European Journal of Cardiovascular Medicine

Neonatal septicemia is a leading cause of mortality and morbidity during the neonatal period¹. By definition neonatal sepsis is defined as a clinical syndrome of bacteraemia with systemic signs and symptoms of infection in the first weeks of life. Illness can rapidly progressive so timely diagnosis of septicaemia is critical.²

In developing countries, total neonatal deaths account for about 30% to 50%. Overall incidence of sepsis is 1-5 /1000 live births and mortality of untreated sepsis can be as high as 50%. In India incidence of sepsis is 38 per 1000 live births in tertiary care institutes and it contributes to 36% of deaths in hospitals³. According to Neonatal Perinatal Database (NNPD), incidence of neonatal sepsis is 30/1000 live births. ¹

Common causes of neonatal septicaemia is Group B Streptococcal Disease in Europe and North America. In developing countries and tropical, Gram Negative organism is most common cause. In India according to NNDP Klebsiella pneumonia followed by Staphylococcus aureus is the most frequent causes.⁴

Immaturity of both cellular and humoral immune systems at birth leads to susceptibility of new born to infection. Particularly this feature is evident in preterm neonates. Infection can be acquired from mother through transplacental route, ascending infection, during passage through an infected birth canal, or exposure to infected blood at delivery⁵.

Initial diagnosis of neonatal sepsis based on clinical signs and symptoms which are non specific as other non infective conditions like aspiration, asphyxia, and metabolic disorders^6.

Neonatal sepsis is classified into Early onset neonatal sepsis (EONS) and Late onset neonatal sepsis (LONS). EONS is defined as onset of signs and symptoms within first 72 hours of life. LONS defined as clinical signs and symptoms occur after 72 hours of life. Before the diagnosis is confirmed, antibiotics therapy is commenced soon after onset of symptoms.⁶The early initiation of appropriate antibiotics therapy results in successful outcome of bacterial infection.⁷

Neonatal sepsis can be of two types according to National Neonatology forum.¹

1. Proven sepsis: newborn with clinical symptoms suggestive of sepsis and isolation of pathogens from blood, CSF (cerebrospinal fluid), urine, and other body fluids or autopsy evidence of sepsis.
2. Probable sepsis: newborn with clinical pictures suggestive of sepsis with one or more following features

Predisposing factors like maternal fever, foul smelling liquor, prolonged rupture of membrane > 12 hours, gastric polymorph count of more than 6/hpf.

Positive sepsis screen with two of the following four parameters

 1- Total leukocyte count < 5000/ cumm or >20,000/cumm.

 2- Band cell to total neutophil ratio of >- 0.2.

 3- CRP>- 0.6 mg/dl

 4- Micro ESR>- 15 mm/hr

Radiological evidence of pneumonia.¹

Isolation of microorganism from blood is the gold standard method for diagnosis of neonatal sepsis⁸. As it is time consuming in addition to the blood culture other tests are used for diagnosis of neonatal sepsis including estimation of white blood cell count (WBC), micro ESR and I/T ratio and CRP which is an acute phase reactant whose level increases within 6 hours of acute inflammation and then decreases. It is reliable in first 24 – 48 hours after onset of infection⁶.

The study was carried out with following.

The Study Design - Prospective, Observational and Analytical study included 95 neonates admitted to NICU with signs suggestive of sepsis or who developed signs of sepsis while in the ward.

Source of Data- The study was carried for one year from 2019 to 2020 in the Department of Pathology, Jawaharlal Nehru Medical College (JNMC) in coordination with Department of Paediatrics, Acharya Vinoba Bhave Rural Hospital (AVBRH), Sawangi(Meghe), Maharashtra, India

Study Procedure:

• Relevant maternal and neonatal histories were recorded in a predesigned and pretested proforma.
• Blood samples (2 ml) were collected from the peripheral venous puncture before initiation of antibiotics.
• Blood was collected under complete aseptic conditions.
• Samples were collected in ethylene diamine tetra acetic acid containing non silionized vacutainer tubes.
• “Peripheral blood smears were drawn, stained with Leishman stain and examined under oil immersion lens of light microscope at the magnification of x1000 for total white blood cell count and I:T ratio. A differential leukocyte count (DLC) was done to obtain the total neutrophil count (TNC), immature neutrophil count (IM), including bands and stabs; and mature neutrophil count. Neutrophils were classified as band forms when there were no nuclear segmentation or when the width of the nucleus at any constriction was not less than one third the width of its widest portion. Band forms together with less mature cell forms were classified as immature polymorphonuclear (PMN) leukocytes. Using these values, I/T ratios were computed”.
• ESR was estimated by Westergren method.
• Serum level of CRP was done by latex agglutination test.

STATISTICAL ANALYSIS         

“Sensitivity, specificity, positive and negative predictive values (NPVs) were calculated for each parameter. P values were also calculated for different parameters. Data was statistically analyzed using SPSS software”.

The study included infants who were admitted to the NICU with evidence of sepsis or who developed signs of sepsis while in the unit. 46 (48.4%) of the infants suspected of EOS were culture positive, resulting in a 0.7 percent incidence of culture positive sepsis. E. coli was the most common microbe, accounting for 34%, followed by Klebsiella (27%), S. aureus (24%), and pseudomonas (9%). EOS was found in a high percentage of preterm (58.6%), boys (65.3%), and LBW babies (52.1% ).

 39 newborns presented with “Fever, refusal to feed and lethargy(41%) , 49 Pneumomia (31.4%) 19 Upper GI bleed and feed intolerance(12.1%), 19 Birth asphyxia             (12.1%), 18 Shock (11.5%), 15 Respiratory failure             (9.6%), 15 Neonatal jaundice          (9.6%), 12 Apnea (7.6%), 12 Hypoglycemia     (7.6%), 11 Meconium aspiration syndrome (7%), 10 Seizure (6.4%), 5 Hypothermia (3.2%), 5 Urinary tract infection     , (3.2%), 4 Meningitis (2.5%)”

On the parameters used for the study in clinically suspected instances of sepsis, the following observations were made.

Table 1: Distribution of demographic profile in newborn with EOS (n = 95).

Table 2: Sensitivity, Specificity, PPV(positive predictive value) and NPV (negative predictive value) of various hematological parameters in EOS.

Table 3: Distribution of various hematological parameters in newborns with EOS (n = 95)

 “Neonatal TLC, IT Ratio, and micro–ESR were found to be statistically significant in early diagnosis of culture positive EOS (p < 0.05, Table 5)”.

Neonatal septicemia is still a leading cause of mortality and morbidity in developing countries like India. The importance of the sepsis screen in the identification of newborn septicaemia cannot be overstated. Furthermore, babies with sepsis generally decline quickly. Early and efficient diagnosis is difficult for clinicians because failure or delay in treatment is likely to result in severe mortality and morbidity. The blood culture not only takes time, but is also complicated, with a low yield. Blood culture is still the “Gold standard for the diagnosis of septicemia in neonates and should be done in all cases of suspected septicemia.”⁷

In the present study maximum incidence of EOS was seen in preterm (58.6%), male (65.3%), low birth weight (52.1%). Blood culture was positive in 48% of cases and negative in 52% of cases. Sensitivity of testing was high for I/T ratio (91.6 %) and also for raised micro ESR ratio (92.1%). Positive predictive value was relative higher for raised micro-ESR and CRP levels (76% each). In blood culture positive patients (46 neonates).

The findings of the present were in concordance to study by Niva Rani Dutta et al. They conducted a similar research on the use of the haematological scoring system (hss) in the early detection of newborn sepsis in a tertiary care hospital in North East India. Blood cultures were negative in 77.15 percent (162/210) of neonates and positive in 22.85 percent (48/210), with Gram negative organisms found in 62.5 percent (30/48) and Gram positive infection in 37.5 percent (18/48).²

In a similar study by Dr Abhilasha Garg et al., of the 100 cases studied, 26%were blood culture positive. 72%were males. 56%were preterm and 40% were very low birth weight neonates. Early onset septicemia was more common, seen in 68% of cases than late onset septicemia (22.4%) cases. E. Coli was the commonest organism isolated in 38.46% of cases followed by klebsiella pneumoniae & staphylococcus aureus. Among the haematological parameters, the positivity was best with ANC & I/T Ratio (84.61%) and the least with platelet count (73.07%). Any 2 or more parameters were positive in 96.15% of the subjects.⁷.

Minichil Worku et al. conducted a similar study aimed at assessing the role of CBC parameters in diagnosing neonatal sepsis. Early onset and late-onset sepsis were developed in about 29.6% (37/250) and 70.4% (88/250) of the neonates, respectively. The TLC, Hgb, lymphocyte count, and ANC parameters have a sensitivity of 64.8, 68, 33.6, and 49.6%, respectively.⁸

Moshira S. Elsayed et al. determine the significance of the hematological scoring system (HSS) for early detection of neonatal sepsis. HSS among septic group had a sensitivity (96%), specificity (90%). Total leukocytic count in the septic group was statistically significantly increased compared with the corresponding values in the probable septic and control groups (P= 0.021*). ⁹

Patel U et al. carried out a research study to determine the usefulness of C-reactive protein (CRP) for evaluation of neonatal sepsis in teaching hospital of central India. Of 82 neonates studied, 67 (81.7%) had positive CRP while 58 (70.73%) had positive blood culture. The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of CRP were 81.7%, 88.0%, 95.7%, 59.5% and 83.2% respectively. ¹⁰

Because neonatal sepsis is a dangerous condition with a high death rate, a high index of suspicion is critical in the diagnosis and treatment of this infection, which is complicated by ambiguous and nonspecific clinical symptoms. While waiting for blood culture results, newborn haematological markers such as IT ratio >0.2, increased micro-ESR, TLC, and CRP are sensitive and specific in early diagnosis of neonatal sepsis. As a result, even in resource-poor nations, neonatal clinical and haematological profiles can be used as early indications of EOS.

ACKNOWLEGEMENT:

We thank the patient who participated and contributed sample to the study.

 INFORMED CONSENT:

Oral consent was obtained from the parents of the newborn babies.

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