 0.74 (95% CI 0.70-0.77). For a sensitivity of 95% (92%-97%), corresponding specificity was 11% (10%-13%), positive predictive value 12% (11%-13%), negative predictive value 95% (92%-97%), positive likelihood ratio 1.1 (95% CI 1.0-1.1) and negative likelihood ratio 0.4 (95% CI 0.3-0.6).

CONCLUSIONS

Our clinical prediction model achieved high sensitivity with low specificity, suggesting it may be suited to excluding early-onset sepsis. Future work will validate and update this model before considering implementation within the Neotree.

Bioinformatic Analysis and Machine Learning Methods in Neonatal Sepsis: Identification of Biomarkers and Immune Infiltration

The disease neonatal sepsis (NS) poses a serious threat to life, and its pathogenesis remains unclear. Using the Gene Expression Omnibus (GEO) database, differentially expressed genes (DEGs) were identified and functional enrichment analyses were conducted. Three machine learning algorithms containing the least absolute shrinkage and selection operator (LASSO), support vector machine recursive feature elimination (SVM-RFE), and random forest (RF) were applied to identify the optimal feature genes (OFGs). This study conducted CIBERSORT to present the abundance of immune infiltrates between septic and control neonates and assessed the relationship between OFGs and immune cells. In total, 44 DEGs were discovered between the septic and control newborns. Throughout the enrichment analysis, DEGs were primarily related to inflammatory signaling pathways and immune responses. The OFGs derived from machine learning algorithms were intersected to yield four biomarkers, namely Hexokinase 3 (HK3), Cystatin 7 (CST7), Resistin (RETN), and Glycogenin 1 (GYG1). The potential biomarkers were validated in other datasets and LPS-stimulated HEUVCs. Septic infants showed a higher proportion of neutrophils (p < 0.001), M0 macrophages (p < 0.001), and regulatory T cells (p = 0.004). HK3, CST7, RETN, and GYG1 showed significant correlations with immune cells. Overall, the biomarkers offered promising insights into the molecular mechanisms of immune regulation for the prediction and treatment of NS.

Blood culture collection practices in NICU; A national survey

Background

Sepsis is the leading cause of mortality and morbidity in neonates. Blood cultures are the gold standard in diagnosing neonatal sepsis; however, there are currently no consensus guidelines for blood culture collection in neonates and significant practice variation exists in Neonatal Intensive Care Units (NICUs) globally.

Objective

To examine current practices in obtaining blood cultures in the evaluation of neonatal sepsis in NICUs across Canada.

Methods

A nine-item electronic survey was sent to each of the 29 level-3 NICUs in Canada, which are equipped to provide highly specialized care for newborns.

Results

Responses were received from 90% (26/29) of sites. Sixty-five percent (17/26) of sites have blood culture collection guidelines for the investigation of neonatal sepsis. Forty-eight percent (12/25) of sites routinely target 1.0 mL per culture bottle. In late-onset sepsis (LOS), 58% (15/26) of sites process one aerobic culture bottle, whereas four sites routinely add anaerobic culture bottles. In early-onset sepsis (EOS) in very low birth weight infants (BW <1.5 kg), 73% (19/26) of sites use umbilical cord blood, and 72% (18/25) use peripheral venipuncture. Two sites routinely collect cord blood for culture in EOS. Only one site applies the concept of differential time-to-positivity to diagnose central-line-associated bloodstream infection.

Conclusions

There is significant practice variation in methods used to obtain blood cultures in level-3 NICUs across Canada. Standardization of blood culture collection practices can provide reliable estimates of the true incidence of neonatal sepsis and help to develop appropriate antimicrobial stewardship strategies.

Vital sign-based detection of sepsis in neonates using machine learning

AIM

Sepsis is a leading cause of morbidity and mortality in neonates. Early diagnosis is key but difficult due to non-specific signs. We investigate the predictive value of machine learning-assisted analysis of non-invasive, high frequency monitoring data and demographic factors to detect neonatal sepsis.

METHODS

Single centre study, including a representative cohort of 325 infants (2866 hospitalisation days). Personalised event timelines including interventions and clinical findings were generated. Time-domain features from heart rate, respiratory rate and oxygen saturation values were calculated and demographic factors included. Sepsis prediction was performed using Naïve Bayes algorithm in a maximum a posteriori framework up to 24 h before clinical sepsis suspicion.

RESULTS

Twenty sepsis cases were identified. Combining multiple vital signs improved algorithm performance compared to heart rate characteristics alone. This enabled a prediction of sepsis with an area under the receiver operating characteristics curve of 0.82, up to 24 h before clinical sepsis suspicion. Moreover, 10 h prior to clinical suspicion, the risk of sepsis increased 150-fold.

CONCLUSION

The present algorithm using non-invasive patient data provides useful predictive value for neonatal sepsis detection. Machine learning-assisted algorithms are promising novel methods that could help individualise patient care and reduce morbidity and mortality.

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.

Fighting Antimicrobial Resistance in Neonatal Intensive Care Units: Rational Use of Antibiotics in Neonatal Sepsis

Antibiotics are the most frequently prescribed drugs in neonatal intensive care units (NICUs) due to the severity of complications accompanying neonatal sepsis. However, antimicrobial drugs are often used inappropriately due to the difficulties in diagnosing sepsis in the neonatal population. The reckless use of antibiotics leads to the development of resistant strains, rendering multidrug-resistant pathogens a serious problem in NICUs and a global threat to public health. The aim of this narrative review is to provide a brief overview of neonatal sepsis and an update on the data regarding indications for antimicrobial therapy initiation, current guidance in the empirical antimicrobial selection and duration of therapy, and indications for early discontinuation.

Biochemical surveillance versus clinical observation of term infants born after prolonged rupture of membranes - A quality assurance initiative

AIM

To examine whether biochemical surveillance vs clinical observation of term infants with prolonged rupture of membranes as a risk factor for early-onset sepsis is associated with differences in patient trajectories in maternity and neonatal intensive care units.

METHODS

A retrospective study of live-born infants with gestational age ≥ 37 + 0 weeks born after prolonged rupture of membranes (≥24 h) in four Norwegian hospitals 2017-2019. Two hospitals used biochemical surveillance, and two used predominantly clinical observation to identify early-onset sepsis cases.

RESULTS

The biochemical surveillance hospitals had more C-reactive protein measurements (p < 0.001), neonatal intensive care unit admissions (p < 0.001) and antibiotic treatment (p < 0.001). Hospitals using predominantly clinical observation initiated antibiotic treatment earlier in infants with suspected early-onset sepsis (p = 0.04) but not in infants fulfilling early-onset sepsis diagnostic criteria (p = 0.09). There was no difference in antibiotic treatment duration (p = 0.59), fraction of infants fulfilling early-onset sepsis diagnostic criteria (p = 0.49) or length of hospitalisation (p = 0.30), and no early-onset sepsis-related adverse outcomes.

CONCLUSION

The biochemical surveillance hospitals had more C-reactive protein measurements, but there was no difference in antibiotic treatment duration, early-onset sepsis cases, length of hospitalisation or adverse outcomes. Personnel resources needed for clinical surveillance should be weighed against the limitation of potentially painful procedures.

Early Diagnosis of Late-Onset Neonatal Sepsis Using a Sepsis Prediction Score

Sepsis represents a common cause of morbidity in the Neonatal Intensive Care Unit (NICU). Our objective was to assess the value of clinical and laboratory parameters in predicting septicemia (positive blood culture) in NICU infants. In the first part of the present study (derivation cohort) we retrospectively reviewed the clinical files of 120 neonates with symptoms of suspected sepsis and identified clinical and laboratory parameters associated with proven sepsis on the day the blood culture was taken, as well as 24 h and 48 h earlier. These parameters were combined into a sepsis prediction score (SPS). Subsequently (validation study), we prospectively validated the performance of the SPS in a cohort of 145 neonates. The identified parameters were: temperature instability, platelet count < 150,000/mm³, feeding volume decrease > 20%, changes in blood glucose > 50%, CRP > 1 mg/dL, circulatory and respiratory deterioration. In the retrospective cohort, on the day the blood culture was obtained, a SPS ≥ 3 could predict sepsis with 82.54% sensitivity, 85.96% specificity, 5.88 PLR (Positive Likelihood Ratio), 0.20 NLR (Negative Likelihood Ratio), 86.67% PPV (Positive Predictive Value), 81.67% NPV (Negative Predictive Value) and 84.17% accuracy. In the prospective cohort, on the day the blood culture was obtained, a SPS ≥ 3 could predict sepsis with 76.60% sensitivity, 72.55% specificity, 2.79 PLR, 0.32 NLR, 83.72% PPV, 62.71% NPV and 75.17% accuracy. We concluded that this combination of clinical and laboratory parameters may assist in the prediction of septicemia in NICUs.

Lymphocyte-to-C-Reactive Protein Ratio as an Early Sepsis Biomarker for Neonates with Suspected Sepsis

Background

Neonatal sepsis is an extremely dangerous and fatal disease among neonates, and its timely diagnosis is critical to treatment. This research is aimed at evaluating the clinical significance of the lymphocyte-to-C-reactive protein ratio (LCR) as an early sepsis indicator in neonates with suspected sepsis.

Methods

Between January 2016 and December 2021, 1269 neonates suspected of developing sepsis were included in this research. Among them, sepsis was diagnosed in 819 neonates, with 448 severe cases, as per the International Pediatric Sepsis Consensus. Data related to clinical and laboratory tests were obtained via electronic medical records. LCR was calculated as total lymphocyte (109 cells/L)/C-reactive protein (mg/L). Multivariate logistic regression analysis was employed to evaluate the effectiveness of LCR as an independent indicator for determining sepsis in susceptible sepsis neonates. Receiver operating characteristic (ROC) curve analysis was conducted for investigating the diagnostic significance of LCR in sepsis. When suitable, the statistical tool SPSS 24.0 was used for statistical analyses.

Results

LCR decreased significantly in the control, mild, and severe sepsis groups. Further analyses exhibited that there was a substantially greater incidence of sepsis in neonates in the low-LCR group (LCR ≤ 3.94) as opposed to the higher LCR group (LCR > 3.94) (77.6% vs. 51.4%, p < 0.001). Correlation analysis indicated a substantial negative association of LCR with procalcitonin (r = -0.519, p < 0.001) and hospital stay duration (r = -0.258, p < 0.001). Multiple logistic regression analysis depicted LCR as an independent indicator for identifying sepsis and severe cases of this disease. ROC curve analysis indicated the optimal cutoff value of LCR in identifying sepsis to be 2.10, with 88% sensitivity and 55% specificity.

Conclusions

LCR has proven to be a potentially strong biomarker capable of identifying sepsis in a timely manner in neonates suspected to have the disease.

Clinical Value of Serum Interleukin-18 in Neonatal Sepsis Diagnosis and Mortality Prediction

Purpose

Previous studies have demonstrated that interleukin-18 (IL-18) levels were elevated in adult patients with sepsis. However, its role in neonatal sepsis remains unknown. The current research was conducted to assess the clinical value of serum IL-18 level as a candidate biomarker in neonatal sepsis diagnosis and prediction of mortality.

Patients and Methods

From July 2022 to September 2022, we prospectively enrolled 91 septic neonates and 31 non-sepsis neonates in the intensive care unit of neonates at Henan Children's Hospital in Zhengzhou, China. Neonatal peripheral blood serum was collected at admission and levels of serum IL-18 were assessed. Employing multivariate logistic regression analysis, the evaluation of the potential of IL-18 as an independent biomarker for sepsis was executed. Furthermore, employing the receiver operating characteristic (ROC) curve analysis, the diagnostic value of IL-18 in sepsis and the ability of IL-18 in predicting the mortality of neonatal sepsis was measured. The statistical package SPSS 24.0 was employed to conduct all statistical analyses.

Results

Serum IL-18 levels in neonates in the sepsis group were elevated compared to the control group, reaching the highest levels in the non-survival sepsis group (P < 0.001). Correlation analysis exhibited a positive relationship between IL-18 levels and age, body temperature, respiratory rate, and C-reactive protein levels. IL-18 was identified as an independent biomarker in identifying sepsis (OR = 4.747, 95% CI 1.493-15.092, P = 0.008) by multiple logistic regression. ROC curve analysis exhibited that IL-18 was good in identifying neonatal sepsis (area under curve (AUC) = 0.77, 95% CI = 0.68-0.85, P < 0.001) and predicting neonatal mortality (AUC = 0.80, 95% CI = 0.63-0.96, P = 0.003).

Conclusion

IL-18 was a potential biomarker for identifying neonatal sepsis and neonatal mortality prediction.

Chorioamnionitis-exposure alters serum cytokine trends in premature neonates

OBJECTIVES

Determine if chronologic age and/or chorioamnionitis exposure alter normal serum cytokine and chemokine levels in uninfected preterm neonates during their initial NICU stay.

STUDY DESIGN

A 7-plex immunoassay measured levels of serum IL-1β, IL-6, IL-8, IL-10, TNF-α, CCL2, and CCL3 longitudinally from chorioamnionitis-exposed and unexposed preterm neonates under 33 weeks' gestation.

RESULTS

Chorioamnionitis-exposed and unexposed preterm neonates demonstrated differences in the trends of IL-1β, IL-6, IL-8, IL-10, TNF-α, and CCL2 over the first month of life. The unexposed neonates demonstrated elevated levels of these inflammatory markers in the first two weeks of life with a decrease by the third week of life, while the chorioamnionitis-exposed neonates demonstrated differences over time without a predictable pattern. Chorioamnionitis-exposed and unexposed neonates demonstrated altered IL-10 and TNF-α trajectories over the first twelve weeks of life.

CONCLUSION

Chorioamnionitis induces a state of immune dysregulation in preterm neonates that persists beyond the immediate neonatal period.

Emerging Materials, Wearables, and Diagnostic Advancements in Therapeutic Treatment of Brain Diseases

Among the most critical health issues, brain illnesses, such as neurodegenerative conditions and tumors, lower quality of life and have a significant economic impact. Implantable technology and nano-drug carriers have enormous promise for cerebral brain activity sensing and regulated therapeutic application in the treatment and detection of brain illnesses. Flexible materials are chosen for implantable devices because they help reduce biomechanical mismatch between the implanted device and brain tissue. Additionally, implanted biodegradable devices might lessen any autoimmune negative effects. The onerous subsequent operation for removing the implanted device is further lessened with biodegradability. This review expands on current developments in diagnostic technologies such as magnetic resonance imaging, computed tomography, mass spectroscopy, infrared spectroscopy, angiography, and electroencephalogram while providing an overview of prevalent brain diseases. As far as we are aware, there hasn't been a single review article that addresses all the prevalent brain illnesses. The reviewer also looks into the prospects for the future and offers suggestions for the direction of future developments in the treatment of brain diseases.

Optimizing antibiotic use in culture-negative healthcare-associated infection with a 'stop' policy: a descriptive analytical study

BACKGROUND AND OBJECTIVES

Many sick neonates receive antibiotics for the clinical diagnosis of probable/possible sepsis. Reports suggest rampant antibiotic use in culture-negative sepsis. We introduced an antibiotic stop policy (ASP), by defining 'completed course duration of antibiotics' in the setting of culture-negative suspected healthcare-associated infection (HAI). Antibiotic overuse days (AOD) before antibiotic stop policy (BASP) and after antibiotic stop policy (AASP) were compared.

METHODS

This descriptive analytical study was conducted to measure the change in AOD after implementing ASP in culture-negative HAI. We also sought to evaluate situations in which antibiotic overuse is likely (lower gestation, ventilation, central lines) and safety of the ASP, measured as not having to restart antibiotics in the week following completed course.

RESULTS

A total of 126 neonates were initiated on a new antibiotic (started or changed) for suspected HAI. Of these, 43 were excluded. Patient days of 5175 and 5208 were analyzed in BASP and AASP, respectively. Implementation of an ASP reduced AOD (from 14.49 to 3.26 AOD per 1000 patient days; p value <0.01). Safety was ensured; the number of babies who had to be restarted on antibiotics within 1 week of stopping therapy was similar in both groups. All-cause mortality and relevant morbidities were comparable between groups.

CONCLUSIONS

A significant decrease in AOD after the introduction of an ASP was noted, in neonates with culture-negative suspected HAI. This difference was noted even in the most vulnerable extreme preterm babies and those requiring ventilation and central lines.

Incidence and risk factors of urinary tract infection in neonatal sepsis

Background

Neonates with sepsis may have concurrent urinary tract infection (UTI), which may be asymptomatic or have nonspecific symptoms. Failure to diagnose UTI, resulting in a delay of appropriate therapy, has been reported to cause renal scarring, hypertension, and kidney failure among infants. This study aimed to determine the contribution of UTI to neonatal sepsis and to assess different risk factors that could be associated with UTI. This cross-sectional study was conducted at the Neonatal Intensive Care Unit (NICU) of Fayoum University Hospital, Fayoum, Egypt, between March 2018 and January 2019. Neonates of both genders from birth to the 28th day of life with clinical features of either early- or late-onset sepsis (during or after the first 3 days of life, respectively) were enrolled in this study. All neonates were subjected to complete history taking from the parents, full clinical examination, and laboratory investigations including complete blood count, C-reactive protein, blood culture, and urine culture.

Results

The current study included 100 neonates admitted to the NICU with clinical and laboratory features of sepsis. Positive blood culture (proven sepsis) was detected in 60%, and the proportion of positive urine culture (UTI) in the entire study group was 11%. The incidence of UTI was 11.7% in proven sepsis compared to 10% in suspected sepsis, and it was 16.36% in late-onset sepsis (LOS) versus 4.44% in early-onset sepsis (EOS). There was a statistically significant association between poor feeding and feeding intolerance and positive urine culture (UTI). Leukopenia and expert panel criteria score showed high sensitivity (81.80% and 90.90%, respectively) but low specificity for the diagnosis of UTI.

Conclusions

Gram-negative bacteria have been highly suspected in cases of neonatal sepsis. Poor feeding and feeding intolerance have association with positive urine culture. Finally, urine culture for sepsis was recommended especially in the late type.

Clinical assessment of neutrophil gelatinase-associated lipocalin as a potential diagnostic marker for neonatal sepsis: a prospective cohort study

Sepsis is a life-threatening condition associated with high morbidity and mortality rates among neonates. Clinical diagnosis is limited due to the neonates' unspecific signs and symptoms as well as the long time required to obtain the blood culture results. Consequently, there is an urgent need for new biomarkers to early diagnose neonatal sepsis. We aimed to evaluate Neutrophil Gelatinase-Associated Lipocalin (NGAL) diagnostic performance to detect neonatal sepsis. We enrolled 30 neonates with sepsis admitted to the neonatal intensive care units and 30 age- and sex-matched healthy neonates recruited from the neonatal outpatient clinic during their routine follow-up visits. We measured NGAL levels by sandwich enzyme-linked immunosorbent assay, the C-reactive protein (CRP) with nephelometry technique using BN II nephelometer, and the complete blood count by Mindray BC-6800 analysers. NGAL, CRP, TLC, haemoglobin, and platelet levels showed significant differences between cases and control (all p < .001). Of the 30 neonates with sepsis, 17 neonates (56.7%) survived. At 0 h, the NGAL level showed no statistically significant difference between the non-survivors and survivors' groups; however, after 96 h, NGAL was significantly higher in the non-survivors group (p ˂ .001). Our diagnostic analysis showed that NGAL levels have strong discrimination power to early differentiate neonates with sepsis; at the 475.00 pg/ml cut-off value, NGAL showed both sensitivity and specificity of 100% with an area under curve of 100%. Conclusion: Our study suggests that NGAL could be a promising biomarker for neonatal sepsis detection. Further studies with larger sample sizes and survival analysis are warranted to confirm this finding and to clarify the efficacy of NGAL in survival prediction. Key findingsNGAL level was high in neonates with sepsisNGAL level was high in non-survived neonatesNGAL could be a promising diagnostic marker for sepsis.

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

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

Effective Rapid Diagnosis of Bacterial and Fungal Bloodstream Infections by T2 Magnetic Resonance Technology in the Pediatric Population

Children are prone to bloodstream infections (BSIs), the rapid and accurate diagnosis of which is an unmet clinical need. The T2MR technology is a direct molecular assay for identification of BSI pathogens, which can help to overcome the limits of blood culture (BC) such as diagnostic accuracy, blood volumes required, and turnaround time. We analyzed results obtained with the T2Bacteria (648) and T2Candida (106) panels in pediatric patients of the Bambino Gesù Children's Hospital between May 2018 and September 2020 in order to evaluate the performance of the T2Dx instrument with respect to BC. T2Bacteria and T2Candida panels showed 84.2% and 100% sensitivity with 85.9% and 94.1% specificity, respectively. The sensitivity and specificity of the T2Bacteria panel increased to 94.9% and 98.7%, respectively, when BC was negative but other laboratory data supported the molecular result. T2Bacteria sensitivity was 100% with blood volumes <2 mL in neonates and infants. T2Bacteria and T2Candida provided definitive microorganism identification in a mean time of 4.4 and 3.7 h, respectively, versus 65.7 and 125.5 h for BCs (P < 0.001). T2 panels rapidly and accurately enable a diagnosis of a pediatric BSI, even in children under 1 year of age and for very small blood volumes. These findings support their clinical use in life-threatening pediatric infections, where the time to diagnosis is of utmost importance, in order to improve survival and minimize the long-term sequalae of sepsis. The T2 technology could be further developed to include more bacteria and fungi species that are involved in the etiology of sepsis.

The Role of C-reactive Protein Estimation in Determining the Duration of Antibiotic Therapy in Neonatal Sepsis

INTRODUCTION

Septicemia is globally considered the most important cause of neonatal morbidity and fatality. Serum C-Reactive Protein (CRP) is an acute phase reactant, which is brought out in response to the inflammatory reaction. It is prophesied to drop down speedily after the coherent weeding out of microbial incitation due to the short half-life of CRP. CRP levels reflect the individual's association between microbial infection and defensive mechanisms.  Methods: This hospital-based cross-sectional study included 150 admitted patients with suspected sepsis in the Department of Pediatrics, Rajendra Institute Medical Sciences (RIMS), Ranchi, India, over a study period of one year (2020 to 2021). CRP was estimated on the day of admission and repeated after 72 hours, on the fifth day, and on the seventh day for serial values of CRP, and the findings were compared by making three groups. Further, the research participants were designated to three different groups according to the CRP estimation levels.

RESULTS

Out of the 150 assumed neonatal septicemia patients, antibiotics were paused in 42 neonates (28%) within 72 hours. In group 2, 8% of neonates' antibiotics were stopped in five days, and a total of 102 neonates (68%) could be discharged on the seventh day of antibiotic therapy as their CRPs became negative on the third day and seventh day consecutively, along with negative blood culture reports. In group 3, antibiotics of 48 neonates (32%) were continued beyond seven days.

CONCLUSION

CRP has a skyscraping specificity and negative predictive values (NPV); thus, by estimating serial CRPs, the antibiotic therapy duration can be determined, which further helps determine the period of hospitalization.

Serial Measurement of Interleukin-6 Enhances Chance to Exclude Early-Onset Sepsis in Very Preterm Infants

The aim of this retrospective study was to evaluate the reliability of peak interleukin-6 (IL-6) level within 24 hours after delivery as a predictor for early-onset sepsis (EOS) in very preterm neonates. Interleukin-6 was assessed at 2 hours and at 12 to 24 hours after delivery. The highest level was considered a peak value. The definition of EOS was based on positive blood culture and clinical signs of infection or negative blood culture, clinical signs of infection, and C-reactive protein >10 mg/L. Among 445 enrolled infants, 53 developed EOS. A peak IL-6 level of more than 200 ng/L had a sensitivity of 89% and specificity of 77% for the presence of EOS. The negative predictive value was 98%. Receiver operating characteristics curve had area under the curve of 0.92. Peak IL-6 is a reliable marker of systemic inflammatory response and might be useful to exclude EOS within the first 24 hours.

Distribution of Presepsin, Krebs von den Lungen 6, and Surfactant Protein A in Umbilical Cord Blood

Presepsin is an early indicator of infection, and Krebs von den Lungen 6 (KL-6) and Surfactant Protein A (SP-A) are related to the pathogenesis of pulmonary infection and fibrosis. This study aimed to establish reference intervals (RIs) of presepsin, KL-6, and SP-A levels and to evaluate the possible influence of neonatal and maternal factors on presepsin, KL-6, and SP-A levels in umbilical cord blood (UCB). Among a total of 613 UCB samples, the outliers were removed. The RIs for presepsin, KL-6, and SP-A levels were defined using non-parametric percentile methods according to the Clinical and Laboratory Standards Institute guidelines (EP28-A3C). These levels were analyzed according to neonatal and maternal factors: neonatal sex, gestational age (GA), birth weight (BW), Apgar score, delivery mode, the presence of premature rupture of membranes (PROM), gestational diabetes mellitus (GDM), and pre-eclampsia. Presepsin, KL-6, and SP-A levels showed non-parametric distributions and left-skewed histograms. The RIs of presepsin, KL-6, and SP-A levels were 64.9–428.3 pg/mL, 43.0–172.0 U/mL, and 2.1–36.1 ng/mL, respectively. Presepsin, KL-6, and SP-A levels did not show significant differences according to sex, GA, BW, Apgar score, delivery mode, PROM, GDM, and pre-eclampsia. The median level and 97.5th centile RI of KL-6 showed a slight increase with increased GA. We established RIs for presepsin, KL-6, and SP-A levels in large-scaled UCB samples. Further investigation would be needed to determine the clinical significance.

Relationship between Maternal Fever and Neonatal Sepsis: A Retrospective Study at a Medical Center

Various risk factors are associated with neonatal sepsis; however, its relationship to maternal postpartum fever is unknown. This study aimed to determine the relationship between maternal postpartum fever and neonatal sepsis. Full-term and late preterm stable infants born from January 2019 to June 2021 and whose mothers developed intra- or post-partum fever were included in the study. After the newborns were transferred to the nursery, laboratory assessments were performed. Based on clinical conditions and data, the newborns were divided into unlikely sepsis and probable/proven sepsis groups. Maternal fever onset, duration, and maximum body temperature were recorded. We included 1059 newborns whose mothers developed fever intra-partum (n = 192), post-partum (n = 844), and intra- and post-partum (n = 23). The newborns were grouped into those with unlikely sepsis (n = 550) and those with probable/proven sepsis (n = 509). The incidence of intrapartum fever was higher in the probable/proven sepsis group than in the unlikely sepsis group (27.9% vs. 13.3%, p < 0.001). The incidence of postpartum fever was lower in the probable/proven sepsis group than in the unlikely sepsis group (74.7% vs. 88.5%, p < 0.001). Development of maternal fever within 1.8 h postpartum and a newborn respiratory rate of >60 breaths/min were positive predictors (91.6%) for neonatal probable/proven sepsis.

Prognostic Role of Procalcitonin and C-reactive Protein in Surgical Neonates: A Single-Institution Experience

Introduction

Neonatal sepsis is a dynamic process where the rigorous evaluation of clinical signs along with appropriately selected biomarkers guides the diagnosis of sepsis. Procalcitonin (PCT) and C-reactive protein (CRP) are the two most commonly used diagnostic biomarkers used in sepsis. Sepsis remains the most important cause of mortality and morbidity in surgical neonates. A cross-sectional study was conducted to assess the prognostic predictability of PCT and CRP in neonatal surgical sepsis.

Methods

All the neonates admitted to the neonatal surgical intensive care unit between January 2019 and December 2020 with features of sepsis were included in the study. Blood cultures, CRP, and PCT on Day one (PCT1) and Day three (PCT3) of suspicion of sepsis were evaluated. The receiver operating characteristics curve was studied to estimate the probability of two markers to predict the mortality in neonatal sepsis.

Results

Of 102 surgical neonates, 63 neonates had early-onset sepsis while 23 (22.5%) neonates died and 30 neonates reported positive blood culture. There was a decline in the overall PCT trend from PCT1 and PCT3, while a significant PCT rise was noted for the non-survival group (p= 0.003). At cut-off of 5 mg/dl for CRP and 2.5 ng/dl for PCT1 and PCT3, the sensitivity (36.0%, 25.8%, 100%), specificity (84.1%, 83.3%, 97.5%), positive predictive value (52.2%, 73.9%, 91.3%), and negative predictive values (73.4%, 38.0%, 100%) were observed.

Conclusion

PCT on Day three of suspected sepsis has higher sensitivity, specificity, and accuracy for prognostication of surgical neonatal sepsis at the cut-off value of 2.5 ng/ml. The rising trend of PCT levels is indicative of a poor prognosis.

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.

C-Reactive Protein-to-Albumin Ratio as an Early Biomarker to Identify Sepsis in Neonates with Pneumonia

Objectives

Neonates with pneumonia often also have sepsis, and the identifying sepsis from pneumonia may be a challenge for clinicians. However, there are no available data regarding the clinical value C-reactive protein-to-albumin ratio (CAR) in identifying sepsis in neonates with pneumonia. The aim of this study was to evaluate the clinical value of CAR in identifying sepsis in neonates with pneumonia.

Methods

847 neonates with pneumonia were included in this study, of which 511 neonates were diagnosed with sepsis. Neonates were divided into the sepsis group and the nonsepsis group. All neonates underwent extensive and necessary clinical and laboratory tests. CAR was calculated as serum C-reactive protein (ng/ml)/albumin (mg/ml). All statistical analyses were performed using the statistical package SPSS 24.0, as appropriate.

Results

Compared with the nonsepsis group, neonates with sepsis have a higher CAR (P < 0.001). Further analysis showed that the prevalence of neonates with sepsis increased significantly from 41.0% in the low CAR group (CAR ≤ 0.024 × 10⁻³) to 80.0% in the high CAR group (CAR > 0.024 × 10⁻³) (P < 0.001). Correlation analysis showed that there was a strong positive correlation between CAR and PCT (r = 0.452, P < 0.001), nSOFA (r = 0.267, P < 0.001), and the prolonged length of hospital stay (r = 0.311, P < 0.001). Multiple logistic regression showed that CAR was an independent risk factor for the presence of sepsis in neonates with pneumonia. Receiver operating characteristic curve analysis revealed that CAR had adequate discriminatory power in predicting sepsis in neonates with pneumonia (area under curve (AUC) = 0.76, 95% CI 0.73-0.79, P < 0.001).

Conclusions

CAR can be used as a new marker to identify sepsis in neonates with pneumonia.

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.

Global DNA hypomethylation and the expression profile of DNA methyltransferase genes in late-onset neonatal sepsis

Aim: Infectious organisms tend to cause DNA methylation changes. Thus, this paper aims to study global DNA methylation and the expression of DNA methyltransferase (DNMT) genes in late-onset neonatal sepsis (LONS). Methods: Global and Alu DNA methylation and expression levels of DNMT were performed using 5mc ELISA, methylation-specific PCR and quantitative real-time-PCR, respectively for LONS and controls. Results: Significant hypomethylation of global DNA and Alu DNA methylation and lower expression of DNMT1 and DNMT3a were observed in LONS compared with controls. Receiver operating characteristic analysis of global and Alu DNA methylation showed good discrimination for the identification of LONS. Conclusion: The hypomethylation of global DNA and Alu elements is evident in neonates with LONS. This may be clinically useful for the prognosis of LONS.

Association of Procalcitonin to Albumin Ratio with the Presence and Severity of Sepsis in Neonates

Purpose

Previous studies have demonstrated that procalcitonin and albumin have a close correlation with sepsis. However, the role of procalcitonin (PCT) to albumin (ALB) ratio (PAR) in sepsis was still unclear, especially in neonates. Thus, this study aimed to investigate the association between PAR and neonatal sepsis.

Patients and Methods

A total of 1,196 neonates with suspected sepsis were included in this study. Neonates were divided into control group and sepsis group, according to whether they were diagnosed with sepsis. Neonates with sepsis were further divided into mild sepsis and severe sepsis group according to the severity of sepsis. PAR was calculated as serum PCT (ng/mL)/ALB (mg/mL). All statistical analyses were performed using the statistical package SPSS 24.0, as appropriate.

Results

Compared with the control group, neonates with sepsis had a higher PAR. PAR also showed a significant gradual increase in the control, mild sepsis, and severe sepsis groups (P<0.001). Correlation analysis showed that there was a strong positive correlation between PAR and hsCRP, neonatal sequential organ failure assessment score (nSOFA), and prolonged length of hospital stay (P<0.001). On multiple logistic regression, higher PAR was independently associated with the presence and severity of neonatal sepsis. According to the receiver operating characteristic curve analysis, a PAR ≥0.065 had 64% sensitivity and 72% specificity in predicting the presence of neonatal sepsis (area under curve (AUC)=0.72, 95% CI=0.69–0.75, P<0.001) and a PAR≥0.070 had 69% sensitivity and 63% specificity in predicting the presence of severe sepsis (AUC=0.71, 95% CI=0.68–0.74, P<0.001).

Conclusion

PAR is significantly higher in neonates with sepsis and correlated with the severity of the disease. Increased PAR is an independent predictor useful for identifying the presence and severity of neonatal sepsis.

Bacterial DNA detection in very preterm infants assessed for risk of early onset sepsis

OBJECTIVES

The aim of this study is to evaluate the diagnostic ability of multiplex real-time polymerase chain reaction (PCR) in very preterm infants assessed for risk of early onset neonatal sepsis (EOS).

METHODS

Prospective observational cohort study. Blood samples of preterm neonates ≤32 weeks of gestation were evaluated by commercial multiplex real-time PCR within 2 h after delivery. The definition of EOS was based on positive blood culture and clinical signs of infection or negative blood culture, clinical signs of infection and abnormal neonatal blood count and serum biomarkers.

RESULTS

Among 82 subjects analyzed in the study, 15 had clinical or confirmed EOS. PCR was positive in four of these infants (including the only one with a positive blood culture), as well as in 15 of the 67 infants without sepsis (sensitivity 27%, specificity 78%). Out of 19 PCR positive subjects, Escherichia coli was detected in 12 infants (63%). Statistically significant association was found between vaginal E. coli colonization of the mother and E. coli PCR positivity of the neonate (p=0.001). No relationship was found between neonatal E. coli swab results and assessment findings of bacterial DNA in neonatal blood stream.

CONCLUSIONS

Multiplex real-time PCR had insufficient diagnostic capability for EOS in high risk very preterm infants. The study revealed no significant association between PCR results and the diagnosis of clinical EOS. Correlation between maternal vaginal swab results and positive PCR in the newborn needs further investigation to fully understand the role of bacterial DNA analysis in preterm infants.

Early-Onset Neonatal Sepsis in Low- and Middle-Income Countries: Current Challenges and Future Opportunities

Neonatal sepsis is defined as a systemic infection within the first 28 days of life, with early-onset sepsis (EOS) occurring within the first 72h, although the definition of EOS varies in literature. Whilst the global incidence has dramatically reduced over the last decade, neonatal sepsis remains an important cause of neonatal mortality, highest in low- and middle-income countries (LMICs). Symptoms at the onset of neonatal sepsis can be subtle, and therefore EOS is often difficult to diagnose from clinical presentation and laboratory testing and blood cultures are not always conclusive or accessible, especially in resource limited countries. Although the World Health Organisation (WHO) currently advocates a ß-lactam, and gentamicin for first line treatment, availability and cost influence the empirical antibiotic therapy administered. Antibiotic treatment of neonatal sepsis in LMICs is highly variable, partially caused by factors such as cost of antibiotics (and who pays for them) and access to certain antibiotics. Antimicrobial resistance (AMR) has increased considerably over the past decade and this review discusses current microbiology data available in the context of the diagnosis, and treatment for EOS. Importantly, this review highlights a large variability in data availability, methodology, availability of diagnostics, and aetiology of sepsis pathogens.

Extended Infusion of Meropenem in Neonatal Sepsis: A Historical Cohort Study

This single-center historical cohort study investigated the effectiveness and safety of extended infusion (EI) compared with short-term infusion (STI) of meropenem in neonatal sepsis. Patient electronic health records from Peking University Third Hospital (1 December 2011−1 April 2021) were screened. Neonates diagnosed with sepsis and treated with meropenem in the neonatal intensive care unit were included (256 patients) as STI (0.5 h, 129 patients) and EI (2−3 h, 127 patients) groups. Three-day clinical effectiveness and three-day microbial clearance were considered the main outcomes. Univariate and multivariate analyses were performed. Baseline characteristics were similar in both groups. EI of meropenem was associated with a significantly higher 3-day clinical effectiveness rate (0.335 (0.180, 0.623), p = 0.001) and 3-day microbial clearance (4.127 (1.235, 13.784), p = 0.021) than STI, with comparable safety. Subgroup analyses showed that neonates with very low birth weight benefited from EI in terms of 3-day clinical effectiveness rate (75.6% versus 56.6%, p = 0.007), with no significant difference in the 3-day clinical effectiveness (85.1% versus 78.3%, p = 0.325) and microbial clearance (6% versus 5%, p > 0.999) rates between 3 h and 2 h infusions. Thus, EI of meropenem may be associated with better effectiveness and comparable safety in treating neonatal sepsis than STI. Nonetheless, historically analyzed safety evaluation might be biased, and these findings need confirmation in randomized controlled trials of larger sample sizes.

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.

Untargeted 1H-NMR Urine Metabolomic Analysis of Preterm Infants with Neonatal Sepsis

One of the most critical medical conditions occurring after preterm birth is neonatal sepsis, a systemic infection with high rates of morbidity and mortality, chiefly amongst neonates hospitalized in Neonatal Intensive Care Units (NICU). Neonatal sepsis is categorized as early-onset sepsis (EOS) and late-onset sepsis (LOS) regarding the time of the disease onset. The accurate early diagnosis or prognosis have hurdles to overcome, since there are not specific clinical signs or laboratory tests. Herein, a need for biomarkers presents, with the goals of aiding accurate medical treatment, reducing the clinical severity of symptoms and the hospitalization time. Through nuclear magnetic resonance (NMR) based metabolomics, we aim to investigate the urine metabolomic profile of septic neonates and reveal those metabolites which could be indicative for an initial discrimination between the diseased and the healthy ones. Multivariate and univariate statistical analysis between NMR spectroscopic data of urine samples from neonates that developed EOS, LOS, and a healthy control group revealed a discriminate metabolic profile of septic newborns. Gluconate, myo-inositol, betaine, taurine, lactose, glucose, creatinine and hippurate were the metabolites highlighted as significant in most comparisons.

MicroRNA Expression in Neonates with Late-onset Sepsis - A Cross-sectional Comparative Study

BACKGROUND

Neonatal sepsis is a major health concern among neonates with higher morbidity and mortality rate. Studies have recently speculated the importance of differential expression of circulating mature micro-RNAs (miRNAs) which could serve as diagnostic as well as prognostic markers for risk of mortality in neonatal sepsis. This study aimed to analyze the expression pattern and to assess the diagnostic/prognostic value of miRNAs miR-21, miR-29a miR-31, miR-146a, and miR-155 in late-onset neonatal sepsis.

METHODS

A cross-sectional comparative study was conducted including 42 healthy controls and 42 neonates with late-onset neonatal sepsis. SYBR green-based miScript RT-PCR assay was used for the expression analysis and the comparative Ct method 2-delta (Ct) method was used for relative quantification of the candidate miRNAs in plasma. Significantly higher expression of miR-21 and miR-155 and lower expression of miR-29a and miR-146a was observed in cases compared to control except miR-31. In subgroups analysis, miR-21(p = .03) showed a significant difference between pre-term and term neonates and miR-31 (p = .01) and miR-155 (p = .03) showed a significant difference between low-birth-weight and normal-birth-weight neonates. miR-146a showed significantly lower expression in the non-survivor group compared to the survivor group (p = .005). A receiver operating characteristic curve (ROC) analysis of miR-21 and miR-29a (0.829 and 0.787 AUC of ROC curves) showed good discrimination for the identification of sepsis from non-sepsis neonates.

CONCLUSION

The current study shows evidence of differential expression of miRNAs in neonatal sepsis and this altered expression of candidate miRNAs could be involved in immune dysregulation, thus leading to sepsis-related severity in newborns.

Look Who's Talking: Host and Pathogen Drivers of Staphylococcus epidermidis Virulence in Neonatal Sepsis

Preterm infants are at increased risk for invasive neonatal bacterial infections. S. epidermidis, a ubiquitous skin commensal, is a major cause of late-onset neonatal sepsis, particularly in high-resource settings. The vulnerability of preterm infants to serious bacterial infections is commonly attributed to their distinct and developing immune system. While developmentally immature immune defences play a large role in facilitating bacterial invasion, this fails to explain why only a subset of infants develop infections with low-virulence organisms when exposed to similar risk factors in the neonatal ICU. Experimental research has explored potential virulence mechanisms contributing to the pathogenic shift of commensal S. epidermidis strains. Furthermore, comparative genomics studies have yielded insights into the emergence and spread of nosocomial S. epidermidis strains, and their genetic and functional characteristics implicated in invasive disease in neonates. These studies have highlighted the multifactorial nature of S. epidermidis traits relating to pathogenicity and commensalism. In this review, we discuss the known host and pathogen drivers of S. epidermidis virulence in neonatal sepsis and provide future perspectives to close the gap in our understanding of S. epidermidis as a cause of neonatal morbidity and mortality.

Clinical Value of Prognostic Nutritional Index in Prediction of the Presence and Severity of Neonatal Sepsis

Purpose

The prognostic nutritional index (PNI) is a common indicator of nutritional and inflammatory status and is associated with various diseases such as cancer, cardiovascular diseases and infectious diseases. However, to date, no study has concentrated on the role of PNI in assessing and predicting the presence and severity of neonatal sepsis. Therefore, the present study aimed to explore the association of the PNI with the presence and severity of neonatal sepsis.

Materials and Methods

A total of 1196 neonates with suspected sepsis were enrolled in this study and their complete clinical and laboratory data were collected. PNI was calculated as serum albumin (g/L) + 5 × total lymphocyte count (10⁹/L). Multivariate logistic regression analysis was performed to identify the risk factors for the presence and severity of neonatal sepsis. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of PNI. All statistical analyses were performed using the statistical package SPSS 24.0.

Results

PNI was lower in neonates with sepsis and decreased significantly with the severity of sepsis. The correlation analysis demonstrated that the PNI was negatively correlated with the levels of the inflammatory marker procalcitonin (PCT) and C-reactive protein (CRP), and the length of hospital stay. Multivariate logistic regression analysis revealed that the PNI was independently and inversely associated with the presence and severity of neonatal sepsis. The area under the ROC curve of the PNI was 0.64 (95% confidence interval (CI): 0.61–0.67, P < 0.001) for severe sepsis and 0.69 (95% CI: 0.60–0.78, P < 0.001) for septic shock. In addition, our data revealed that PNI was also independently correlated with the length of hospital stay.

Conclusion

PNI is an independent predictor for the presence and severity of neonatal sepsis.