Does a serum C-Reactive Protein of less than 10mg/l predict the absence of Early Onset Neonatal Sepsis?

Wentzel, Bradley Carl (2018-03)

Thesis (MMed)--Stellenbosch University, 2018.

Thesis

Abstract: The identification of early onset neonatal sepsis (EONS) remains a challenge. EONS carry a high case fatality. Balanced against this, the unnecessary use of antibiotics carries a high risk in neonates. It has cost implications, increases the risk for necrotising enterocolitis, late onset sepsis, can prolong hospitalisation and changes the microbiome. The use of biomarkers would be useful if this proves to be accurate. The aim of this study was to assess if a serum C-reactive protein (CRP) <10mg/l, measured within the first 36 hours of life predicted the absence of EONS in a high-risk group of neonates admitted to a tertiary hospital in a middle-income country. Material and Methods: The study was performed in the neonatal wards of Tygerberg Hospital during the period 1 January 2014 to 31 December 2014. It was a retrospective study that used a stratified randomisation method. Included in the study were neonates with risk factors for EONS and a CRP less than 10mg/l in whom a blood culture was performed. Results: 138 neonates were admitted to the study (mean birth weight 1 828 ±787 grams, gestational age 32 ± 3.9 weeks). The commonest indications for admission were Spontaneous Preterm Labour (SPTL) (46%), Respiratory Distress Syndrome (RDS) (17%) and Prolonged Preterm Rupture of Membranes (PPROM) (12%). 22% (n=30) of neonates were born to HIV-infected mothers. Surfactant replacement therapy was administered to 19% of the neonates. A serum CRP <4mg/l was present in 91% (n=125) and >4mg/l in 8% (n=13). An organism was isolated from the blood culture specimens in 2 (1.4%) of the cases. Both organisms were most likely contaminants when the clinical course of the neonates was considered. A serum CRP < 4mg/l when compared to a CRP >4 but <10mg/l did not differ in its ability to identify EONS. Conclusion: Our results are limited by the small sample size and the low occurrence rate of pathogen positive blood cultures in our neonatal population. In our study population, we had 2 infants from whom a contaminant was cultured. A quality improvement intervention targeting blood sampling technique and sterility measures may be of benefit. This study supports current practice at Tygerberg Hospital where a neonate suspected of having EONS; who has a CRP level < 10mg/l, taken between 12 and 36 hours and clinically well; antibiotics can be stopped.

Abstrak: Dit bly ʼn uitdaging om vroeë aanvangs neonatale sepsis (VANS) te diagnoseer. VANS het ‘n hoë mortaliteit. Gebalanseer hierteenoor dra die onnodige, en onoordeelkundige gebruik van antibiotika in neonate risikos. Dit het koste implikasies, verhoog die risiko vir nekrotiserende enterocolitis, laat aanvang-sepsis, verleng hospitalisasie en verander die mikrobioom. Die gebruik van biomerkers sou van waarde wees indien hulle akkuraat was. Die doel van hierdie studie was om te bepaal of ‘n serum C-reaktiewe proteïene (CRP) van minder as 10 mg/l, soos gemeet in die eerste 36 uur van lewe die afwesigheid van VANS kon voorspel in a hoë risiko groep neonate wat toegelaat is tot a tersiêre hospitaal in ʼn middel inkomste land. Studiemetode: Die studie is uitgevoer in die neonatale sale van Tygerberg Hospitaal vanaf die 1ste Januarie 2014 tot die 31ste Desember 2014. Dit was ‘n retrospektiewe studie en ‘n gestratifiseerde ewekansigheid metode is gebruik. Neonate met risiko-faktore vir VANS met ‘n CRP van < 10mg/l en waar ʼn bloed kultuur ook uitgevoer was, is in die studie opgeneem. Resultate: 138 neonate is in die studie opgeneem (mediane gewig 1 828 ±787 gram, gestasie 32 ± 3.9 weke). Die algemeenste indikasie vir toelating was Spontane preterm kraam (46%), Respiratoriese Noodsindroom (17%) en Verlengde premature ruptuur van vliese (12%). 22% (n=30) van die neonate se moeders was HIV-geïnfekteerd. Surfaktant vervangingsterapie is aan 19% toegedien. ʼn Serum CRP van <4mg/l was teenwoordig in 91% (n=125) en >4mg/l maar <10mg/l in 8% (n=13) van die neonate. ʼn Bakteriële organisme is geïsoleer in 2 (1.4%) van die bloedkulture. In beide gevalle is die bloed kultuur as ʼn kontaminant beskou na die kliniese verloop van die neonaat in ag geneem is. ʼn Serum CRP <4mg/l het nie verskil van ʼn CRP van >4mg/l ,maar <10mg/l, om VANS te voorspel nie. Gevolgtrekking: Die resultate van hierdie studie is beperk deur die klein studiepopulasie en die lae insidensie van patogeen positiewe bloedkulture in die neonatale bevolkingsgroep. In ons studie het ons 2 pasiënte gehad wat kontaminante gekweek het. ‘n Kwaliteits-verbetering intervensie wat bloedkultuur tegniek en steriliteits maatreëls aanspreek kan van groot waarde wees. Hierdie studie ondersteun huidige praktyk in Tygerberg Hospitaal. Indien ‘n neonaat risiko vir VANS het word ‘n CRP geneem tussen 12-36 ure, indien die CRP <10 en die neonaat is klinies gesond, word die antibiotika gestop.

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