Neonatal sepsis: a major global public health challenge

Bacteriological Profile and Antibiotic Susceptibility Patterns of Late-Onset Neonatal Sepsis in Levels III and IV Neonatal Intensive Care Units

Late-onset sepsis (LOS), which occurs 72 hours after birth, remains an important cause of mortality and morbidity in the neonatal intensive care unit (NICU). Differences in infant populations and the complexity of care at various NICU levels may result in varying bacteriological profiles and antibiotic susceptibility patterns. The objective of the current study was to determine and compare the bacteriological profiles, antibiotic susceptibility, and risk factors for LOS in levels III and IV NICU within a single hospital system. This was a retrospective study of infants with LOS and positive blood cultures, admitted to levels III and IV NICUs between 2012 and 2021. Of the 173 infants included in our study, 105 were admitted to the level IV NICU and 68 to the level III NICU. Infants in the level III NICU had a lower gestational age and birth weight at the time of LOS. Seventy percent of the infants had a central line. Gram-positive organisms were responsible for the vast majority of infections (75%), with coagulase-negative Staphylococcus (CoNS) being the most common bacteria in both units. Gram-negative bacteria were more frequently isolated from the level IV NICU (36.2%) compared to the level III NICU (8.8%). Escherichia coli (E. coli) and Enterobacter sp. were the most frequently isolated gram-negative bacteria. All gram-positive bacteria were susceptible to vancomycin, and all gram-negative bacteria were susceptible to meropenem. The prevalent bacteriological profile and antibiotic susceptibility patterns in the NICU should guide the choice of empiric antibiotics for LOS. It is important to monitor sepsis and antimicrobial resistance patterns in the NICU and implement risk-specific strategies to reduce the burden of LOS. · LOS in NICUs is predominantly caused by gram-positive bacteria, mainly CoNS.. · Higher frequency of gram-negative bacteria, including E. coli and Enterobacter, in level IV NICU.. · All gram-negative isolates were meropenem-sensitive; vancomycin effective for gram-positives..

Association between NICU intensivist staffing and neonatal outcomes

We aimed to evaluate whether neonatal intensive care unit (NICU) intensivist staffing is associated with improved survival outcomes among neonates admitted to NICUs in South Korea. This nationwide retrospective cohort study included all neonates hospitalized in NICUs between January 1, 2019, and December 31, 2021. Patients were categorized into two groups based on intensivist staffing: the intensivist group, comprising neonates admitted to hospitals with full-time NICU intensivists, and the non-intensivist group, comprising those treated in hospitals without dedicated NICU intensivist coverage. A total of 79,306 neonates were included in the final analysis; among them, 44,330 (56.1%) were admitted to NICUs with registered NICU intensivists. In multivariable logistic regression analysis, the intensivist group had a significantly lower odds of 30-day mortality (odds ratio [OR]: 0.73; 95% confidence interval [CI] 0.58-0.92; P = 0.007) compared to the non-intensivist group. Similarly, in Cox regression analysis, the intensivist group showed a lower risk of 1-year all-cause mortality (hazard ratio: 0.79; 95% CI 0.69-0.91; P = 0.001). These findings suggest that the presence of dedicated NICU intensivists is associated with improved short- and long-term survival outcomes among neonates, supporting policies to enhance specialized staffing in neonatal intensive care settings.

Demystifying Prolonged Antibiotic Use for Blood Culture-negative Sepsis Evaluations in the Neonatal Intensive Care Unit

OBJECTIVE

This study aimed to determine the incidence and clinical characteristics of infants evaluated and treated with a prolonged course of antibiotics for culture-negative sepsis in a quaternary Neonatal Intensive Care Unit (NICU) over a 4-year period.

STUDY DESIGN

Retrospective chart review of patients in the NICU at Children's Hospital of Philadelphia who had negative blood cultures and received ≥5 days of antibiotics. Data collection included demographics, clinical and laboratory data, and underlying diagnoses. Statistical analysis included Mann-Whitney and chi-square tests, and multivariable logistic regression.

RESULTS

We identified 774 culture-negative sepsis evaluations where antibiotic treatment was continued ≥5 days. While the majority were attributed to a focal etiology, 146 had negative blood cultures and no focal source. Infants with no focal source were younger at the time of sepsis evaluation, of greater gestational age, and more frequently required extracorporeal membrane oxygenation (P < 0.001). In multivariable analysis, evaluations for early-onset disease and need for extracorporeal membrane oxygenation were increased among infants with no focal source (P < 0.01). Although rates of invasive ventilation, and central venous catheters were similar, length of stay and mortality were significantly higher in late-onset episodes (P < 0.001 and P = 0.029, respectively). Consultation with the infectious disease team increased during the study period (P = 0.002).

CONCLUSIONS

Although it is challenging to limit the initiation of antibiotics in infants with complex underlying disease processes with concern for sepsis, minimizing antibiotic use can be achieved by timely discontinuation when cultures are negative. A robust antimicrobial stewardship program can identify valid reasons for prolonged antibiotic administration and suggest approaches to minimize antibiotic exposure.

Proposed Core Outcomes After Neonatal Sepsis: A Consensus Statement

Importance

Sepsis is one of the leading causes of neonatal mortality. There is heterogeneity in the outcomes measured and reported in studies of neonatal sepsis. To address this challenge, a core outcome set (COS) for research on neonatal sepsis was needed.

Objective

The Neonatal Sepsis Core Outcome Set (NESCOS) project aims to develop a COS for research evaluating the effectiveness of neonatal sepsis treatments.

Evidence Review

For this consensus statement, the research team obtained ethics approval and used a 4-stage process: (1) a systematic review of qualitative studies, (2) a real-time Delphi (RTD) survey to identify important outcomes for consensus meetings, (3) consensus meetings to finalize the COS, and (4) dissemination of the findings. The study was conducted from May 2, 2022, to October 27, 2023. The steering group and project participants consisted of health care workers, researchers, academics, parents, and parent representatives from low-, middle-, and high-income countries. An RTD survey and consensus meetings were conducted, with measures including a 9-point Likert scale rating (where 1 indicated not at all important and 9 indicated critically important) for outcome importance and a minimum 80% agreement threshold among stakeholders for final COS inclusion. The systematic review identified 19 outcomes, which were combined with outcomes from previous systematic reviews of clinical trials.

Findings

The RTD survey included 306 participants, leading to the identification of 55 outcomes for further discussion in consensus meetings. The finalized COS comprises 9 outcomes: all-cause mortality, need for mechanical ventilation, brain injury on imaging, neurologic status at discharge, escalation of antimicrobial therapy, central nervous system infections, multiorgan dysfunction, neurodevelopmental impairment, and quality of life of parents.

Conclusions and Relevance

This consensus-based COS for research on neonatal sepsis treatments will help standardize the outcomes measured and reported, enhancing the comparability of research findings. Future efforts should focus on establishing standardized and reliable methods for measuring these outcomes.

Prevalence and pathogen profiles of bacteremia in neonates hospitalized for clinical Sepsis in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Bacteremia is prevalent in neonates, largely attributed to factors inherent in the neonatal period. However, the prevalence of proven bacteremia in Ethiopian neonates has not been previously synthesized. Accordingly, this systematic review and meta-analysis aimed to analyze the prevalence of bacteremia and pathogen profiles in neonates hospitalized for clinical sepsis in Ethiopia.

METHODS

This systematic review and meta-analysis followed the preferred reporting items for systematic review and meta-analysis (PRISMA) 2020. The literature search was conducted across five databases including PubMed, Google Scholar, Web of Science, Science Direct, and Research for Life spanning from January 2015 to July 2023. The search strategy used MeSH terms and involved screening titles and abstracts, reviewing full-text articles, and including only observational studies published in English within the specified timeframe. Data extraction and quality assessment were performed by three experienced reviewers using a validated data collection tool and the Joanna Briggs Institute quality assessment tool, respectively. The prevalence of neonatal bacteremia was determined through a random effects model, with heterogeneity among studies assessed using the Q statistic and the I2 statistic. Publication bias was evaluated using a funnel plot and Egger's regression test, and STATA version 16.0 was used for all analysis at 95% confidence level.

RESULTS

A meta-analysis of nine studies revealed a bacteremia prevalence of 40.0% (95% CI: 34.0-46.0%). Subgroup analysis indicated variations in prevalence based on regions and study designs, with Oromia at 44.0% (95% CI: 28.0, 61.0%) and Amhara at 39.0% (95% CI: 27.0, 51.0%). Longitudinal studies exhibited a higher prevalence (47.0%, 95% CI: 27.0-68.0%) compared to cross-sectional designs (38.0%, 95% CI: 32.0-44.0%). Gram-negative bacteria were identified as the predominant etiological agents, representing 59.5% (95% CI: 56.8-62.3%) of cases. Among the bacterial species, Staphylococcus aureus emerged as the most prevalent (20.0%, 95% CI: 18.0%, 22.0%), followed by coagulase-negative staphylococci and Klebsiella pneumoniae, each contributing to 17.0% (95% CI: 15.0%, 20.0%) of bacteremia cases.

CONCLUSION

The study revealed a significant high prevalence of bacteremia, with differences noted across regions and study designs. Key pathogens identified were Staphylococcus aureus, Klebsiella pneumoniae and coagulase-negative staphylococci. It is advisable to implement surveillance systems, targeted prevention strategies, diagnostic stewardship, and further research on regional variations and bacterial profiles to effectively enhance the ominous future.

Whole-Genome Sequencing of Invasive Neonatal Escherichia coli From Uppsala County, Sweden

BACKGROUND

This study sought to investigate associations between virulence factors and phylogeny in all neonatal Escherichia coli bloodstream infections from patients admitted to the neonatal intensive care unit at Uppsala University Hospital between 2005 and 2020.

METHODS

A total of 37 E. coli isolates from 32 neonates were whole-genome sequenced and analyzed for virulence factors related to extraintestinal E. coli; patient-related data were collected retrospectively from the medical records.

RESULTS

E. coli isolates that belong to phylogroup B2 were associated with mortality (odds ratio [OR], 26; P < .001), extreme prematurity with delivery before gestational week 28 (OR, 9; P < .05), and shock (OR, 9; P < .05) compared with isolates of non-B2 group. Female neonates were more often infected with isolates of phylogroup B2 E. coli compared with male neonates (OR, 7; P = .05). The identification of the genotoxin determinant clb coding for colibactin exhibited strong associations with mortality (OR, 67; P < .005), gestational age (OR, 18; P < .005), and shock (OR, 26; P < .005).

DISCUSSION

The study highlighted the correlation between neonatal E. coli bacteremia caused by phylogroup B2 and the role of colibactin. Results emphasize difference between male and female neonates in E. coli populations in bloodstream infections.

Predictors of gentamicin therapy failure in neonates with sepsis

Sepsis is a common disease with high morbidity and mortality among newborns in intensive care units world-wide. Gram-negative bacillary bacteria are the major source of infection in neonates. Gentamicin is the most widely used aminoglycoside antibiotic in empiric therapy against early-onset sepsis. However, therapy failure may result due to various factors. The purpose of this study was to identify predictors of gentamicin therapy failure in neonates with sepsis. This was a prospective cross-sectional study at the Neonatal Intensive Care Unit at Windhoek Central Hospital over a period of 5 months in 2019. Neonates received intravenous gentamicin 5 mg/kg/24 h in combination with either benzylpenicillin 100 000 IU/kg/12 h or ampicillin 50 mg/kg/8 h. Logistic regression modeling was performed to determine the predictors of treatment outcomes. 36% of the 50 neonates were classified as having gentamicin treatment failure. Increasing treatment duration by 1 day resulted in odds of treatment failure increasing from 1.0 to 2.41. Similarly, one unit increase in CRP increases odds of gentamicin treatment failure by 49%. The 1 kg increase in birthweight reduces the log odds of treatment failure by 6.848, resulting in 99.9% decrease in the odds of treatment failure. One unit increase in WBC reduces odds of gentamicin treatment failure by 27%. Estimates of significant predictors of treatment failure were precise, yielding odds ratios that were within 95% confidence interval. This study identified the following as predictors of gentamicin therapy failure in neonates: prolonged duration of treatment, elevated C-reactive protein, low birthweight, and low white blood cell count.

Markers of platelet activation foR identification of late onset sEpsis in infaNTs: PARENT study protocol

BACKGROUND

Newborns are at high risk of sepsis. At present there is no definitive "rule in" blood test for sepsis at the point of clinical concern. A positive blood culture remains the gold standard test for neonatal sepsis, however laboratory markers that correlate prospectively with culture positive sepsis could aid clinicians in making decisions regarding administration of empiric antibiotic therapies.

METHODS

This multi-site, prospective observational study will take place in two neonatal intensive care units (National Maternity Hospital and Rotunda Hospital, Dublin). Neonates born at less than 34 weeks will be enroled and informed consent obtained prior to late onset sepsis work up. If at any point subsequently during their neonatal intensive care stay they develop signs and symptoms of possible sepsis requiring blood culture, an additional sodium citrate sample will be obtained. Infants will be categorised into three groups as follows: (i) culture positive sepsis, (ii) culture negative sepsis where an infant receives 5 days of antibiotics (iii) non sepsis. Our primary outcome is to establish if differential platelet/endothelial activation can prospectively identify neonatal culture positive late onset sepsis.

TRIAL REGISTRATION NUMBER

NCT05530330 IMPACT: Preterm infants are a high risk group for the development of sepsis which is a major cause of mortality in this population. Platelets have been associated with host response to invasive bacterial infections both in animal models and translational work. A positive blood culture is the gold standard test for neonatal sepsis but can be unreliable due to limited blood sampling in the very low birth weight population. This study hopes to establish if platelet/endothelial associated plasma proteins can prospectively identify late onset neonatal sepsis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Advancement in biomarker based effective diagnosis of neonatal sepsis

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

Late-Onset Sepsis in Very Low Birth Weight Infants

BACKGROUND AND OBJECTIVES

Late-onset sepsis is associated with significant morbidity and mortality among very low birth weight (VLBW) infants. Our objective was to determine risk factors associated with late-onset sepsis and to present temporal trends in overall and pathogen-specific rates.

METHODS

Population-based study by the Israel Neonatal Network on VLBW infants (≤1500 g) born between 1995 and 2019. Late-onset sepsis required clinical symptoms and microbiologic confirmation. Bivariate and multivariable analyses were performed to identify risk factors. The study period was divided into 4 epochs. Overall and pathogen-specific late-onset sepsis rates for each epoch were compared.

RESULTS

The study population comprised 31 612 VLBW infants, of whom 7423 (23.5%) had late-onset sepsis. An increased adjusted risk of late-onset sepsis was associated with gestational age <27 w (odds ratio [OR] 8.90, 95% confidence interval [CI] 7.85-10.09) and delivery room resuscitation (OR 1.43, 95% CI 1.34-1.52) and a decreased adjusted risk among infants born between 2013 and 2019 (OR 0.32, 95% CI 0.29-0.35). Late-onset sepsis rates declined from 29.5% in 1995 to 2000 to 13.0% in 2013 to 2019. Gram-negative and fungal rates decreased in all epochs, whereas gram-positive rates decreased only in the last epoch. The adjusted hazard ratios (95% CI) decreased in the 2013 to 2019 versus 1995 to 2000 epochs and were: all late-onset sepsis, 0.40 (0.37-0.43); gram-positive, 0.47 (0.37-0.59); gram- negative, 0.54 (0.48-0.61); fungal, 0.17 (0.12-0.22).

CONCLUSIONS

The strongest risk factor for late-onset sepsis was gestational age <27 w. Over a 25-year period, the pathogen-specific rates of late-onset sepsis among VLBW infants decreased approximately twofold for gram-positive and gram-negative bacterial infections and sixfold for fungal infections.

Development and clinical impact assessment of a machine-learning model for early prediction of late-onset sepsis

BACKGROUND AND AIM

Preterm infants are prone to neonatal infections such as late-onset sepsis (LOS). The consequences of LOS can be severe and potentially life-threatening. Unfortunately, LOS often presents with unspecific symptoms, and early screening laboratory tests have limited diagnostic value and are often late. This study aimed to build a predictive algorithm to aid doctors in the early detection of LOS in very preterm infants.

METHODS

In a retrospective cohort study, all consecutively admitted preterm infants (GA ≤ 32 weeks) from 2008 until 2019 were included. They were classified as LOS or control according to blood culture results, currently the gold standard. To generate features, routine and continuously measured oxygen saturation and heart rate data with a minute-by-minute sampling rate were extracted from electronic medical records. Care was taken not to include variables indicative of existing LOS suspicion. The timing of a positive blood culture served as a proxy for LOS-onset. An equivalent timestamp was generated in gestational-age-matched control patients without a positive blood culture. Three machine learning (ML) techniques (generalized additive models, logistic regression, and XGBoost) were used to build a classification algorithm. To simulate the performance of the algorithm in clinical practice, a simulation using multiple alarm thresholds was performed on hourly predictions for the total hospitalization period.

RESULTS

292 infants with LOS were matched to 1497 controls. The median gestational age before matching was 28.1 and 30.3 weeks, respectively. Evaluation of the overall discriminative power of the LR algorithm yielded an AUC of 0.73 (p < 0.05) at the moment of clinical suspicion (t = 0). In the longitudinal simulation, our algorithm detects LOS in at least 47% of the patients before clinical suspicion without exceeding the alarm fatigue threshold of 3 alarms per day. Furthermore, medical experts evaluated the algorithm as clinically relevant regarding the feature contributions in the model explanations.

CONCLUSIONS

An ML algorithm was trained for the early detection of LOS. Performance was evaluated on both prediction horizons and in a clinical impact simulation. To the best of our knowledge, our assessment of clinical impact with a retrospective simulation on longitudinal data is the most extensive in the literature on LOS prediction to date. The clinically relevant algorithm, based on routinely collected data, can potentially accelerate clinical decisions in the early detection of LOS, even with limited inputs.

Evaluation of Haematological Parameters and Uric Acid in the Diagnosis of Late Onset Neonatal Sepsis

Introduction A number of parameters studied in a whole blood count can be helpful in the diagnosis of neonatal sepsis. The platelet/lymphocyte ratio (PLR) is a systemic inflammatory marker in early sepsis and has been used as a diagnostic indicator in cardiovascular events and cancer. Being one of the major antioxidants in human biological fluids, serum uric acid is responsible for neutralising free radicals. The red cell distribution width/platelet ratio (RPR) is a diagnostic marker in adult inflammatory diseases. The objective of our study is to investigate the relationship of late neonatal sepsis with whole blood count parameters and serum uric acid levels. Materials and methods Newborns older than postnatal three days who had clinical and laboratory findings of sepsis were included in the study. The study included 140 newborns who were divided into three groups, 53 in the culture-proven late sepsis group, 47 in the clinical sepsis group, and 40 in the healthy control group. The whole blood count parameters and serum uric acid levels were examined in both the clinical sepsis and proven sepsis patients at the time when they were diagnosed with sepsis. Results The birth week was significantly lower in the evidenced and clinical sepsis patients compared to the healthy control group. Development of late sepsis was significantly higher in the male gender than in healthy controls. Serum uric acid levels were significantly higher in proven or clinical sepsis than in healthy controls. The level of serum uric acid (3.77±1.6) in proven sepsis was significantly higher than the control group (2.83±1.1). The uric acid level had an area under the curve (AUC) 0.552-0.717, 35% sensitivity, 95% specificity, 94.6% positive predictive value (PPV), and 36.9% negative predictive value (NPV) in the diagnosis of proven and clinical late sepsis. Neutrophil/lymphocyte ratio (NLR) was significantly higher in proven sepsis than in healthy newborns and was higher in the clinical sepsis group than in the proven sepsis group (p: 0.002). While the mean eosinophil value was 618.5±472.1 in proven sepsis, it was 549.3±294.9 in the control group and there was a statistically significant difference between the two groups (p: 0.036). Conclusion In late-onset neonatal sepsis, the NLR level was higher, and the eosinophil level was lower in the clinical sepsis patients than in healthy newborns. We believe that a higher level of serum uric acid in sepsis is effective in the early diagnosis of patients who also had other clinical findings of sepsis.

Clinical and laboratory findings to differentiate late-onset sepsis caused by Gram-negative vs Gram-positive bacteria among perterm neonates: A retrospective cohort study

PURPOSE

Late-onset sepsis (LOS) is a clinical condition that results in serious morbidity and mortality in preterm neonates. The aim of this study was to identify differences in clinical and laboratory findings of LOS caused by Gram-negative vs Gram-positive bacteria among perterm neonates and to evaluate the diagnostic accuracy of biomarkers.

METHODS

The retrospective cohort study included 649 preterm neonates with LOS assigned to either the Gram-positive group (n = 194, 29.89 %) or the Gram-negative group (n = 455, 70.11 %). Demographic data, serum levels of C-reactive protein (CRP), and complete blood counts at 0-24 h (T1), 24-48 h (T2), and 48-72 h (T3) were retrieved and compared.

RESULTS

At T1, T2, and T3, serum CRP levels were higher (p < 0.001), while platelet (PTL) counts were significantly lower (p < 0.001) in the Gram-negative group vs Gram-positive group. The area under the curve (AUC) of the PLT count was 0.688 (95 % confidence interval [CI] = 0.644-0.731) at T1, 0.795 (95 % CI = 0.743-0.848) at T2, and 0.785 (95 % CI = 0.739-0.831) at T3, indicating good discriminatory power, while the AUC of serum CRP was 0.654 (95 % CI = 0.61-0.697) at T1, 0.831 (95 % CI = 0.781-0.888) at T2, and 0.94 (95 % CI = 0.744-0.843) at T3.

CONCLUSIONS

Neonatal LOS caused by Gram-negative bacteria was associated with higher CRP and lower PLT levels. These results suggested that PLT and CRP values may be useful biomarkers to differentiate sepsis caused by Gram-negative vs Gram-positive bacteria among perterm neonates.

Late-onset neonatal sepsis: genetic differences by sex and involvement of the NOTCH pathway

BACKGROUND

Late-Onset Neonatal Sepsis (LOS) is a rare condition, involving widespread infection, immune disruption, organ dysfunction, and often death. Because exposure to pathogens is not completely preventable, identifying susceptibility factors is critical to characterizing the pathophysiology and developing interventions. Prior studies demonstrated both genetics and infant sex influence susceptibility. Our study was designed to identify LOS associated genetic variants.

METHODS

We performed an exploratory genome wide association study (GWAS) with 224 LOS cases and 273 controls from six European countries. LOS was defined as sepsis presenting from 3 to 90 days of age; diagnosis was established by clinical criteria consensus guidelines. We tested for association with both autosomal and X-chromosome variants in the total sample and in sex-stratified analyses.

RESULTS

In total, 71 SNPs associated with neonatal sepsis at p < 1 × 10^-4 in at least one analysis. Most importantly, sex-stratified analyses revealed associations with multiple SNPs (28 in males and 16 in females), but no variants from single-sex analyses associated with sepsis in the other sex. Pathway analyses showed NOTCH signaling is over-represented among genes linked to these SNPS.

CONCLUSION

Our results indicate genetic susceptibility to LOS is sexually dimorphic and corroborate that NOTCH signaling plays a role in determining risk.

IMPACT

Genes associate with late onset neonatal sepsis. Notch pathway genes are overrepresented in associations with sepsis. Genes associating with sepsis do not overlap between males and females. Sexual dimorphism can lead to sex specific treatment of sepsis.

Association of antenatal magnesium sulfate with reduced late-onset sepsis in extreme preterm infants

OBJECTIVES

Neonatal intensive care has changed extensively over the last decades resulting in improved survival of extreme preterm infants. However, improved survival is associated with prolonged hospitalization, mechanical ventilation and use of invasive devices, which are all predisposing factors for LOS. LOS is known to increase short- and long-term morbidities resulting in impaired neurodevelopmental outcome. Besides treatment with antibiotics and supportive care, there is an unmet need for adjunctive therapies to prevent neonatal sepsis and hereby improve outcome.

METHODS

In a retrospective single-center design, we explored underlying pre-, peri- and postnatal factors in extreme preterm infants with and without LOS to potentially identify future strategies in the prevention of LOS in these infants.

RESULTS

Associations formerly published could be confirmed, such as lower birth weight, longer duration of respiratory support, parenteral nutrition and NICU stay and a higher incidence of almost all neonatal morbidities. A new interesting finding was the fact that infants with LOS received more antenatal magnesium sulfate (p = 0.002). After nearest neighbor matching based on birth weight, gestational age, gender and multiplicity increased duration of parenteral nutrition and NICU stay, the incidence of PVL remained significantly different between the two groups (LOS/no LOS), but also the association between antenatal magnesium sulfate administration and less LOS held true (p = 0.004).

CONCLUSION

In this study, extreme preterm infants receiving antenatal magnesium sulfate developed less LOS. Whether this is merely an associative factor reflecting illness severity or an interesting link for new preventive strategies for LOS, should be further explored.

Glimpses from My Academic Journey : Based on the 15th Dr. K. C. Chaudhuri Lifetime Achievement Award Oration Delivered on 9th October 2022

This article is based on the contents of 'Dr. K. C. Chaudhuri Lifetime Achievement Award Oration' delivered on the Indian Journal of Pediatrics Annual Day 2022. The author shares glimpses of his academic journey from a remote village to a central Institute. This includes his career as a medical teacher and developing the Department of Neonatology at JIPMER, Pondicherry. This article is primarily focused on some of the significant research conducted during his tenure, like perinatal asphyxia, therapeutic hypothermia, neonatal sepsis, intrauterine growth restriction, and human milk banking.

Determinants of late-onset neonatal sepsis among neonates admitted to the neonatal intensive care unit of Arba-Minch general hospital, southern Ethiopia

INTRODUCTION

Neonatal sepsis can be either early (<7 Days) or late-onset ≥7days) neonatal sepsis depending on the day of the occurrence. Despite the decrement in early onset neonatal sepsis, there is still an increment in late-onset neonatal sepsis. Ethiopian demography and health survey report showed an increment in neonatal mortality in 2019/20.

OBJECTIVE

The objective of this study was to assess the determinants of late-onset neonatal sepsis among neonates admitted to the neonatal intensive care unit at Arba-Minch general hospital, southern Ethiopia.

METHODS

An institution based study was conducted from March 1, 2021, to June 30, 2021 in Arba-Minch general hospital. Cases were neonates diagnosed with late-onset neonatal sepsis with their index mother chart and controls were neonates admitted with other diagnoses at the same period. Cases and controls were selected consecutively. Data extraction tool and interview which was developed by reviewing different kinds of literature was used to collect data. Data were entered by using Epi data version 3.1software and transformed to Statistical Package for Social Sciences version 25 software for analysis. The binary logistic regression model was used to assess determinants and variables with a p-value <0.2 were transformed to multivariable logistic regression then, a p-value < 0.05 with 95% confidence interval were used to declare significant association with the outcome variable.

RESULT

A total of 180 subjects (60 cases and 120 controls) were included in this study. The mean age of neonates was 12.1 days with standard deviations of 4.3. Multivariable logistic regression analysis showed that; history of either sexually transmitted disease /urinary tract infection [AOR = 9.4; 95%CI(3.1-28.5)], being preterm (gestational age of <37 weeks) [AOR = 4.9; 95%CI (1.7-13.7)], use of endotracheal intubation/mechanical intubation [AOR = 8.3; 95%CI (1.8-26.4)]and either mixed types of infant feeding option or formula feeding before admission [AOR = 12.7; 95%CI(3.7-42.8)]were significantly associated with late-onset neonatal sepsis.

CONCLUSION AND RECOMMENDATIONS

This study revealed that antenatal, intrapartum and postpartum factors have shown an association with late-onset neonatal sepsis. It is recommended to strengthen counseling and advice to mothers with specific risk factors of late-onset neonatal sepsis.

Infectious aetiologies of neonatal illness in south Asia classified using WHO definitions: a primary analysis of the ANISA study

Background

Globally, neonatal mortality accounts for almost half of all deaths in children younger than 5 years. Aetiological agents of neonatal infection are difficult to identify because the clinical signs are non-specific. Using data from the Aetiology of Neonatal Infections in south Asia (ANISA) cohort, we aimed to describe the spectrum of infectious aetiologies of acute neonatal illness categorised post-hoc using the 2015 WHO case definitions of critical illness, clinical severe infection, and fast breathing only.

Methods

Eligible infants were aged 0–59 days with possible serious bacterial infection and healthy infants enrolled in the ANISA study in Bangladesh, India, and Pakistan. We applied a partial latent class Bayesian model to estimate the prevalence of 27 pathogens detectable on PCR, pathogens detected by blood culture only, and illness not attributed to any infectious aetiology. Infants with at least one clinical specimen available were included in the analysis. We assessed the prevalence of these aetiologies according to WHO's case definitions of critically ill, clinical severe infection, and infants with late onset, isolated fast breathing. For the clinical severe definition, we compared the prevalence of signs by bacterial versus viral aetiology.

Findings

There were 934 infants (992 episodes) in the critically ill category, 3769 (4000 episodes) in the clinical severe infection category, and 738 (771 episodes) in the late-onset isolated fast breathing category. We estimated the proportion of illness attributable to bacterial infection was 32·7% in infants in the critically ill group, 15·6% in the clinical severe infection group, and 8·8% among infants with late-onset isolated fast breathing group. An infectious aetiology was not identified in 58–82% of infants in these categories. Among 4000 episodes of clinical severe infection, those with bacterial versus viral attribution had higher proportions of hypothermia, movement only when stimulated, convulsions, and poor feeding.

Interpretation

Our modelled results generally support the revised WHO case definitions, although a revision of the most severe case definition could be considered. Clinical criteria do not clearly differentiate between young infants with and without infectious aetiologies. Our results highlight the need for improved point-of-care diagnostics, and further study into neonatal deaths and episodes with no identified aetiology, to ensure antibiotic stewardship and targeted interventions.

Funding

The Bill and Melinda Gates Foundation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS AND RECOMMENDATIONS

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

Association of lower vitamin a levels in neonates and their mothers with increased risk of neonatal late-onset sepsis: A case-control study

BACKGROUND

In developing countries, neonatal sepsis is one of the major causes of mortality and morbidity. Vitamin A deficiency also affects the immune system severely and is associated with various neonatal infections. We aimed to compare maternal and neonatal vitamin A levels among neonates with and without late-onset sepsis.

MATERIAL AND METHODS

40 eligible infants were entered into this case-control study according to inclusion criteria. The case group included 20 term or near-term infants who had late-onset neonatal sepsis from three to seven days of life. The control group consisted of 20 term or near-term infants who were icteric hospitalized neonates without sepsis. Demographic, clinical and paraclinical features, as well as neonatal and maternal vitamin A levels, were compared between the two groups.

RESULTS

The average gestational age of the neonates was 37.1 ± 1.2, ranging from 35 to 39 days. There was a significant difference between the septic and non-septic groups in terms of white blood cell and neutrophil count, C-reactive protein, and neonatal and maternal vitamin A levels. A Spearman correlation analysis showed a significant direct correlation among maternal and neonatal vitamin A levels (correlation coefficient = 0.507; P-value = 0.001). Multivariate regression analysis showed that neonates' vitamin A level had a significant direct association with sepsis (OR: 0.541; P-value=0.017).

CONCLUSION

Our findings demonstrated the association of lower vitamin A levels in neonates and their mothers with an increased risk of late-onset sepsis, which emphasizes the importance of the consideration of vitamin A level evaluation and its appropriate neonatal and maternal supplementation.

Role of Bifidobacteria on Infant Health

Bifidobacteria are among the predominant microorganisms during infancy, being a dominant microbial group in the healthy breastfed infant and playing a crucial role in newborns and infant development. Not only the levels of the Bifidobacterium genus but also the profile and quantity of the different bifidobacterial species have been demonstrated to be of relevance to infant health. Although no definitive proof is available on the causal association, reduced levels of bifidobacteria are perhaps the most frequently observed alteration of the intestinal microbiota in infant diseases. Moreover, Bifidobacterium strains have been extensively studied by their probiotic attributes. This review compiles the available information about bifidobacterial composition and function since the beginning of life, describing different perinatal factors affecting them, and their implications on different health alterations in infancy. In addition, this review gathers exhaustive information about pre-clinical and clinical studies with Bifidobacterium strains as probiotics in neonates.

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

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

Antibiotic Discontinuation 24 h After Neonatal Late-Onset Sepsis Work-Up-A Validated Decision Tree Model

Objectives: Neonatal late-onset sepsis work-up is a frequent occurrence in every neonatal department. Blood cultures are the diagnostic gold standard, however, a negative culture prior to 48-72 h is often considered insufficient to exclude sepsis. We aimed to develop a decision tree which would enable exclusion of late-onset sepsis within 24 h using clinical and laboratory variables. Study Design: Infants evaluated for late-onset sepsis during the years 2016-2019, without major malformations, in a tertiary neonatal center were eligible for inclusion. Blood cultures and clinical and laboratory data were extracted at 0 and 24 h after sepsis work-up. Infants with bacteriologically confirmed late-onset sepsis were compared to matched control infants. Univariate logistic regression identified potential risk factors. A decision tree based on Chi-square automatic interaction detection methodology was developed and validated. Results: The study cohort was divided to a development cohort (105 patients) and a validation cohort (60 patients). At 24 h after initial evaluation, the best variables to identify sepsis were C-reactive protein > 0.75 mg/dl, neutrophil-to-lymphocyte ratio > 1.5 and sick-appearance at 24 h. Use of these 3 variables together with blood culture status at 24 h, enabled identification of all infants that eventually developed sepsis through the decision tree model. Our decision tree has an area under the receiver operating characteristic curve of 0.94 (95% CI: 0.90-0.98). Conclusions: In non-sick appearing infants with a negative blood culture at 24 h and normal laboratory values, sepsis is highly unlikely and discontinuing antibiotics after 24 h is a viable option.

Profound Pathogen-Specific Alterations in Intestinal Microbiota Composition Precede Late-Onset Sepsis in Preterm Infants: A Longitudinal, Multicenter, Case-Control Study

BACKGROUND

The role of intestinal microbiota in the pathogenesis of late-onset sepsis (LOS) in preterm infants is largely unexplored but could provide opportunities for microbiota-targeted preventive and therapeutic strategies. We hypothesized that microbiota composition changes before the onset of sepsis, with causative bacteria that are isolated later in blood culture.

METHODS

This multicenter case-control study included preterm infants born under 30 weeks of gestation. Fecal samples collected from the 5 days preceding LOS diagnosis were analyzed using a molecular microbiota detection technique. LOS cases were subdivided into 3 groups: gram-negative, gram-positive, and coagulase-negative Staphylococci (CoNS).

RESULTS

Forty LOS cases and 40 matched controls were included. In gram-negative LOS, the causative pathogen could be identified in at least 1 of the fecal samples collected 3 days prior to LOS onset in all cases, whereas in all matched controls, this pathogen was absent (P = .015). The abundance of these pathogens increased from 3 days before clinical onset. In gram-negative and gram-positive LOS (except CoNS) combined, the causative pathogen could be identified in at least 1 fecal sample collected 3 days prior to LOS onset in 92% of the fecal samples, whereas these pathogens were present in 33% of the control samples (P = .004). Overall, LOS (expect CoNS) could be predicted 1 day prior to clinical onset with an area under the curve of 0.78.

CONCLUSIONS

Profound preclinical microbial alterations underline that gut microbiota is involved in the pathogenesis of LOS and has the potential as an early noninvasive biomarker.

Incidence and microbiological characteristics of neonatal late onset sepsis in a neonatal intensive care unit in Peru

OBJECTIVES

Our study aimed to determine the incidence of late onset sepsis and the most frequent microorganisms causing it in the neonatal unit at Hospital Cayetano Heredia in Lima, Peru.

METHODS

Descriptive and retrospective study. We reviewed all positive blood cultures and cultures of cerebrospinal fluid drawn from inborn patients beyond 72 h of life, admitted to the neonatal unit from January 2015 to December 2019.

RESULTS

The incidence of late onset sepsis was 7.4% of admitted patients and 10.04 per 1000 live births. During our study period, 234 episodes of late onset sepsis occurred in 204 patients. The incidence was higher in very low birth weight infants, reaching 36.2% and even higher in extremely low birth weight infants (40.7%). Coagulase-negative Staphylococcus and then Klebsiella spp. were the most frequent causative microorganisms. The most frequent cause of late onset sepsis in very low birth weight infants was gram-negative bacteria (Klebsiella spp., was the most frequent causative microorganism).

CONCLUSIONS

Late onset neonatal sepsis is prevalent in our neonatal unit. It is important to know which are the most prevalent causative microorganisms to be able to choose adequate antibiotic coverage and to design strategies to prevent infection.

Up-regulation of BTLA expression in myeloid dendritic cells associated with the treatment outcome of neonatal sepsis

Dentritic cells (DCs) dysfunction has been verified detrimental for sepsis and B and T lymphocyte attenuator (BTLA) is an immune-regulatory receptor shown to be associated with DCs dysfunction. However, the role of BTLA expression in myeloid DCs (mDCs) in neonatal sepsis is unknown. In the current study, we found BTLA-expressing mDCs were elevated in neonates with sepsis and the BTLA expression level in mDCs was positively correlated to the severity of sepsis. The presence of BTLA negatively regulated the phagocytosis capacity and bactericidal ability of mDCs as well as the maturation markers expression of mDCs. Our data also showed BTLA⁺mDCs shifted into an anti-inflammatory phenotype with decreased expression of IL-6, TNF-α and IL-12, but increased IL-10. in addition, we found BTLA expression indeedly altered the mDCs allo-stimulatory capacity. Therefore, BTLA expression in mDCs could be a useful predictive marker for neonatal sepsis and targeting BTLA expression in mDCs may be a new therapeutic strategy.

Association of Neutrophil-Lymphocyte Ratio and the Presence of Neonatal Sepsis

The neutrophil–lymphocyte ratio (NLR) is an emerging risk factor of sepsis that is receiving increasing attention. However, the relationship between NLR and the presence of sepsis in neonates is poorly studied. Here, we retrospectively recruited 1480 neonates and collected and analyzed relevant clinical and laboratory data. According to the International Pediatric Sepsis Consensus, 737 neonates were diagnosed with sepsis, and 555 neonates were suspected for having infection. Neonates with hyperbilirubinemia (n = 188) served as controls. Neonates with sepsis had significantly elevated neutrophil counts and NLR (P < 0.001). The proportion of neonates with sepsis increased significantly from 41.6% when NLR < 0.91 to 66.2% when NLR > 1.88 group (P < 0.001). Multiple logistic regression analysis showed that NLR was an independent risk factor for the presence of neonatal sepsis. Receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off value NLR for predicting the presence of neonatal sepsis was 1.62 (area under curve (AUC) = 0.63, 95% CI 0.60–0.66, P < 0.001). In conclusion, our data suggest that elevated NLR levels are associated with a higher neonatal sepsis risk.

Survival Status and Predictors of Mortality among Newborns Admitted with Neonatal Sepsis at Public Hospitals in Ethiopia

BACKGROUND

One-fourth of neonatal death is due to neonatal sepsis and nearly 98% of these deaths are occurring at low- and middle-income countries. In Ethiopia, forty percent of under-five mortality occurs during the neonatal period, of which neonatal sepsis accounts for 30-35% of neonatal deaths next to prematurity and its complications. On the other side, among the survived neonates with neonatal sepsis, there exist as vulnerable to short and long-term neurological and developmental morbidity impacting the overall productivity of the child as adult.

METHODS

A longitudinal prospective cohort study was conducted among selected 289 neonates with neonatal sepsis who were admitted in the neonatal intensive care unit at public hospitals in Ethiopia from 1st March 2018 to 31st December 2019. Data were entered into Epi data version 3.02 and exported to SPSS V 25 for analysis. The Kaplan-Meier survival curve together with log-rank test was used to estimate the survival time of the neonates. Variables which had p value < 0.05 in multivariable analysis using the cox proportional hazard model were declared as statistically significant predictors of mortality.

RESULTS

The study was conducted with a total of 289 neonates admitted with neonatal sepsis. The cumulative proportion of surviving at the end of the fourth day was 99.5%, and it was 98.2% at the end of the fifth day. In addition, it was 96.6%, 93.5%, and 91.1% at the end of the sixth, seventh, and eighth day, respectively. The incidence of mortality was 8.65 per 100 neonates admitted with neonatal sepsis. Having a history of intrapartum fever (AHR: 14.5; 95% CI: 4.25, 49.5), history of chorioamnionitis (AHR: 5.7; 95% CI: 2.29, 13.98), induced labor (AHR: 7; 95% CI: 2.32, 21.08), and not initiating exclusive breastfeeding within one hour (AHR: 3.4; 95% CI: 1.34, 12.63) were the independent predictors of mortality.

CONCLUSION

The survival status of neonates among neonates admitted with neonatal sepsis was high at the early admission days and high cumulative proportion of death as the admission period increased. The risk of mortality was high among the neonates with early onset of neonatal sepsis as compared with late onset of neonatal sepsis and history of intrapartum fever, history of diagnosed chorioamnionitis, onset of labor, and EBF initiation within one hour were the independent predictors of mortality among neonates admitted with neonatal sepsis.

Can we improve early identification of neonatal late-onset sepsis? A validated prediction model

OBJECTIVE

No single test can accurately identify neonatal late-onset sepsis (LOS). Our aim was to use clinical evaluation with laboratory tests to rapidly assess sepsis risk.

STUDY DESIGN

A retrospective case-control study was performed in a tertiary Neonatal Center during the years 2016-2019. Infants with bacteriologically confirmed LOS were compared with control infants. A clinical health evaluation score was assigned to each infant. A prediction model was developed and validated by multivariable analysis.

RESULTS

The study included 145 infants, 48 with sepsis, and 97 controls. LOS was independently associated with: sick appearance (OR: 5.7, 95% CI: 1.1-29.1), C-reactive protein > 0.75 (OR: 5.4, 95% CI: 1.1-26.3), and neutrophil-to-lymphocyte ratio > 1.5 (OR: 6.7, 95% CI: 1.2-38.5). Our model had an area under the receiver operating characteristic curve of 0.92 (95% CI: 0.86-0.97).

CONCLUSIONS

Clinical evaluation with neutrophil-to-lymphocyte ratio and C-reactive protein can rapidly identify LOS enabling decreased health costs and antibiotic use.

Antimicrobial resistance and virulence determinants in coagulase-negative staphylococci isolated mainly from preterm neonates

Coagulase-negative staphylococci (CoNS) are the most common isolates from blood culture in neonates resulting in high mortality and morbidity. This study investigated CoNS obtained from blood cultures of neonates for antibiotic resistance and virulence factors, and possible association with inflammatory response (C-reactive protein). A total of 93 CoNS isolates were collected from 76 blood cultures of neonates at the Maternity hospital in Kuwait in a six-month period and investigated for susceptibility to antibiotics, carriage of staphylococcal cassette chromosome mec (SCCmec), and virulence-associated genes. The 93 CoNS isolates consisted of S. epidermidis (76; 81.7%), S. capitis (12; 12.9%), S. hominis (2; 2.1%), S. warneri (2; 2.1%) and S. haemolyticus (1; 1.0%). Eighty-six (92.4%) of the isolates were resistant to cefoxitin (MR-CoNS) while 49 (52.7%) expressed multi-antibiotic resistance. The methicillin-resistant isolates (MR-CoNS) carried SCCmec III, SCCmec IVa and four combinations of SCCmec types including SCCmec types I+IVa (one S. warneri and 25 S. epidermidis isolates), types I+III (one S. epidermidis isolate), types III+IVa (six S. epidermidis isolates) and types I+III+IVa (one S. epidermidis isolate). The most common virulence-related genes were icaC, seb, arc detected in 69.7%, 60.5%, 40.8% of the isolates respectively. Two isolates were positive for tst1. No association between C-reactive protein and antibiotic resistance or virulence factors was established. This study revealed that S. epidermidis carrying different SCCmec genetic elements, was the dominant CoNS species isolated from neonatal blood cultures with 90.3% and 36.6% of the isolates positive for genes for biofilm and ACME production respectively.

Rapid multiplex detection of the resistance genes mecA, vanA and vanB from Gram-positive cocci-positive blood cultures using a PCR-dipstick technique

Introduction. Among the causative agents of bloodstream infections (BSIs), methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) are the key causative pathogens. Their rapid detection directly from Gram-positive cocci-positive blood culture specimens will promote timely treatment and help to implement effective infection control measures.Aim. We aim to develop a PCR-dipstick technique for the rapid detection of MRSA and VRE directly from positive blood culture specimens.Methodology. PCR-dipstick is a PCR-based multiplex detection technique where DNA-DNA hybridization is employed, and the results are interpreted with the naked eye. It was designed to target three drug resistance genes: mecA in MRSA and vanA/vanB in VRE from positive blood culture specimens. A total of 120 clinical isolates were used to evaluate the sensitivity and specificity of PCR-dipstick. Then, PCR-dipstick was examined for MRSA and VRE detection directly from positive blood cultures.Results. PCR-dipstick showed 100 % sensitivity and specificity in detecting mecA, vanA and vanB genes directly from bacterial colonies in comparison with multiplex PCR for genomic DNA followed by agarose gel electrophoresis. Further, it could differentially detect multiple resistant genes in pooled bacterial colonies (n=10). Ultimately, PCR-dipstick could detect MRSA and VRE in positive blood cultures in ~3 h.Conclusion. The results of the current study substantiate that PCR-dipstick can be used as an efficient detection system for MRSA and VRE directly from Gram-positive cocci-positive blood cultures. Its affordability and rapidity indicate that PCR-dipstick can be an effective tool for controlling nosocomial pathogens.

The role of the season at admission in neonatal sepsis: a retrospective chart review of a 1-year data at University of Gondar comprehensive specialized hospital

Objective

Neonatal sepsis is a global public health concern in general and causes a massive burden in developing countries particularly in sub-Saharan Africa. Though it is mostly preventable, neonatal sepsis remained the leading cause of mortality in developing countries. This study was conducted to determine the current proportion and identify factors associated with neonatal sepsis to suggest directions.

Results

In this study 504 randomly selected neonatal charts were reviewed. The proportion of overall neonatal sepsis was 63.69% (95% CI 59.38, 67.79), where early-onset sepsis was 59.33% (95% CI 54.96, 63.55) and late-onset sepsis was 4.17% (95% CI 2.73, 6.31). Maternal intra-partum fever, season of birth and admission, vaginal mode of delivery and preterm gestational age at birth increased the likelihood of overall and early-onset neonatal sepsis. In conclusion of this study, neonatal sepsis remaining the leading cause of morbidity among younger infants. Intra-partum conditions were major contributors to neonatal sepsis. Thus, providing emphasis on associated factors in particular and universal safe obstetric care in general is recommended.

Unfinished agenda of the neonates in developing countries: magnitude of neonatal sepsis: systematic review and meta-analysis

Purpose

Neonatal sepsis is the major cause of mortality and morbidity globally, particularly in developing countries. Despite studies revealed the extent of neonatal sepsis in developing countries, the findings were inconclusive. Therefore, the main aim of this study was to determine the pooled prevalence of neonatal sepsis in developing countries.

Methods

We used a systematic review and Meta-analysis study method. The reviewed studies were accessed through an electronic web-based search strategy from the electronic database (PUBMED), advanced google scholar, different journal sites. The data extraction was done by two researchers using a data extraction table and the disparity between data extractors was resolved by the third researcher. The analysis was done using STATA version 11. The I2 test was used to assess heterogeneity across studies. The Funnel plot, Begg's test, and Egger's test were used to check for publication bias. The random-effect model was used to determine the pooled effect size. All studies related to neonatal sepsis which fulfill the inclusion criteria were considered into this study. The quality of each study was checked using the Newcastle-Ottawa Scale and studies graded low score were excluded from the study.

Results

At the end, 36 articles fit with our study objectives. Studies conducted in Ethiopia were significant the source of heterogeneity of the study with a coefficient = 90, P-value = 0.025. The overall pooled prevalence of the study was 29.92%. The limitations of this study would be the authors were only used articles reported in the English language, and publication bias.

Conclusion

The pooled prevalence of neonatal sepsis was found to be high which accounted for a third of the neonates. Despite countries have established possible prevention and treatment mechanisms, neonatal sepsis is the major public health problem in lower and middle-income countries till now.

Procalcitonin as an Early Laboratory Marker of Sepsis in Neonates: Variation in Diagnostic Performance and Discrimination Value

BACKGROUND

As an early recognition of neonatal sepsis is important for triggering the initiation of treatment, this study was thus designed to assess the diagnostic performance and discrimination value of procalcitonin (PCT) in neonatal sepsis cases.

METHODS

This cross-sectional study, which was carried out at the Paediatric Intensive Care Unit of Hospital Universiti Sains Malaysia (HUSM) in Kelantan, Malaysia, had involved 60 neonates admitted for suspected sepsis. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and the area under receiver operating characteristics curve (AUC) for PCT were determined at initial presentation (0 h) as well as 12 h and 24 h after presentation in comparison to blood culture as the gold standard.

RESULTS

The study consisted of 27 (45.0%) male and 33 (55.0%) female neonates with a mean (SD) age of 76.8 (48.25) h. At cut-off PCT value of > 2 ng/mL, the sensitivity, specificity, PPV and NPV were 66.7%, 66.7%, 33.3% and 88.9% at 0 h. The respective parameters were 83.3%. 56.3%, 32.3% and 93.1% at 12 h and 83.3%, 52.1%, 30.3% and 92.6% at 24 h. AUC was 71.6%, 76.6% and 71.7% at 0 h, 12 h and 24 h.

CONCLUSIONS

Diagnostic performance and discrimination values of PCT for diagnosis of neonatal sepsis varied with time of obtaining the blood samples. The PCT result at 12 h demonstrates the most optimal diagnostic performance and discrimination values.

Clinical Characteristic and Pathogen Spectrum of Neonatal Sepsis in Guangzhou City from June 2011 to June 2017

Background

Preterm and low birth weight (birth weight <2500 g) neonates are vulnerable to sepsis, and the causative pathogens vary in different regions and times. The objective of this study was to identify common organisms leading to neonatal sepsis and identify the characteristic of patients infected with different bacteria, which may help in the selection of antibiotics for empirical treatment.

Material/Methods

We retrospectively collected the clinical and microbiological data of neonates with culture-proven sepsis in our clinical setting from June 2011 to June 2017. The demography, composition, and distribution of the pathogens and the clinical characteristic of the cases infected with different bacteria were analyzed.

Results

Of a total of 1048 bacteria that were isolated from patient samples, detailed clinical and microbiological data of 297 cases were available. Escherichia coli, Klebsiella pneumoniae, and coagulase-negative Staphylococcus (co-NS) were the top 3 isolated pathogens. Streptococcus agalactiae predominantly led to early-onset sepsis, while K. pneumoniae and Staphylococcus aureus mainly led to late-onset sepsis. K. pneumoniae was mainly acquired in the hospital. Leukopenia was more commonly seen than leukocytosis in our study, and patients infected with K. pneumoniae and Candida spp encountered more thrombocytopenia.

Conclusions

The results of our study revealed the composition of the pathogens of neonatal sepsis in our region and the clinical characteristic of sepsis caused by different bacteria; these data may help in the selection of antibiotics for empirical treatment of neonates with high risk of sepsis.

Determinants and Outcome of Community-Acquired Late-Onset Neonatal Sepsis in Rural Bangladesh

Background. This study examined the sociodemographic as well as other determinants and outcome of community-acquired late-onset neonatal sepsis (LONS) in rural Bangladesh at Matlab. Methods. In this retrospective chart review, we used an unmatched case-control design (1:2 ratio) to evaluate the factors associated with LONS and their outcomes among babies admitted to the neonatal ward of Matlab Hospital of icddr,b, from January 2012 to December 2014. Neonates presenting with any of the clinical signs of serious bacterial infection during 3 to 28 days of life constituted the cases (LONS), and those without LONS constituted the controls. All the data were retrieved from the electronic databases of Matlab Hospital and Matlab Health and Demographic Surveillance System. Results. Among 1482 admitted neonates, 202 were cases and 404 were randomly selected controls. In babies with LONS, case fatality rate (1% vs 0%, P = .037), duration of inpatient stay (4 days vs 2 days, P < .001), and referral to higher center (9% vs 5%, P = .020) were higher. In an adjusted model, undernutrition (weight for length Z score < −2; odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.2-2.94), admission in winter season (OR = 1.62, 95% CI = 1.09-2.41), mother’s schooling <10 years (OR = 1.76, 95% CI = 1.09-2.85), primiparity (OR = 1.55, 95% CI = 1.05-2.29), home delivery (OR = 1.87, 95% CI = 1.07-3.26), and household food insecurity (OR = 2.78, 95% CI = 1.31-5.88) were found to be independently associated with LONS. Conclusion. LONS posed considerable socioeconomic burden to the rural community. Further studies are required to consolidate our findings.

Machine learning models for early sepsis recognition in the neonatal intensive care unit using readily available electronic health record data

BACKGROUND

Rapid antibiotic administration is known to improve sepsis outcomes, however early diagnosis remains challenging due to complex presentation. Our objective was to develop a model using readily available electronic health record (EHR) data capable of recognizing infant sepsis at least 4 hours prior to clinical recognition.

METHODS AND FINDINGS

We performed a retrospective case control study of infants hospitalized ≥48 hours in the Neonatal Intensive Care Unit (NICU) at the Children's Hospital of Philadelphia between September 2014 and November 2017 who received at least one sepsis evaluation before 12 months of age. We considered two evaluation outcomes as cases: culture positive-positive blood culture for a known pathogen (110 evaluations); and clinically positive-negative cultures but antibiotics administered for ≥120 hours (265 evaluations). Case data was taken from the 44-hour window ending 4 hours prior to evaluation. We randomly sampled 1,100 44-hour windows of control data from all times ≥10 days removed from any evaluation. Model inputs consisted of up to 36 features derived from routine EHR data. Using 10-fold nested cross-validation, 8 machine learning models were trained to classify inputs as sepsis positive or negative. When tasked with discriminating culture positive cases from controls, 6 models achieved a mean area under the receiver operating characteristic (AUC) between 0.80-0.82 with no significant differences between them. Including both culture and clinically positive cases, the same 6 models achieved an AUC between 0.85-0.87, again with no significant differences.

CONCLUSIONS

Machine learning models can identify infants with sepsis in the NICU hours prior to clinical recognition. Learning curves indicate model improvement may be achieved with additional training examples. Additional input features may also improve performance. Further research is warranted to assess potential performance improvements and clinical efficacy in a prospective trial.

Risk Factors Associated with Neonatal Sepsis: A Case Study at a Specialist Hospital in Ghana

Worldwide, neonatal sepsis accounts for an estimated 26% of under-five deaths, with sub-Saharan Africa having the highest mortality rates. Though worldwide neonatal deaths have decreased by over 3.6 million per year since 2000, neonatal sepsis remains a notable hindrance to the progress in the decline of cause-specific mortality rates especially in sub-Saharan Africa. This study aimed at examining the risk factors of neonatal sepsis at the Trauma and Specialist Hospital, Winneba. The study was an unmatched case control retrospective study. Cases were neonates who had sepsis with their index mothers and controls were neonates who did not have sepsis with their index mothers. Neonatal and maternal medical records were retrieved from January to December 2017. Data abstraction lasted for one month and 2650 folders for the neonates and their index mothers were retrieved. Nine hundred (900) neonatal folders were considered valid for the study and likewise for the maternal folders. One hundred and three (103) folders were considered cases while 797 were considered as controls. Data were entered using the Statistical Package for Social Sciences Version 22. Logistic regression was used to determine the risk of neonatal sepsis. Maternal factors that predicted the occurrence of sepsis among neonates were parity (p<0.027), mode of delivery (p<0.001), bleeding disorder (p<0.001), and PROM (p<0.001). Neonatal risk factors which predicted the occurrence of sepsis were APGAR score in the first and fifth minute (p<0.001), resuscitation at birth (p<0.004), duration of stay in the facility (p<0.001), and neonatal age on admission (p<0.001). The study found both maternal and neonatal factors to have a strong association with the risk of developing neonatal sepsis. Encouraging maternal antenatal care utilization would help identify the risk factors during prenatal and postnatal care and appropriate interventions implemented to reduce the likelihood of the neonate developing sepsis.

Regulatory role of miRNA-26a in neonatal sepsis

The present study aimed to investigate the expression of microRNA (miRNA) 26a in blood mononuclear cells and serum in neonatal sepsis, as well as its role in the disease pathogenesis. In total 28 cases of neonatal sepsis were included in the study. The mRNA expression levels of miRNA-26a and interleukin (IL)-6 in the blood mononuclear cells and serum samples were detected by reverse transcription-quantitative polymerase chain reaction. The protein expression of IL-6 was detected by western blot analysis and ELISA. The in vitro septic environment was simulated by lipopolysaccharide (LPS) in THP-1 cells, and the expression of miRNA-26a and IL-6 were determined. Interaction between miRNA-26a and IL-6 was confirmed by a dual-luciferase reporter assay. Compared with the control group, the mRNA and protein expression levels of IL-6 in the blood mononuclear cells and serum samples from the neonates with sepsis were significantly elevated, while the expression of miRNA-26a was significantly decreased. In addition, similar results were observed in the LPS-induced septic models in THP-1 cells. Furthermore, the results of the dual-luciferase reporter assay demonstrated that IL-6 was the direct target of miRNA-26a. The expression of IL-6 was significantly upregulated in the blood mononuclear cells and serum in neonatal sepsis, which may be associated with the downregulation of miRNA-26a. miRNA-26a may regulate the disease pathogenesis and immune responses.

Decidual stromal cell-derived PGE2 regulates macrophage responses to microbial threat

PROBLEM

Bacterial chorioamnionitis causes adverse pregnancy outcomes, yet host-microbial interactions are not well characterized within gestational membranes. The decidua, the outermost region of the membranes, is a potential point of entry for bacteria ascending from the vagina to cause chorioamnionitis. We sought to determine whether paracrine communication between decidual stromal cells and macrophages shaped immune responses to microbial sensing.

METHOD OF STUDY

Decidual cell-macrophage interactions were modeled in vitro utilizing decidualized, telomerase-immortalized human endometrial stromal cells (dTHESCs) and phorbol ester-differentiated THP-1 macrophage-like cells. The production of inflammatory mediators in response to LPS was monitored by ELISA for both cell types, while phagocytosis of bacterial pathogens (Escherichia coli and Group B Streptococcus (GBS)) was measured in THP-1 cells or primary human placental macrophages. Diclofenac, a non-selective cyclooxygenase inhibitor, and prostaglandin E₂ (PGE₂ ) were utilized to interrogate prostaglandins as decidual cell-derived paracrine immunomodulators. A mouse model of ascending chorioamnionitis caused by GBS was utilized to assess the colocalization of bacteria and macrophages in vivo and assess PGE₂ production.

RESULTS

In response to LPS, dTHESC and THP-1 coculture demonstrated enhancement of most inflammatory mediators, but a potent suppression of macrophage TNF-α generation was observed. This appeared to reflect a paracrine-mediated effect of decidual cell-derived PGE₂ . In mice with GBS chorioamnionitis, macrophages accumulated at sites of bacterial invasion with increased PGE₂ in amniotic fluid, suggesting such paracrine effects might hold relevance in vivo.

CONCLUSION

These data suggest key roles for decidual stromal cells in modulating tissue responses to microbial threat through release of PGE₂ .

Inhibition of necroptosis attenuates lung injury and improves survival in neonatal sepsis

BACKGROUND

Neonatal sepsis represents a unique therapeutic challenge owing to an immature immune system. Necroptosis is a form of programmed cell death that has been identified as an important mechanism of inflammation-induced cell death. Receptor-interacting protein kinase 1 plays a key role in mediating this process. We hypothesized that pharmacologic blockade of receptor-interacting protein kinase 1 activity would be protective in neonatal sepsis.

METHODS

Sepsis was induced in C57BL/6 mouse pups (5-7 days old) by intraperitoneal injection of adult cecal slurry. At 1 hour after cecal slurry injection, the receptor-interacting protein kinase 1 inhibitor necrostatin-1 (10 µg/g body weight) or vehicle (5% dimethyl sulfoxide in phosphate buffered saline) was administered via retro-orbital injection. At 20 hours after cecal slurry injection, blood and lung tissues were collected for various analyses.

RESULTS

At 20 hours after sepsis induction, vehicle-treated pups showed a marked increase in serum levels of interleukin 6, interleukin 1-beta, and interleukin 18 compared to sham. With necrostatin-1 treatment, serum levels of interleukin 6, interleukin 1-beta, and interleukin 18 were decreased by 77%, 81%, and 63%, respectively, compared to vehicle. In the lungs, sepsis induction resulted in a 232-, 10-, and 2.8-fold increase in interleukin 6, interleukin 1-beta, and interleukin 18 mRNA levels compared to sham, while necrostatin-1 treatment decreased these levels to 40-, 4-, and 0.8-fold, respectively. Expressions of the neutrophil chemokines keratinocyte chemoattractant and macrophage-inflammatory-protein-2 were also increased in the lungs in sepsis, while necrostatin-1 treatment decreased these levels by 81% and 61%, respectively, compared to vehicle. In addition, necrostatin-1 treatment significantly improved the lung histologic injury score and decreased lung apoptosis in septic pups. Finally, treatment with necrostatin-1 increased the 7-day survival rate from 0% in the vehicle-treated septic pups to 29% (P = .11).

CONCLUSION

Inhibition of receptor-interacting protein kinase 1 by necrostatin-1 decreases systemic and pulmonary inflammation, decreases lung injury, and increases survival in neonatal mice with sepsis. Targeting the necroptosis pathway might represent a new therapeutic strategy for neonatal sepsis.

Activation of Invariant Natural Killer T Cells Redirects the Inflammatory Response in Neonatal Sepsis

Sepsis is the third leading cause of death in the neonatal population, due to susceptibility to infection conferred by immaturity of both the innate and adaptive components of the immune system. Invariant natural killer T (iNKT) cells are specialized adaptive immune cells that possess important innate-like characteristics and have not yet been well-studied in septic neonates. We hypothesized that iNKT cells would play an important role in mediating the neonatal immune response to sepsis. To study this, we subjected 5- to 7-day-old neonatal C57BL/6 mice to sepsis by intraperitoneal (i.p.) cecal slurry (CS) injection. Thirty hours prior to or immediately following sepsis induction, pups received i.p. injection of the iNKT stimulator KRN7000 (KRN, 0.2 µg/g) or vehicle. Ten hours after CS injection, blood and tissues were collected for various analyses. Thirty-hour pretreatment with KRN resulted in better outcomes in inflammation, lung injury, and survival, while immediate treatment with KRN resulted in worse outcomes compared to vehicle treatment. We further analyzed the activation status of neonatal iNKT cells for 30 h after KRN administration, and showed a peak in frequency of CD69 expression on iNKT cells and serum IFN-γ levels at 5 and 10 h, respectively. We then used CD1d knockout neonatal mice to demonstrate that KRN acts through the major histocompatibility complex-like molecule CD1d to improve outcomes in neonatal sepsis. Finally, we identified that KRN pretreatment exerts its protective effect by increasing systemic levels of TGF-β1. These findings support the importance of iNKT cells for prophylactic immunomodulation in neonates susceptible to sepsis.

Emerging Technologies for Molecular Diagnosis of Sepsis

Rapid and accurate profiling of infection-causing pathogens remains a significant challenge in modern health care. Despite advances in molecular diagnostic techniques, blood culture analysis remains the gold standard for diagnosing sepsis. However, this method is too slow and cumbersome to significantly influence the initial management of patients. The swift initiation of precise and targeted antibiotic therapies depends on the ability of a sepsis diagnostic test to capture clinically relevant organisms along with antimicrobial resistance within 1 to 3 h. The administration of appropriate, narrow-spectrum antibiotics demands that such a test be extremely sensitive with a high negative predictive value. In addition, it should utilize small sample volumes and detect polymicrobial infections and contaminants. All of this must be accomplished with a platform that is easily integrated into the clinical workflow. In this review, we outline the limitations of routine blood culture testing and discuss how emerging sepsis technologies are converging on the characteristics of the ideal sepsis diagnostic test. We include seven molecular technologies that have been validated on clinical blood specimens or mock samples using human blood. In addition, we discuss advances in machine learning technologies that use electronic medical record data to provide contextual evaluation support for clinical decision-making.

Multiplex Cytokine Profiling Identifies Interleukin-27 as a Novel Biomarker For Neonatal Early Onset Sepsis

BACKGROUND

Early onset sepsis (EOS) remains a major cause of mortality and morbidity in neonates, and traditional clinical markers effective for adults are less effective in these patients. This study aimed to assess the value of individual plasma biomarkers as well as biomarker combinations for predicting EOS in neonates.

METHODS

This prospective study included 151 neonates with suspected EOS. Plasma levels of interleukin (IL)-27, IL-6, IL-8, tumor necrosis factor (TNF)-α, heat shock protein (HSP) 70, macrophage inflammatory protein (MIP)-1α, MIP-1β, granzyme B, and matrix metalloproteinase (MMP)-8 were measured through multiplex cytokine profiling and assessed along with C-reactive protein (CRP) and procalcitonin (PCT). Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive ability of biomarkers individually and in combination. Logistic regression model was constructed to identify independent predictors of EOS.

RESULTS

The proven sepsis and probable sepsis groups were combined to form the infected group (n = 68), and the possible sepsis and low-risk sepsis groups were combined to form the uninfected group (n = 83). The ROC area under the curve was 0.747 for IL-27 (P <0.01). In addition, IL-6, TNF-α, HSP 70, MMP-8, PCT, and CRP were significantly predictive of EOS, whereas IL-8, granzyme B, MIP-1α, and MIP-1β were not. Both IL-27 and PCT were identified as independent predictors of EOS in the multivariate model, and the combined use of these markers showed significantly increased predictive ability for EOS.

CONCLUSION

Our results indicate that elevated IL-27 strongly correlates with EOS and may provide additional diagnostic value along with PCT.