Neonatal Sepsis: Haematological Perspectives

www.idosr.org Obeagu et al ©IDOSR PUBLICATIONS International Digital Organization for Scientific Research IDOSR JOURNAL OF SCIENTIFIC RESEARCH 8(2) 161-166, 2023. https://doi.org/10.59298/IDOSR/2023/10.2.6013 ISSN: 2550-794X Neonatal Sepsis: Haematological Perspectives * Emmanuel Ifeanyi Obeagu1, Ndakize Benjamin Kigabo2, Getrude Uzoma Obeagu3, Okechukwu Paul-Chima Ugwu4 and Sophia Kazibwe5 1 Department of Medical Laboratory Science, Kampala International University, Uganda. Department of Paediatrics and Child Care Health, Kampala International University, Uganda. 3 School of Nursing Science, Kampala International University, Uganda. 4 Department of Publications and Extension, Kampala International University, Uganda. 5 Department of Public Management, Management Science, Human Resource Management, Kampala International University, Uganda. Email: emmanuelobeagu@yahoo.com 2 ABSTRACT Neonatal sepsis (NS) is a leading cause of neonatal morbidity and mortality and is considered a global public health challenge. The organisms and pathogens most commonly associated with neonatal sepsis vary by country. Pathogens range from Gram-positive and Gramnegative bacteria to viruses and fungi, with bacteria being the most commonly identified. Bacteria most commonly involved include Staphylococcus aureus, coagulase-negative staphylococci (CONS), Streptococcus pneumoniae, Streptococcus pyogenes, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Salmonella typhi, and Group B Streptococcus increase, or urine culture is usually delayed for a day or two. A battery of tests, including C-reactive protein, total leukocyte count, absolute neutrophil count, platelet count, neutrophil cytoplasmic vacuolization, and polymorphic gastric aspiration cytology, was performed in neonates with a clinical diagnosis of NS. It's an excellent screening test. Keywords: Sepsis, neonates, haematological parameters, laboratory diagnosis, clinical findings INTRODUCTION NS, initiation of antibiotic therapy is Neonatal sepsis is a leading cause of recommended before diagnostic results neonatal morbidity and mortality and is are available. However, some patients with considered a global public health bacterial infections may have negative challenge [1-10]. Symptoms and signs may blood cultures (clinical infections), be subtle, varied, and nonspecific. In requiring other approaches to identify addition, delays in diagnosis and initiation infection [12]. Many studies have been of treatment result in high morbidity and conducted to develop screening tests or mortality. 5 million newborns die each scoring systems that can identify infected year, mainly in Africa and Asia, of which infants at initial evaluation and avoid 1.6 million (20%) are due to neonatal other invasive diagnostic procedures, sepsis. The incidence of neonatal sepsis in intravenous antibiotic therapy, motherdeveloped countries ranges from 1 to 10 infant separation, and increased parental per 1000 live births, whereas it is three anxiety. Attempts have been made [13]. times higher in Pakistan [12]. Definitive Current microbiological gold-standard diagnosis based on blood, CSF, or urine blood culture screens have low yields in culture is usually delayed by a day or two. addition to long turnover times, and In neonates with clinical manifestations or collection of small amounts of blood can epidemiological factors associated with 161 www.idosr.org Obeagu et al lead to false-negative results [14]. instead of fixed normal ranges for WBC, Additional traditional blood, including ANC, and I/T ratio [16]. Therefore, a rapid measurement of white blood cell count and accurate diagnostic test is needed to (WBC), absolute neutrophil count (ANC), guide the management of neonates with immature-to-total neutrophil ratio (I/T), sepsis. Detection of bacteria and and C-reactive protein (CRP) Biologic tests inflammatory cells on postnatal day 1 may also require serial surveillance with Gram-stain gastric aspirate cytology (GAC) low sensitivity and specificity [15]. To may indicate maternal amnionitis, a risk better predict sepsis, recent findings factor for early-onset infection [12]. suggest using age-specific nomograms Neonatal sepsis Neonatal sepsis is a blood infection that In the 1990s, the American Academy of occurs in infants less than 90 days of age. Pediatrics (AAP) began to recommend the Early sepsis occurs in the first week of life. use of intrapartum antibiotic prophylaxis Late sepsis occurs after 1 week to 3 (IAP) to prevent perinatal GBS, and in 2002, months. The organisms and pathogens the AAP and the American College of most commonly associated with neonatal Obstetricians and Gynecologists instituted sepsis vary by country. Pathogens range guidelines on the universal screening by from Gram-positive and Gram-negative culture of all pregnant women from 35- to bacteria to viruses and fungi, with bacteria 37-week gestation. Due to the widespread being the most commonly identified. The use of prophylactic antibiotics for most commonly implicated bacteria neonates, particularly intrapartum include Staphylococcus aureus, coagulase antibiotic use in mothers with positive negative staphylococci (CONS), cultures for GBS, the incidence of GBSStreptococcus pneumoniae, Streptococcus associated neonatal sepsis has declined pyogenes, Escherichia coli, Klebsiella significantly, a decrease of 70% in the US pneumoniae, Pseudomonas aeruginosa, [19]. During the same period, other Salmonella typhi, and Group B countries such as Canada and Taiwan have streptococcus (GBS) [17]. Viruses include recommended the universal use of IAP and echovirus, enterovirus, parechovirus, have seen a decline in the incidence of coxsackie virus, adenovirus, parainfluenza neonatal sepsis secondary to GBS infection virus, rhinovirus, herpes simplex virus as well [20]. In countries where IAP is used, respiratory syncytial virus, and the most common causative agents of coronavirus Candida albicans and other neonatal sepsis are Escherichia coli and Candida species are the most common Gram-positive bacteria [21]. fungi associated with neonatal sepsis [18]. Risk Factors In early-onset neonatal sepsis (EONS), venous catheters and other invasive which is usually associated with vertical medical devices, and prolonged transmission of pathogens from mother to hospitalization [24]. Other risk factors child, the most common pathogens are include premature rupture of membranes, group B Streptococcus, Escherichia coli, amnionitis, meconium aspiration, LBW, CONS, Haemophilus influenzae, and VLBW, ELBW, premature birth, >3 vaginal Listeria monocytogenes [21-22]. ]. In lateexaminations during labor, maternal fever onset neonatal sepsis (LONS), which is during labor, or other maternal infections most commonly associated with iatrogenic during labor [25]. Among term infants, or nosocomial infections, the most males have a higher incidence of sepsis common pathogens are CONS, followed by compared with female infants, an Staphylococcus aureus and Escherichia association not seen in preterm infants coli [23]. Risk factors include use of central [26]. Clinical findings Given the relatively subtle findings seen sepsis until more ominous clinical during clinical examination, neonates are findings and vital sign abnormalities at significant risk of delayed detection of occur. Early-onset individuals may have a 162 www.idosr.org Obeagu et al history of fetal distress, including rhinitis, accessory muscle use, cyanosis, perinatal fetal tachycardia. Shortly after and apnea are common in neonatal sepsis. delivery, other clinical cues such as Neurological symptoms and signs include meconium-stained amniotic fluid and low lethargy, seizures, irregular breathing, Apgar scores may appear at the initial high-pitched crying, hypotension, neonatal assessment. Caretakers may hypoactive deep tendon reflexes, and report a history of food intolerance, abnormal primitive reflexes. irritability, excessive sleepiness, or Gastrointestinal signs include decreased "looking weird." Vital sign abnormalities food intake, vomiting, diarrhea, jaundice, include both hypothermia and fever. Fever abdominal distension, and is more common in term infants, but hepatosplenomegaly. Cutaneous findings premature infants are more likely to include petechiae, impetigo, cellulitis, and become hypothermia. Tachycardia or abscesses. Basal metabolic acidosis due to bradycardia, signs of poor circulation such poor perfusion can manifest as tachypnea as cold or pale extremities, and a rapid, and shortness of breath in the absence of lint-like pulse may occur. Respiratory respiratory infection [27]. symptoms and signs such as moaning, Diagnostic Testing As the symptoms and signs of neonatal (CBC) was performed to determine the total sepsis are often very subtle and vague, it and fractional white blood cell (WBC) is imperative to perform diagnostic testing counts, the absolute and immature in any neonate with significant risk factors neutrophil counts, and the immature and and concerning signs and symptoms. total neutrophil count ratios. Must be There are various multivariate predictive evaluated. Absolute leukocytosis has a low scoring systems based on retrospective susceptibility to neonatal sepsis, but is studies that may be used to predict the useful for clinical decision-making when need for antibiotics and extensive there is mild to moderate clinical laboratory evaluation of a neonate versus suspicion of sepsis. Interestingly, a low observation for concerning signs and WBC count, a low absolute neutrophil symptoms. One such example is the EONS count (ANC), and a neutrophil-tocalculator based on a large retrospective prematurity ratio (I/T) greater than or population study performed in the US to equal to 0.2 were highly predictive of support clinicians in the decision to start infection. has been shown [31]. Dividing antibiotics in neonates suspected of the I/T by the total neutrophil count to having sepsis [28]. The newborn's prior obtain the I/T ratio has been shown to probability of EONS obtained from provide improved specificity and area maternal risk factors such as under the curve over I/T and ANC alone in chorioamnionitis and premature rupture diagnosing EONS [32].The I/T2 ratio of membranes is combined with findings accounts for both elevated immature based on the clinical examination, creating neutrophils and the neutropenia that is of a scoring system that can determine the concern in the setting of sepsis. ANC, I/T, need for antibiotics and level of and I/T2 sensitivity, specificity, odds monitoring required This scoring system ratio, and area under the curve were has been shown to reduce the proportion highest at 4 hours postpartum compared of newborns undergoing extensive to previous [33]. Therefore, placental laboratory evaluation and administration culture results should not be used as a of antibiotics without any adverse effects reason for antibiotic therapy. Urinary tract [29]. The number needed to treat (NNT) for infections are rare within the first 72 hours the high-risk group requiring antibiotics of life. Therefore, urine cultures are determined by this scoring system was performed only when assessing LONS [28]. still 118, highlighting the challenges Neonates with evidence of EONS or LONS involved in coming up with better should undergo routine lumbar puncture diagnostic tools in picking up EONS at an (LP). Approximately 23% of neonates with early stage [30]. A complete blood count culture-positive bacteremia also develop 163 www.idosr.org Obeagu et al meningitis [28]. Acute-phase reactants phase reactants such as procalcitonin, IL-6 such as C-reactive protein (CRP), and IL-8 can improve diagnostic accuracy procalcitonin, interleukin (IL-6 and IL-8) [33]. Procalcitonin (PCT) is more specific levels, presepsin, haptoglobin, and than CRP against bacterial infection and neutrophil CD64 are potential biomarkers increases faster than CRP in response to for neonatal sepsis. being investigated. infection. In normal-weight infants, PCT CRP may not be elevated during the early levels above 0.5 ng/mL are associated with stages of infection because it takes time to nosocomial infections, and in VLBW synthesize in the liver and eventually infants levels above 2.4 ng/mL should appears in the blood. Serial measurement prompt antibiotic therapy [33]. of CRP in combination with other acute CONCLUSION neonatal sepsis. A battery of tests, Although the incidence of neonatal sepsis including C-reactive protein, total has declined in some parts of the world, it leukocyte count, absolute neutrophil remains a significant problem worldwide. count, platelet count, neutrophil Tests for the identification and diagnosis cytoplasmic vacuolization, and of neonatal sepsis continue to be polymorphic gastric aspiration cytology, developed, and new test techniques are was performed in neonates with a clinical still being tested. Monitoring and diagnosis of NS. It's an excellent screening management of risk factors and IAPs test. These tests are readily available, remain important in preventing and inexpensive, reliable and sensitive in controlling infection in this vulnerable detecting neonatal sepsis. Combining the population. 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