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ORIGINAL CONTRIBUTION
Year : 2001  |  Volume : 55  |  Issue : 9  |  Page : 495-500
 

Early diagnosis of neonatal sepsis using a hematological scoring system


Department of Pathology and Pediatrics, Tata main Hospital, Jamshedpur, India

Correspondence Address:
Sharmila Ghosh
306, Rishab Apartment,, Tulsi Pipe Road, Lower Parel, Mumbai : 400 013
India
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How to cite this article:
Ghosh S, Mittal M, Jaganathan G. Early diagnosis of neonatal sepsis using a hematological scoring system. Indian J Med Sci 2001;55:495-500

How to cite this URL:
Ghosh S, Mittal M, Jaganathan G. Early diagnosis of neonatal sepsis using a hematological scoring system. Indian J Med Sci [serial online] 2001 [cited 2014 Nov 22];55:495-500. Available from: http://www.indianjmedsci.org/text.asp?2001/55/9/495/43147


The inability of neonates to completely muster the minimum inflammatory response makes them more sucesptible to bacterial invasion of the blood stream than older children and adults and the risks are even higher in those born prematurely [1] . Diagnosis of neonatal septicemia may be difficult as the early signs of sepsis may be subtle and different at different gestational ages [1] . The need is for an infallible test or combination of tests for bacteraemias that is easily performed with quick availability of reports. Some of the tests for sepsis such as haptoglobin estimation and counterimmunoelectrophoresis are not available in all laboratories. In this study we have studied the hematologic profiles of 103 newborn infants according to the scoring system of Rodwell et al [2] for the early detection of sepsis in high-risk infants.


  Subject and Methods Top


The present study is a prospective analysis of the hematologic profiles of 105 neonates admitted in the neonatal care unit of this hospital between November 1999 to Fevruary 2000. Infants were enrolled in the study if there were predisposing per inatal factors or if there was clinical suspicion of sepsis. Two babies, one with plasmodium vivax malaria and another with congenital toxoplasmosis, were exclued from the study. Blood sample was obtained by peripheral venipuncture and the sepsis work up included blood and CSF culture and routine blood counts along with the hematologic score. The total leucocyte counts were counted on a Syrnex counter and corrected for nucleated red blood cells. Differential counts were performed on Leishman stained blood smears by counting at least 200 cells. A band was defined as a neutrophil in which the nucleus was indeted by more than one half, but in which the isthmus between the lobes was wide enough to reveal two distinct margins with nuclear material between [3] . All films were reviewed by a pathologist blinded to the infection status of the infants. Degenerative morphologic changes in neutophils were graded 0 to 4+ according to Zipursky et a1 [4] . The percentage of neutrophils with Dhole bodies, vacuolation and toxic granulation were graded as also the severity of toxic granulation. The hematological findings were analyzed according to the hematologic scoring system (HSS) of Rodwell et al [2] . The HSS assigns a score of one for each of the seven criteria found to be significantly associated with sepsis [Table l] with one exception. An abnormal total count is assigned a score of 2 instead of 1, if no mature polymorphs are seen on the peripheral smear to compensate for the low 1:M ratio. Sensitivity, specificity, positive and negative predictive values were evaluated for each of the seven criteria of HSS.


  Results Top


Based on the clinical findings and laboratory data infants were classified into three categories : sepsis (n=30), probable infection (n=8) and non infected (n=65). The diagnosis of sepsis was made when there were positive findings on blood culture. Infant were classified as having probable infection when the blood culture was negative but there was a strong clinical history for infection (four babies had meconium aspiration syndrome, two babies had respiratory distress, one had fever and another had vomiting and icterus). Infants were considered to be non infected when the blood culture was negative and there was no strong clinical evidence of infection. In all cases sepsis was confirmed by blood culture as there were no positive findings on CSF culture. The commonest organism isolated was E. coli (30%, n=9), followed by staphylococcus aureus Scientific Name Search  (27% n=8), Klebsiella pneumoniae Scientific Name Search  (17%, n=5), Pseudomonas (n+4), Group B streptococcus (n=2) and Enterococci (n+1) Sepsis was more common in infants more than 24 hours old, with a prevalence of 64%.

The hemotologic profiles of all the infants were analysed in the light of the HSS. A score of three was taken as the cut of point as it provided acceptable levels of sensitivity, specificity and positive predictive values. A score of xxx3 identified 28 of the 30 babies with sepsis and in addition five infants without sepsis. Each of the seven criteria of the HSS were evaluated as shown in [Table 2]. An abnormal 1:T ratio had the highest sensitivity (93%) and identified more than 90% of the infants with sepsis of probable infection. An abnormal 1:M ratio was also found to be highly sensitive (92%) in identifying infants with sepsis. These two criteria along with thrombocytopenia (<1,50,000/cm [3] ) had a high negative predictive value over 94%. Hence the likelihood of sepsis being present in the absence of these findings is low. The study also found that the higher the score the greatere the certainty that sepsis was present [Figure 1]. The five false positive cases had borderline scores of 3 each. The performance of the scoring system as predictor of sepsis is shown in [Table 3].


  Discussion Top


The major problem in neonatal infections is the identification of the infected infant and the equally important task of identifying the non-infected infant [5] . Many babies are treated with several days of antibiotics because of possible infection while waiting for negative bacteriologic cultures. One hundred and five neonates with suspected sepsis were enrolled in this study. Two babies, one with plasmodium vivax malaria and another with congenital toxoplasmosis were excluded from the study. The latter infant showed large number of reactive lymphocytes in the peripheral blood. A similar finding has also been reported by /Forestier et al [6] . A total of 103 neonates with suspected sepsis were analyzed according to the HSS. Sepsis was confirmed in 30 infants based on positive blood culture. In contrast to the developed world where group B streptococcus (GBS) continues to be the most common bacterial pathogen, studies from developing countries have identified gram negative organism as the more frequent infecting agent [1],[8] . In some studies staphylococcus aureus was most frequently isolated [7],[8]. In our study, E coli and staphylococcus aureus were the commonest organisms isolated. Eight infants categorised as having probable infection has clinical evidence but lacked microbiologic proof of infection. These neonates pose a diagnostic and therapeutic dilemma because fatal infection has been reported in the presence of negative blood cultures [11] .

Among the different parameters analysed in the light of the HSS, we found that an elevated 1:T ratio was the most reliable indicator of sepsis. An abnormal 1:M ratio was also highly sensitive in identifying sepsis. This was similar to the observations of many authors [2],[4],[12] . Degenerative changes in neutrophils was not found to be a very sensitive indicator of sepsis. However, thrombocytopenia was found to be consistently associated with poor prognosis confirming the findings of other studies [2],[5],[12] . On the first day of life, hematologic response occurs after a latent period of four hours following infection [1] .The two infants in whom HSS failed to detect sepsis were less than 24 hours old.

The advantage of HSS lies in the fact that it is applicable to all infants, including those who have received antibiotic therpy prior to sending blood for culture. The successful recovery of microorganism from blood culture on the other hand depends on many complex factors [13] . The HSS is derived from a single test that is fast, easily performed and readily available in most hospitals and thus could allow a more systematic approach to decisions regarding antibiotic therapy. Recently rapid detection of microorganisms in blood cultures of newborn infants using automated blood culture system, DNA probe and fluorometric detection systems have shown promising results [14],[15],[16] .Thus, the HSS is a useful test to distinguish the infected from the non infected infants. It has high of sensitivity and specificity, the certainty of sepsis being present increasing with higher scores.

Objective : To assess the utility of the hematologic scoring system (HSS) of Rodwell et al for the early detection of neonatal sepsis.

Design : Analysis of the peripheral smear findings according to the HSS by a pathologist blinded to the infection status of the neonate.

Subjects : One hundred and three high risk neonates having predisposing perinatal factors or clinical suspicion of sepsis.

Results: Analysis of the hematologic profiles in the light of the HSS found that an abnormal immature to total neutrophil (1:T) ratio followed by an abnormal immature to mature neutrophil (1:M) ratio were the most sensitive indicators in identifying infants with sepsis. These two criteria along with thrombocytopenia (<1,50,000/cm [3] ) had a high negative predictive value over 94%. The study also found that the higher the score the greater the certainty of sepsis being present.

Conclusion: The HSS is simple, quick, cost effective and readily available tool in the early diagonisis of neonatal sepsis and could provide a guideline to decisions regarding antibiotic therapy.

 
  References Top

1.Neonatal bacteraemia diagnosis and management (Editorial) Br. Med J 1997;2 :1385-86.  Back to cited text no. 1    
2.Rodwell RL, Leslie AL, Tudehope Dl. Early diagnosis of neonatal sepsis using a Hematological scoring system. J Pediatr, 1988; 112:161-6.  Back to cited text no. 2    
3.Manroe BL, Weinberg AG, Rosenfeld CR, Browne R. The neonatal blood count in health and disease. Reference values for neutrophilic cells J. Pediatr 1979;95:89-98.  Back to cited text no. 3    
4.Zipursky A, Alko J, Mitner R, Akenzua GI. The hematology of bacterial infections in premature infants. Pediatrics 1976,57: 839-53.  Back to cited text no. 4    
5.Philip AGS, Hewitt JR. Early diagnosis of neonatal sepsis. Pediatrics 1980;65:1036-41.  Back to cited text no. 5    
6.Forestier F, Hohlfeld P, Vial Y, Olin V, Andreax JP, Tissot JD. Blood smears and prenatal diagnosis. Br J Haematol, 1996;95:278-80.  Back to cited text no. 6    
7.Stoll BL. The global impact of neonatal injection. In : still BL, Weisman LE (EDS) Clinics in perinatology-infetions in perinatology. WB Saunders, Philadelphia, 1997, pp 1-22.  Back to cited text no. 7    
8.Karunasekera KA, Pathirana D.A preliminary study on neonatal siptiecmia in a tertiary referral hospital peadiatric unit Ceylor Med J 1999:44:81-6.  Back to cited text no. 8    
9.Das PK, Basu K, Chakrabarty P, BhoMmiidc PK. Clinical and bacteriological profile of neonatal infection in mectropolitan city based medical college nursery. J Indian Med Assoc 1999: 97:3-5.  Back to cited text no. 9    
10.Sharma JN, Dutta S, Deka A, Profile of sephticmia in North Eastern India. Bulletin of National Neonatology Forum 1999; 13:7-8.  Back to cited text no. 10    
11.Squire E, Favara B, Favara B, Todd J. Diagnosis of neonatal bacterial infection hematologic and pathologic findings in fatal and non fatal cases. Pediatrics 1979; 64:60-64.  Back to cited text no. 11  [PUBMED]  
12.Basu S, Guruprasad, Narang A, Garewal G. Diagnosis of sepsis in the high risk neonate using a hematologic scoring system. Indian J Hematolo Blood Transfusion 1999;17:32-34.  Back to cited text no. 12    
13.Dutta R. Blood Cultures. Bullentin National Neonatology Forum 1999; 13:43-46.  Back to cited text no. 13    
14.Gars-Prats JA, Cooper TR, Schneider VF, Stager CE, Hansen TN. Rapid detection of microorganisms in blood cultures of newborn infants utilising an automated blood culture system. Pediatrics 2000; 105: 523-7.  Back to cited text no. 14    
15.Hertz D, Fuller D, Davis T, Popile L, Stevenson D, Lemons J. Comparison of DNA probe technology and automated continuous monitoring blood culture systems in the detection of neonatal bacteraernia. J Perinatol 1999;19:290-3.  Back to cited text no. 15    
16.Pauli IJ, Lekhawat P, Kehl S, Sasidharan P. Early detection of bacteraemia in the neonatal intensive care unit using the new BALTEC system. J Perinatol 1999; 19:127-31.  Back to cited text no. 16    


    Figures

  [Figure 1]
 
 
    Tables

  [Table l], [Table 2], [Table 3]

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2004 - Indian Journal of Medical Sciences
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