Multiple leucocyte activation markers to detect neonatal infection

Expression of CD64 and CD69 as biomarkers for late-onset sepsis diagnosis in infants born prematurely

BACKGROUND

The incidence of Late-Onset Sepsis (LOS) increases as gestational age decreases in newborns. The clinical signs of neonatal sepsis are not specific for diagnosis in preterm infants. The gold standard for its diagnosis is the blood culture test, which requires more than 24 h to obtain results, with positive results obtained in 10-3 % of cases analysed. As the molecular markers on the lymphocyte surface CD64 and CD69 are involved in early innate immune activation, they may be helpful for faster diagnosis.

AIM

Measure the expression of CD64 and CD69 on lymphocytes in clinical and confirmed sepsis patients and compared to that in infants without sepsis.

METHODOLOGY

We used peripheral blood samples from three groups of preterm babies with suspected sepsis (n = 31), confirmed sepsis (n = 10) and without sepsis (n = 47). Using flow cytometry, we measure the expression of CD64 on neutrophils and CD69 on NK cells.

RESULTS

Expression of CD64 on neutrophils and CD69 on NK cells did not increase in the clinical or confirmed sepsis groups compared to the without sepsis group.

CONCLUSIONS

Leukocytes from infants born prematurely may have tightly regulated mechanisms that control their activation phenotype, rendering them unsuitable for diagnosing sepsis.

Enhanced SARS-CoV-2-Specific CD4+ T Cell Activation and Multifunctionality in Late Convalescent COVID-19 Individuals

Background: Examination of CD4+ T cell responses during the natural course of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection offers useful information for the improvement of vaccination strategies against this virus and the protective effect of these T cells. Methods: We characterized the SARS-CoV-2-specific CD4+ T cell activation marker, multifunctional cytokine and cytotoxic marker expression in recovered coronavirus disease 2019 (COVID-19) individuals. Results: CD4+ T-cell responses in late convalescent (>6 months of diagnosis) individuals are characterized by elevated frequencies of activated as well as mono, dual- and multi-functional Th1 and Th17 CD4+ T cells in comparison to early convalescent (<1 month of diagnosis) individuals following stimulation with SARS-CoV-2-specific antigens. Similarly, the frequencies of cytotoxic marker expressing CD4+ T cells were also enhanced in late convalescent compared to early convalescent individuals. Conclusion: Our findings from a low-to middle-income country suggest protective adaptive immune responses following natural infection of SARS-CoV-2 are elevated even at six months following initial symptoms, indicating the CD4+ T cell mediated immune protection lasts for six months or more in natural infection.

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.

Decreased Expression of CD69 on T Cells in Tuberculosis Infection Resisters

BACKGROUND

CD69 is a biomarker of T-cell activation status, but its activation status in human Mycobacterium tuberculosis (Mtb) infection remains elusive.

METHODS

A set of cohorts of patients with different tuberculosis (TB) infection status including active TB patients (ATB), latent tuberculous infection patients (LTBI) and close contacts (CCs) of ATB was designed, and the expression profiles of CD69 and several T-cell markers were determined on Mtb antigen-stimulated T cells by flow cytometry.

RESULTS

The frequencies of CD4+ and CD8+ T cells were both comparable among Mtb-infected individuals including ATB and LTBI, which guaranteed the consistency of the background level. A t-Distributed Stochastic Neighbor Embedding (tSNE) analysis on a panel of six phenotypic markers showed a unique color map axis gated on T cells in the CCs group compared with ATB and LTBI populations. By further gating on cells positive for each individual marker and then overlaying those events on top of the tSNE plots, their distribution suggested that some markers were expressed differently in the CCs group. Further analysis showed that the expression levels of CD69 on both CD4+ and CD8+ T cells were significantly lower in the CCs group, especially in interferon-γ-responding T cells.

CONCLUSION

Our findings suggest that the T-cell activation status of CD69 is associated with Mtb infection and may have the potential to distinguish LTBI from those populations who have been exposed continuously to Mtb but have not become infected.

Neonatal Sepsis

Neonatal sepsis is associated with severe morbidity and mortality in the neonatal period. Clinical manifestations range from subclinical infection to severe local or systemic infection. Neonatal sepsis is divided into three groups as early-onset neonatal sepsis, late-onset neonatal sepsis and very late-onset neonatal sepsis according to the time of the onset. It was observed that the incidence of early-onset neonatal sepsis decreased with intrapartum antibiotic treatment. However, the incidence of late-onset neonatal sepsis has increased with the increase in the survival rate of preterm and very low weight babies. The source of the causative pathogen may be acquisition from the intrauterine origin but may also acquisition from maternal flora, hospital or community. Prematurity, low birth weight, chorioamnionitis, premature prolonged rupture of membranes, resuscitation, low APGAR score, inability to breastfeed, prolonged hospital stay and invasive procedures are among the risk factors. This article reviews current information on the definition, classification, epidemiology, risk factors, pathogenesis, clinical symptoms, diagnostic methods and treatment of neonatal sepsis.

Identification of the association between rs41274221 polymorphism in the seed sequence of microRNA-25 and the risk of neonate sepsis

BACKGROUND

Many studies have investigated the role of microRNA-25 (miR-25) in the initiation and progression of sepsis in newborns. In this study, we aim to explore how rs41274221 polymorphism in miR-25 compromises the interaction between miR-25 and CD69, so as to understand the mechanisms involved in the control of sepsis in newborns.

METHODS

Computational analysis, luciferase assay, real-time polymerase chain reaction (PCR), and western blot analysis were performed in this study.

RESULTS

The luciferase assays results showed that CD69 was a target gene of miR-25, because the luciferase activity in cells transfected with wild type CD69 was much lower than that in the cells transfected with mutant CD69 or the scramble control. Real-time PCR and western blot analysis results showed that the expression of miR-25 in sepsis patients was significantly upregulated as compared with that in the normal control group, and the CD69 position ratio as well as the messenger RNA (mRNA) and protein level of CD69 in sepsis patients was much higher than those in the normal control group. As compared with the scramble control, miR-25 mimics, and CD69 small interfering RNA (siRNA) downregulated the mRNA and protein expression of CD69, whereas the expression of CD69 mRNA and protein in cells transfected with miR-25 inhibitors was significantly higher as compared with that in the scramble control. In addition, interferonγ production was significantly downregulated in cells transfected with miR-25 inhibitors but notably upregulated in cells transfected with miR-25 mimics or CD69 siRNA.

CONCLUSION

The single-nucleotide polymorphism (SNP; rs41274221) in miR-25 is associated with the risk of sepsis in newborns.

In neonates with vitamin D deficiency, low lymphocyte activation markers are risk factors for infection

Background: Vitamin D has regulatory effects on different cells of the immune system and low levels are associated with several immune-mediated diseases. Aim: To investigate the association between neonatal 25-hydroxy vitamin D (25-OHD) level and the expression of lymphocyte activation markers (HLA-DR, CD69, CD25, CD45RA) on T-lymphocyte subpopulations and its impact in neonatal infection. Methods: 25-OHD level was measured in the cord blood of 56 neonates and their mothers using an enzyme immune-assay method. Based on the 25-OHD level, infants were categorised into four groups: severe deficiency (n = 7), moderate deficiency (n = 21), mild deficiency (n = 15) and normal 25-OHD level (n = 13). Mothers were classified into deficient (n = 18), insufficient (n = 21) and normal levels (n = 17). T-lymphocyte subpopulations and lymphocyte activation markers were investigated using flow cytometry. Results: There was a positive correlation between maternal and cord blood 25-OHD levels (r = 0.503, p = 0.001). The group with severe 25-OHD deficiency had the significantly lowest level of total lymphocytes, CD3+ T lymphocytes, CD4+ T-helper and CD8+ T-cytotoxic lymphocytes and CD4+CD45RA+ naïve T-cells compared with the other groups. The frequencies of CD8+CD25+, CD4+CD25+ and CD4+HLA-DR+ activated T-lymphocytes were significantly lower in the severe, moderate and mild deficiency groups than in the normal group. Seven of 43 (16.27%) infants with 25-OHD deficiency were admitted with sepsis to the neonatal intensive care unit and there were no cases of sepsis in the normal 25-OHD group. Conclusion: Vitamin D deficiency is associated with a reduction of lymphocyte subsets and altered T-lymphocyte activation which are considered to be risk factors for neonatal infection.

Unique aspects of the perinatal immune system

The early stages of life are associated with increased susceptibility to infection, which is in part due to an ineffective immune system. In the context of infection, the immune system must be stimulated to provide efficient protection while avoiding insufficient or excessive activation. Yet, in early life, age-dependent immune regulation at molecular and cellular levels contributes to a reduced immunological fitness in terms of pathogen clearance and response to vaccines. To enable microbial colonization to be tolerated at birth, epigenetic immune cell programming and early life-specific immune regulatory and effector mechanisms ensure that vital functions and organ development are supported and that tissue damage is avoided. Advancement in our understanding of age-related remodelling of immune networks and the consequent tuning of immune responsiveness will open up new possibilities for immune intervention and vaccine strategies that are designed specifically for early life.

Biomarkers for diagnosis of neonatal sepsis: a literature review

Sepsis is an important cause of mortality and morbidity in neonatal populations. There has been constant search of an ideal sepsis biomarker that have high sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), so that both the diagnosis and exclusion of neonatal sepsis can be made at the earliest possible and appropriate antibiotics can be started to neonate. Ideal sepsis biomarker will help in guiding us when not to start antibiotics in case of suspect sepsis and total duration of antibiotics course in case of proven sepsis. There are numerous sepsis biomarkers that have been evaluated for early detection of neonatal sepsis but till date there is no single ideal biomarker that fulfills all essential criteria's for being an ideal biomarker. The most commonly used biomarkers are C-reactive protein (CRP) and procalcitonin (PCT), but both have shown varied sensitivity, specificity, PPV and NPV in different studies. We conducted literature search for various neonatal sepsis biomarkers and this review article will cover briefly all the markers with current available evidence.

Monocyte and lymphocyte surface molecules in severe sepsis and non-septic critically ill Patients

The aim of the present study was to investigate whether expression of monocyte and lymphocyte surface molecules differs between patients with severe sepsis and non-septic patients treated in the intensive care unit (ICU). The expression of monocyte CD14, CD40, CD80 and HLA-DR, and lymphocyte CD69 were analyzed using quantitative flow cytometry on three consecutive days in 27 patients with severe sepsis and in 15 non-septic patients. Receiver operating characteristic analyses were performed and each corresponding area under the curve (AUC) was determined. The results showed that the expression levels of CD40 on monocytes and CD69 on CD4+ T cells and on natural killer (NK) cells were highest in patients with severe sepsis (p < 0.05). Monocyte CD40 and NK cell CD69 expression levels were higher in patients with severe sepsis and positive blood culture compared with those with negative blood culture (p < 0.05). The highest values of AUC for severe sepsis detection were 0.836 for CD40, 0.872 for CD69 on NK cells, and 0.795 for CD69 on CD4+ T cells. These findings suggest that monocyte CD40 and CD69 on NK cells and CD4+ T cells could prove useful for new approaches in the identification of severe sepsis in the ICU.

Expression of lymphocyte activation markers of preterm neonates is associated with perinatal complications

Background

Inappropriate activation of T lymphocytes plays an important role in perinatal complications. However, data on T lymphocyte activation markers of preterm infants is scarce. We investigated the association between gender, gestational and postnatal age, preeclampsia (PE), premature rupture of membranes (PROM) as well as prenatal steroid treatment (PS) and the frequency of activated T lymphocyte subsets (HLA-DR+, CD69+, CD25+, CD62L+) and major T lymphocyte subpopulations (CD4, CD8, Th1, Th2, naïve, memory) in peripheral blood during the first postnatal week in preterm infants.

Results

Cord blood and peripheral blood samples were collected from 43 preterm infants on the 1st, 3rd, and 7th days of life. We assessed the frequency of the above T lymphocyte subsets using flow cytometry. The ‘mixed effect model’ was used to analyze the effects of clinical parameters on T lymphocyte markers. The frequency of CD25+ T lymphocytes was higher in PROM. The frequency of CD4+ and CD8+ cells and the CD4+/CD8+ cell ratio was decreased in PE. The frequency of CD62L+ T lymphocytes was higher in male compared with female infants. PS did not affect the frequency of the investigated markers. CD4+ CD25+ cells had a lower frequency at birth than on day 7. Th2 lymphocytes had a lower frequency on postnatal days 1 and 3 when compared to day 7.

Conclusions

Our observations indicate that alterations affecting the expression of T lymphocyte activation markers are associated with the above factors and may play a role in the development of perinatal complications.

Identification of a human neonatal immune-metabolic network associated with bacterial infection

Understanding how human neonates respond to infection remains incomplete. Here, a system-level investigation of neonatal systemic responses to infection shows a surprisingly strong but unbalanced homeostatic immune response; developing an elevated set-point of myeloid regulatory signalling and sugar-lipid metabolism with concomitant inhibition of lymphoid responses. Innate immune-negative feedback opposes innate immune activation while suppression of T-cell co-stimulation is coincident with selective upregulation of CD85 co-inhibitory pathways. By deriving modules of co-expressed RNAs, we identify a limited set of networks associated with bacterial infection that exhibit high levels of inter-patient variability. Whereas, by integrating immune and metabolic pathways, we infer a patient-invariant 52-gene-classifier that predicts bacterial infection with high accuracy using a new independent patient population. This is further shown to have predictive value in identifying infection in suspected cases with blood culture-negative tests. Our results lay the foundation for future translation of host pathways in advancing diagnostic, prognostic and therapeutic strategies for neonatal sepsis.

Infection remains a leading cause of morbidity and mortality in neonates worldwide. Here the authors report disproportionate immune stimulatory, co-inhibitory and metabolic pathway responses that specifically mark bacterial infection and can be used to predict sepsis in neonatal patients at the first clinical signs of infection.

Epstein-Barr virus latent membrane protein 1 induces CD69 expression through activation of nuclear factor-κB

Latent membrane protein‑1 (LMP-1) of Epstein‑Barr virus (EBV) promotes tumorigenesis. Here, we report that LMP-1 activates the immunoregulatory molecule CD69 gene transcription through a nuclear factor-κB (NF-κB)‑dependent pathway. CD69 expression was upregulated in LMP-1‑expressing EBV-immortalized human B-cell lines and an EBV-positive Burkitt's lymphoma cell line. LMP-1 expression increased CD69 expression at the transcriptional level. CD69 promoter was regulated by LMP-1 activation of NF-κB via the carboxy-terminal activation region 1 and 2. Promoter deletion analysis indicated that two NF-κB binding sites are necessary for activation of the CD69 promoter. Electrophoretic mobility shift analysis demonstrated that LMP-1 activates both NF-κB binding sites in the CD69 promoter. This is the first report of the regulation of CD69 expression by LMP-1, and this novel finding may, thus, represent an important link between the EBV oncoprotein LMP-1 and its critical role in the development of EBV-associated diseases.

Flow cytometry in the detection of neonatal sepsis

Neonatal sepsis remains a burden problem by showing minimal initial symptoms of subtle character, nonspecific manifestation, and diagnostic pitfalls. The clinical course can be fulminant and fatal if treatment is not commenced promptly. It is therefore crucial to establish early diagnosis and initiate adequate therapy. Besides clinical symptoms, the most reliable laboratory markers in establishing diagnosis is currently the combined measurement of CRP and a cytokine (IL-6 and IL-8). Due to their different kinetics, a diagnostic gap might occur and thus withholding antimicrobial therapy in clinical suspicion of infection is not acceptable. We therefore need parameters which unerringly differentiate between infants in need for antimicrobial therapy and those who are not. Flow cytometry promises to be a useful tool in this field, allowing the determination of different cellular, dissolved, and functional pathophysiological components of sepsis. Despite technical and methodical advances in flow cytometry, its use in clinical routine is still limited. Advantages and disadvantages of promising new parameters in diagnosis of sepsis performed by flow cytometry, particularly CD64, HLA-DR, and apoptosis, are reviewed here. The necessity of tests to be used as an “ideal” parameter is presented.

CD69 does not affect the extent of T cell priming

CD69 is rapidly upregulated on T cells upon activation. In this work we show that this is also the case for CD69 expression on dendritic cells (DC). Thus, the expression kinetics of CD69 on both cell types is reminiscent of the one of costimulatory molecules. Using mouse models of transgenic T cells, we aimed at evaluating the effect of monoclonal antibody (MAb)-based targeting and gene deficiency of CD69 expressed by either DC or T cells on the extent of antigen (Ag)-specific T cell priming, which could be the result of a putative role in costimulation as well as on DC maturation and Ag-processing and presentation. CD69 targeting or deficiency of DC did not affect their expression of costimulatory molecules nor their capacity to induce Ag-specific T cell proliferation in in vitro assays. Also, CD69 targeting or deficiency of transgenic T cells did not affect the minimal proliferative dose for different peptide agonists in vitro. In in vivo models of transgenic T cell transfer and local Ag injection, CD69 deficiency of transferred T cells did not affect the extent of the proliferative response in Ag-draining lymph nodes (LN). In agreement with these results, CD69 MAb targeting or gene deficiency of Vaccinia-virus (VACV) infected mice did not affect the endogenous formation of virus-specific CD8(+) T cell populations at the peak of the primary immune response. Altogether our results argue against a possible role in costimulation or an effect on Ag processing and presentation for CD69.

Toll-like receptors expression and interferon-γ production by NK cells in human sepsis

Introduction

During the course of infection, natural killer (NK) cells contribute to innate immunity by producing cytokines, particularly interferon-gamma (IFN-γ). In addition to their beneficial effects against infection, NK cells may play a detrimental role during systemic inflammation, causing lethality during sepsis. Little is known on the immune status of NK cells in patients with systemic inflammatory response syndrome (SIRS) or sepsis in terms of cell surface markers expression and IFN-γ production.

Methods

We investigated 27 sepsis patients and 11 patients with non-infectious SIRS. CD56^bright and CD56^dim NK cell subsets were identified by flow cytometry and Toll-like receptor (TLR)2, TLR4, TLR9, CX3CR1, CD16 and CD69 expression were analyzed, as well as ex vivo IFN-γ production by NK cells in whole blood samples.

Results

We first showed that in NK cells from healthy controls, TLR2 and TLR4 expression is mainly intracellular, similarly to TLR9. Intracellular levels of TLR2 and TLR4, in both CD56^bright and CD56^dim NK cell subsets from sepsis patients, were increased compared to healthy subjects. In addition, the percentage of CD69⁺ cells was higher among NK cells of sepsis patients. No difference was observed for TLR9, CX3CR1, and CD16 expression. The ex vivo stimulation by TLR4 or TLR9 agonists, or whole bacteria in synergy with accessory cytokines (IL-15+IL-18), resulted in significant production of IFN-γ by NK cells of healthy controls. In contrast, for SIRS and sepsis patients this response was dramatically reduced.

Conclusions

This study reports for the first time an intracellular expression of TLR2 and TLR4 in human NK cells. Surface TLR4 expression allows discriminating sepsis and SIRS. Furthermore, during these pathologies, NK cells undergo an alteration of their immune status characterized by a profound reduction of their capacity to release IFN-γ.

Tracking changes of lymphocyte subsets and pre-inflammatory mediators in full-term neonates with suspected or documented infection

Investigation was made of changes in immune system parameters during the course of neonatal infection. The study population consisted of 95 full-term neonates matched for chronological age and sex, divided into three groups: suspected infection (n=20), sepsis (n=25), infection-free control subjects (n=50). Serial measurements were made of the cytokines interleukin-6 (IL-6), interleukin-1b (IL-1b) and tumour necrosis factor-α (TNF-α), lymphocyte subsets [CD3+, CD4+, CD8+, natural killer (NK) cells and B cells], the immunoglobulins (Ig) (IgG, IgM and IgA), C-reactive protein (CRP), and the total blood count, before, 2 days after initiation of treatment and after stopping treatment (time periods first, second and third, respectively). IL6, TNF-α, IL1-b and CRP were higher at the first time period in the sepsis group, and IL6 and TNF-α continued to be higher in this group at the second period. IL-6 and TNF-α were precise sepsis predictors with sensitivity and specificity of 0.92, 0.98 and 0.91, 0.92, respectively. NK cells, B cells, CD3+, CD4+, CD8+ were higher in the sepsis and suspected infection groups, but the ratios CD3+/CD4+, CD3+/CD8+, CD4+/CD8+ showed no difference from the controls. IgG was lower and IgM higher in the sepsis group. In the control subjects CD3+, CD4+, CD8+ lymphocytes increased with increasing age. It is concluded that IL-6 and TNF are good diagnostic markers of sepsis in full-term neonates. Lymphocyte subsets were affected by both the clinical condition and the chronological age. NK and B cells may be elevated in suspected and documented sepsis, and further studies are needed to determine their clinical significance.

Natural killer cell responses to infections in early life

Natural killer (NK) cells are an important component of innate immune responses to infectious diseases. They mediate protection by being able to rapidly lyse infected cells and produce cytokines (primarily interferon-γ) that shape innate and adaptive immune responses. This review summarizes current knowledge on the phenotype and functional abilities of NK cells from healthy newborns/infants and on NK cell responses against viral, bacterial and protozoan infections in early life. Interestingly, NK cell blood counts are higher in newborns than in adults but they do not display striking differences in phenotype, except for an increased frequency of expression of the inhibitory CD94/NKG2A receptor. They display some inherent functional defects, mainly a lower cytolytic capacity that may contribute to the immaturity of the neonatal immune system. Changes in circulating levels of NK cells observed during pediatric infections and the ability of NK cells from newborns and children to produce interferon-γ at the encounter with pathogens indicate that NK cells participate in the immune response to infectious diseases in early life. Unfortunately, information is currently insufficient to assess whether these NK cell responses really contribute to control infections, either vertically transmitted or acquired in infancy.

Pathophysiology and treatment of septic shock in neonates

Neonatal septic shock is a devastating condition associated with high morbidity and mortality. Definitions for the sepsis continuum and treatment algorithms specific for premature neonates are needed to improve studies of septic shock and assess benefit from clinical interventions. Unique features of the immature immune system and pathophysiologic responses to sepsis, particularly those of extremely preterm infants, necessitate that clinical trials consider them as a separate group. Keen clinical suspicion and knowledge of risk factors will help to identify those neonates at greatest risk for development of septic shock. Genomic and proteomic approaches, particularly those that use very small sample volumes, will increase our understanding of the pathophysiology and direct the development of novel agents for prevention and treatment of severe sepsis and shock in the neonate. Although at present antimicrobial therapy and supportive care remain the foundation of treatment, in the future immunomodulatory agents are likely to improve outcomes for this vulnerable population.

Neonates with culture proven sepsis have lower amounts and percentage of CD45RA+ T cells

To evaluate the expression of lymphocyte subsets in newborns diagnosed as culture proven or culture negative sepsis and to investigate the differentiation. The aim of this study is to explore neonatal immunology in newborns diagnosed as culture proven or culture negative neonatal sepsis and to identify their place in the diagnosis. This prospective study was performed in newborns who were diagnosed as neonatal sepsis and hospitalized in a tertiary care hospital and who were classified as culture proven sepsis (n=12), as culture negative sepsis (n=21) and healthy (n=17). Lymphocyte subsets were obtained at time of diagnosis. Culture proven sepsis had statistically significant increase of WBC compared to culture negative sepsis and control groups (p<0.05). Significant decreases were observed of percentage of lymphocyte, when compared to culture negative sepsis and control group (p<0.05). Percentage of CD4(+) was lower in culture proven sepsis and absolute count of CD4(+) was lower in culture negative sepsis (p<0.05). Percentage and absolute count of CD45RA(+) were lower in culture negative sepsis than control and percentage of CD45RA(+) was lower in culture proven sepsis than control (p<0.05). Percentage of CD45RO(+) was higher in culture proven sepsis than control group (p<0.05). It is clear that during neonatal sepsis lymphocyte subsets are different from healthy controls. Whether the described abnormalities represent the absence of a normal maturation process, rather, pathological events is still not clear.

Lymphocyte phenotyping to distinguish septic from nonseptic critical illness

BACKGROUND

Clinical signs and symptoms of sepsis are nonspecific and often indistinguishable from those of nonseptic critical illness. This ambiguity frequently delays the diagnosis of sepsis until culture results can confirm the presence or absence of an infectious organism. Lymphocyte phenotyping can be conducted rapidly and may provide information on the presence of infection before culture results are available. In this study, we hypothesized that lymphocyte phenotype can distinguish between septic and nonseptic critical illness.

STUDY DESIGN

C57Bl/6 mice were subjected to either P aeruginosa pneumonia or lipopolysaccharide-induced acute lung injury (ALI). Animals were sacrificed 24 hours postinjury and splenic lymphocytes were harvested. Additionally, 13 patients in a surgical ICU were enrolled in the study. Whole blood was obtained and lymphocytes were isolated by density gradient centrifugation. Lymphocyte phenotype was identified through flow cytometry after labeling lymphocytes for CD3, CD4, CD8, CD20, CD40, CD69, and CD86 with fluorochrome-conjugated antibodies.

RESULTS

CD69 expression on B cells and CD8+ splenocytes from septic mice was significantly increased compared with acute lung injury mice (p < 0.001 and p < 0.05, respectively). Similarly, CD4+ and CD8+ lymphocytes from septic patients had a two- to threefold increase in the expression of CD69 compared with nonseptic critically ill patients (p < 0.05).

CONCLUSIONS

These data indicated that CD69 expression on lymphocytes may be useful in distinguishing between septic and nonseptic critical illness. Continued investigation into the expression of CD69 during sepsis is warranted.

Biomarkers in neonatal infection

Infected newborn infants are often difficult to differentiate from patients suffering from noninfective diseases. Whilst delaying treatment with antibiotics of infected infants may be fatal, widespread indiscriminate use in all cases with suspected bacterial infection could lead to both drug-induced complications and the development of multidrug-resistant organisms. Conventional biomarkers, such as blood cell counts and morphology, have serious limitations. Investigators in this area of research have, therefore, made strenuous efforts to discover more reliable biomarkers with superior diagnostic utilities and clinically relevant characteristics to help neonatal clinicians differentiate between infected and noninfected infants. The major classes of biomarkers in neonatal infection of recent interest will be discussed, including: acute phase reactants, cytokines, chemokines and leukocyte surface antigens. The application of these biomarkers to derive prognostic information useful to neonatal clinicians will also be considered.

Evaluation of procalcitonin for diagnosis of neonatal sepsis of vertical transmission

Background

The results of recent studies suggest the usefulness of PCT for early diagnosis of neonatal sepsis, with varying results. The aim of this prospective multicenter study was to determine the behavior of serum PCT concentrations in both uninfected and infected neonates, and to assess the value of this marker for diagnosis of neonatal sepsis of vertical transmission.

Methods

PCT was measured in 827 blood samples collected prospectively from 317 neonates admitted to 13 acute-care teaching hospitals in Spain over one year. Serum PCT concentrations were determined by a specific immunoluminometric assay. The diagnostic efficacy of PCT at birth and within 12–24 h and 36–48 h of life was evaluated calculating the sensitivity, specificity, and likelihood ratio of positive and negative results.

Results

169 asymptomatic newborns and 148 symptomatic newborns (confirmed vertical sepsis: 31, vertical clinical sepsis: 38, non-infectious diseases: 79) were studied. In asymptomatic neonates, PCT values at 12–24 h were significantly higher than at birth and at 36–48 h of life. Resuscitation at birth and chorioamnionitis were independently associated to PCT values. Neonates with confirmed vertical sepsis showed significantly higher PCT values than those with clinical sepsis. PCT thresholds for the diagnosis of sepsis were 0.55 ng/mL at birth (sensitivity 75.4%, specificity 72.3%); 4.7 ng/mL within 12–24 h of life (sensitivity 73.8%, specificity 80.8%); and 1.7 ng/mL within 36–48 h of life (sensitivity 77.6%, specificity 79.2%).

Conclusion

Serum PCT was moderately useful for the detection of sepsis of vertical transmission, and its reliability as a maker of bacterial infection requires specific cutoff values for each evaluation point over the first 48 h of life.

Measurement of neutrophil membrane CD64 and HLA-Dr in a patient with abdominal sepsis

A patient with abdominal sepsis, had both intra and extracellular bacteria in a blood smear, and high levels of neutrophil membrane CD64 and HLA-Dr. Intracellular bacteria are only observed in the terminal phase of a sepsis. Our patient recovered, suggesting that a high expression of neutrophil CD64 is indicative for a good prognosis.

Diagnostic markers for neonatal sepsis

PURPOSE OF REVIEW

To review the current evidence on the use of infection markers for diagnostic evaluation of sepsis in neonates.

RECENT FINDINGS

Recent research in immunology has led to the discovery of cell surface antigens, chemokines, cytokines and acute phase proteins that can potentially be used to 'rule in' or 'rule out' sepsis. The diagnostic utilities of key inflammatory mediators, including CD11b, CD64, interleukin-6 and interleukin-8, are promising and likely to become increasingly used as markers of infection for both diagnostic and prognostic purposes.

SUMMARY

Serial measurements and use of combinations of markers have been reported to improve sensitivity and negative predictive value of these tests. Current markers are not infallible, however, and do not permit neonatologists to withhold antibiotics in sick infants with suspected infection. Thus, many have emerged as useful indicators for early discontinuation of unnecessary antimicrobial therapy. Some infection markers are also useful for identifying infants with severe infection and adverse prognosis. Advances in flow cytometry have allowed simultaneous measurement of key markers using only minimal blood volume. Judicious selection of a panel of markers with complementary properties could greatly increase the ability of neonatologists to diagnose infection and discern valuable prognostic information.

Effects of Age and Nutrition on Expression of CD25, CD44, and l-Selectin (CD62L) on T-cells from Neonatal Calves

Effects of the plane of nutrition and age on the proliferation and activation of lymphocyte subsets from milk replacer-fed calves were investigated in vitro. Holstein calves were fed a standard (0.45 kg/d of a 20% crude protein, 20% fat milk replacer, n = 4) or intensified (1.14 kg/d of a 28% crude protein, 20% fat milk replacer, n = 4) diet from 1 to 8 wk of age. Average daily weight gain of intensified-diet (0.66 kg/d) calves was greater than that of standard-diet (0.27 kg/d) calves. Relative to the pokeweed mitogen-induced responses of CD4(+) cells from steers (5 to 6 mo of age), CD4(+) cells from 1-wk-old calves showed decreased proliferative activity, delayed increase in CD25 expression, and no demonstrable increase in CD44 expression or decrease in CD62L expression. Calf CD8(+) and gammadeltaT-cell receptor(+) cells, unlike T-cells from the older animals, did not demonstrate decreased expression of CD62L after stimulation with mitogen. The increased expression of CD44 by mitogen-stimulated gammadeltaT-cell receptor(+) cells from older animals was not seen in gammadeltaT-cell receptor(+) cells from 1-wk-old calves. At wk 8 of age, mitogen-induced proliferation and expression of activation antigens by T-cells from standard-fed calves were similar to responses of T-cells from steers indicating rapid maturation of T-cell function during the neonatal period. Feeding calves an intensified milk replacer was associated with decreased proliferation of mitogen-stimulated CD4(+), CD8(+), and gammadeltaT-cell receptor(+) cells; decreased CD25 expression by mitogen-stimulated CD4(+) and CD8(+) cells; and decreased CD44 expression by mitogen-stimulated CD8(+) cells. These results indicate that the functional capacity of the calf's T-cell population becomes more adult-like during the first weeks of life and suggest that nutrition modulates T-cell function during this period of immune maturation.

Immunologic markers in the neonatal period: diagnostic value and accuracy in infection

Diagnosis of early-onset neonatal infection has led to the development of several screening tests including C-reactive protein, a very commonly used marker, and cytokines (mainly interleukin-6 and -8), alone or in combination with C-reactive protein, based on the premise that their increases in response to infection may precede that of C-reactive protein. In recent years the search for diagnostic tests has turned to procalcitonin, a propeptide of calcitonin, which appears to be a promising marker of infection in newborn infants. Additionally, specific leukocyte cell surface antigens (mainly CD11b and CD64), detected by flow cytometry, are evaluated as markers of neonatal infection, since their expression on the cell membrane increases in substantial quantities after leukocyte activation by bacteria or their cellular products. This review aims to examine the role of these newly available immunologic indices and to assess their validity as diagnostic markers of infection during the neonatal period.

Neutrophil CD64 is a sensitive diagnostic marker for early-onset neonatal infection

This prospective study aimed to evaluate the diagnostic utilities of neutrophil CD64 expression for the identification of early-onset clinical infection and pneumonia in term infants and to define the optimal cutoff value so that it may act as a reference with which future studies can be compared. Term newborns in whom infection was suspected when they were <72 h of age were recruited into the study. C-reactive protein (CRP) and expression of CD64 on neutrophils were measured at 0 h (at the time of sepsis evaluation) and 24 h. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of CRP, CD64, and the combination of these two markers for predicting neonatal sepsis were determined. A total of 338 infants with suspected clinical sepsis were investigated, 115 of whom were found to be clinically infected. CRP and CD64 in infected infants were both significantly elevated at 0 and 24 h compared with noninfected infants (p < 0.001). The calculated optimal cutoff value for CD64 was 6136 antibody-phycoerythrin molecules bound/cell. CD64 has a very high sensitivity (96%) and NPV (97%) at 24 h. The addition of CRP only marginally enhanced the sensitivity and NPV (97 and 98%, respectively). In conclusion, neutrophil CD64 is a very sensitive diagnostic marker for the identification of early-onset clinical infection and pneumonia in term newborns. The results strongly suggest that measurement of neutrophil CD64 may allow neonatal clinicians to discontinue antibiotic treatment at 24 h in infants who are clinically stable and whose CD64 expressions are below the optimal cutoff level.