Comparative assessment of umbilical cord blood with peripheral venous blood using hematological scoring system as an early predictive screening method for the detection of early-onset neonatal sepsis in the tertiary care center of Central India

Background: Sepsis is one of the major causes of neonatal morbidity and mortality. Early recognition and diagnosis of early-onset neonatal sepsis (EONS) is difficult because of the variable and non-specific clinical presentation of this condition. Hence, there is a need for early predictive screening method for EONS. Aims and Objectives: To compare the umbilical cord blood Haematological Scoring System (HSS) with peripheral venous blood as an early predictive screening method for detection of EONS. Materials and Methods: 100 inborn neonates with two or more risk factors for EONS, chosen by sequential sampling method were included in this prospective analytical study. Blood samples were collected from the umbilical cord and peripheral vein analyzed for hematological parameters, sepsis screen, and peripheral smear for HSS of Rodwell et al., send for blood culture. Blood cultures were performed as gold standard for diagnosing neonatal sepsis and sepsis screen was done to corroborate the diagnosis of neonatal sepsis. Results: Of 100 neonates, 21 belongs to sepsis; 14 to probable sepsis; 65 to no sepsis. HSS in umbilical cord blood (UCB) had Sensitivity-74.28%, Specificity-92.30%, PPV-83.87%, NPV-86.95% and HSS in PVB had Sensitivity-62.85%, Specificity- 87.69%, PPV-75.86%, NPV-81.69%. Conclusion: HSS score in UCB can be used as a simple, quick, cost-effective, and readily available screening test with decent sensitivity and high specificity, for the detection of EONS.

Early-Onset Neonatal Sepsis: Role of C-Reactive Protein, Micro-ESR, and Gastric Aspirate for Polymorphs as Screening Markers

Introduction. Early-onset neonatal sepsis is a major cause of morbidness and death in newborn children. Its timely diagnosis is usually a challenge in developing countries like India. Aim. To study the efficacy of C-reactive protein (CRP), micro-ESR, and gastric aspirate for polymorphs in the diagnosis of early-onset neonatal sepsis. Materials and Methods. This study included sixty term and preterm children, inborn and referred cases. The children who presented before day seven of life with clinical suspicion of sepsis or who were at high risk of developing sepsis were included. These were further investigated. Significant values for screening tests were taken as C − reactive protein > 0.6 mg / dl , micro-ESR—after 1 hour, fall in the column of blood in capillary tube was measured, and result was taken as mm fall in 1 hr, and gastric aspirate for polymorphs > 5 polymorphs / HPF . Sepsis screen positive result was 2 or more positive tests. The statistical evaluation was done using Fisher, and ANOVA tests using SPSS 20.0 version. Results. Sixty children were included in the study with forty as the referred ones. Most of them had tachypnea (45%). CRP showed high sensitivity, whereas micro-ESR and gastric aspirate for polymorphs showed high specificity. Conclusions. Neonatal sepsis screening is required for the detection of infection as the blood culture report may not be positive in all the cases, and even if positive, the result takes few hours. CRP showed high sensitivity, whereas micro-ESR and gastric aspirate for polymorphs showed high specificity independently as well as when combined.

Role of Antibiotics in Neonates Born through Meconium Stained Amniotic Fluid

The objective of our study was to compare the clinical course and infection related outcome in cases of meconium stained amniotic fluid neonates treated with or without antibiotic therapy. One hundred fifty eligible neonates were randomized to antibiotic group and non antibiotic group. Both groups were compared for development of sepsis screen and final outcome in both groups were compared. The incidence of sepsis screen positive was observed in both groups. In antibiotic group sepsis screen was positive in 5 cases and in non antibiotic group sepsis screen was positive in 4 cases. overall incidence of sepsis screen positive was similar in both antibiotic and non antibiotic group. The difference was not found to be statistically significant (p value = 1.00 and chi square value 0.118). Final outcome in both antibiotic group and non antibiotic group showed that in antibiotic group, out of 75 neonates 71 were discharged successfully and 4 were died. In non antibiotic group, 73 were discharged successfully and 2 died, out of 75 neonates. There was statistically no significant difference on final outcome between these two groups (p value 0.68 and chi square value 0.694). Conclusion: There was no difference in the incidence of infection and in final outcome in neonates born through meconium stained amniotic fluid treated with or without antibiotics. Keywords: Meconium Stained Amniotic Fluid, Neonates, Antibiotic Therapy.

Antimicrobial Resistance and Predictors of Adverse Outcomes in Neonates with Bacterial Meningitis: a Retrospective Study from a Tertiary Care Hospital of Northern India

This study aimed to determine antimicrobial resistance pattern and predictors of adverse outcome in neonatal meningitis. A retrospective study by analyzing case files of 134 cases of neonatal meningitis. We noted an alarming degree of multidrug resistance (MDR) among both gram-negative (Klebsiella spp., 50%; Escherichia coli, 100%; and and Acinetobacter spp., 50%), as well as positive (Enterococcus, 100%) isolates in cerebrospinal fluid (CSF) culture. The incidence rate of adverse outcome (i.e., mortality and abnormal neurological examination at discharge) was 8.2 and 17.2%, respectively. On univariate analysis, delayed seeking of medical care, bulging anterior fontanelle, vomiting, positive sepsis screen, shock during hospital course, ventriculitis, diversion procedures for raised intracranial pressure, central line placement, low CSF sugar, and failed hearing screening test at discharge were associated with increased risk of adverse outcome. Further, delayed seeking of medical care, shock during hospital course, positive sepsis screen, thrombocytopenia, and MDR infections were independently found to be associated with adverse outcomes. An alarming degree of antimicrobial resistance among the CSF isolates necessitates the need to understand the pathogenesis of resistance and curtail the irrational prescription of antibiotics in neonatal meningitis. Further, delayed seeking of medical care, shock during hospital course, positive sepsis screen, thrombocytopenia, and MRD infection may have prognostic value in neonatal meningitis

Diagnostic Utility of Cord Blood Serum Procalcitonin in Early Onset Neonatal Sepsis in Comparision to Sepsis Screening Parameters

Neonatal sepsis is an important cause of neonatal deaths globally. Diagnosis of neonatal sepsis is established based on microbiological tests of sepsis screen and clinical status. Mid phase markers of inflammation like CRP & Serum Procalcitonin are considered useful and sensitive for diagnosis. Most of the studies evaluating serum PCT as a diagnostic marker for neonatal septicemia have been carried out in peripheral venous blood with smaller sample sizes with inclusion of neonates without considering perinatal sepsis score. This hospital based, prospective study compares the diagnostic utility of cord blood Procalcitonin (PCT) with venous blood PCT; alone and as part of sepsis screening parameters currently in use in perinatal sepsis score positive neonates. Statistical analysis for cord blood Serum Procalcitonin (PCT) for detecting blood culture positive patients showed that PCT has a sensitivity of 44.4%, a high specificity of 86.4%, a low PPV of 33.3% and a high NPV of 91.1%. Overall diagnostic accuracy is 80.9%, indicating that cord blood PCT is a good test for identifying these patients (p < 0.05). However, venous blood PCT failed to demonstrate similar results. Conclusions- Umbilical blood sampling protects the neonates from pain of venipunctures. Cord blood PCT estimations have statistically significant correlation with blood culture and other sepsis screen parameters and better sensitivity and specificity than venous blood PCT. This early serological biomarker is valuable for the diagnostic armamentarium of neonatal septicemia for early diagnosis and management while awaiting blood culture reports and helps in reducing separation of probable sepsis neonates from mother, thus contributing in developmental supportive care.

Role of C-reactive protein and gastric aspirate polymorphs in early onset neonatal sepsis

Background: Neonatal septicemia is a major cause of morbidity and mortality in the neonates. It presented a diagnostic challenge in the resource poor setting of most of the developing countries of world.Methods: This prospective observational study included all term and preterm babies inborn and outborn referred cases. We included neonates less than 7 days of age with clinical suspicion of sepsis. Significant values for screening tests were taken as total leucocyte count (TLC) of >25,000/<5000, C-reactive protein>0.6 mg/dl and gastric aspirate polymorphs>5 per HPF. Sepsis screen was considered positive for two or more positive tests. Blood culture was used as the gold standard. The statistical analysis was done using SPSS 22.0 version.Results: A total number of 60 subjects were included in the study with 45 (75%) as outborn neonates. Most of them presented with tachypnea followed by difficulty in feeding and lethargy. Significant p values were observed using CRP and gastric aspirate polymorphs as independent sepsis screening markers and when combined together (p<0.001).Conclusions: Sepsis screen in neonates is required for detection of infection as blood culture may be negative and even positive result takes time. CRP showed high sensitivity. Gastric aspirate cytology with its relatively high specificity and negative predictive values serves as a good screening tool to rule out neonates unaffected by sepsis. When all the three parameters were combined together, sensitivity and specificity increased to 100% and 91.67% respectively with p values of 0.001.

Haematological Parameters in Neonatal Sepsis in a Tertiary Care Centre Study

BACKGROUND Neonatal septicaemia is a bacterial infection with positive blood culture in first four weeks of life. The early sepsis screen is vital as it detects earlier and benefits the clinician to treat the infection reducing neonatal mortality and morbidity. We wanted to evaluate various haematological screening parameters and C-reactive protein (CRP) in blood culture positive neonates in sepsis. METHODS This prospective study was conducted for a period of one year. Blood samples from hundred clinically suspected neonatal septicaemia cases were subjected to aerobic culture and sepsis screen tests like C-reactive protein, erythrocyte sedimentation ratio (ESR), total WBC count, absolute neutrophil count, immature / total neutrophil count (I / T) ratio and platelet count. The culture results were correlated with the sepsis screen tests. RESULTS Of the hundred cases studied, 18 % were blood culture positive and 66 % were males. Early onset septicaemia was more common, seen in 64 % of cases than late onset septicaemia (26 %) cases. Staphylococcus aureus was the commonest organism isolated in 38.46 % of cases followed by Klebsiella pneumoniae & E. Coli. Among the haematological parameters, the positivity was best with Creactive protein (94.44 %) followed by immature & mature neutrophil ratio (I / M) (94.44 %), I / T ratio (88.88 %) and the least with absolute neutrophil count (66.0 %). Any two or more parameters were positive in 94.44 % of the subjects. CONCLUSIONS Sepsis screen has good sensitivity, specificity and is a valuable aid for early diagnosis of neonatal septicaemia. Sepsis screen is simple, cost effective, less time consuming and easy to perform. As an individual test C-reactive protein has shown highest sensitivity, specificity and is a sensitive and responsive indicator of neonatal sepsis. KEYWORDS Blood Culture, Neonatal Septicaemia, Sepsis Screen

Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen

Objective: To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution. Design: Retrospective cohort study. Setting: Two affiliated academic medical centers in Los Angeles, California. Patients: Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards. Methods: We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation. Results: Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91–4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28–3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34–0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22–0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria. Conclusions: Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.

Preterm vaginal en caul delivery in a case of severe oligohydramnios with pyelonephritis

En caul deliveries are very rare and are associated with prematurity. Approximately 40 percent of spontaneous premature births are thought to be caused by infection. Preterm along with oligohydramnios can lead to en caul delivery. We report a case of 27-year-old gravida 4 multiparous women with a history of 2 normal vaginal deliveries NSVD and 1 spontaneous abortion, who presented at 32 weeks of gestation in active labour and delivered preterm viable female with an intact placenta contained within the amniotic sac as a unit “en caul.” Since the patient gave a history of lower back pain with burning micturition for 1 month which remained consistent after delivery, ultrasonography whole abdomen was done and bilateral pyelonephritis was diagnosed. However, the baby’s sepsis screen was negative and discharged healthy. We report this case because of its rarity of occurrence and to show that intact amniotic membrane during birth can protect the baby from birth trauma and infections.