Journal Club Presentation

Organized by:

DEPARTMENT OF NEONATOLOGY (NU – I) MMCH

Chairperson

Dr. Md. Anwar Hossain

MBBS, M Phil, MCPS (Pediatrics) FCPS (Pediatrics), MD (Neonatology)

Assistant Professor

Department of Neonatology Mymensingh Medical College

Speaker Dr. Md. Abu Taher

Assistant Registrar

Neonatology(U-1), MMCH

Title

Role of micro-ESR and I/T ratio in the early diagnosis of Neonatal Sepsis.



Source:

•

Mymensingh Medical Journal

2009 Jan ; 18(1): 56-61



Authors:

Walliullah SM, Islam MN, Siddika M, Hossain MA, Chowdhury AK.



Study period:

19 months (15 th March’05 –15 th Octeber’06)

Study place:

Dhaka Shishu Hospital, Dhaka.

Objective of the study:

 Objective of this study is to find out the sensitivity and specificity of Micro-ESR and I/T ratio separately and combined in early diagnosis of neonatal sepsis.

Introduction:

 Septicemia is one of the major cause of neonatal mortality and morbidity.  Despite considerable progress in hygiene condition, introduction of newer antimicrobials , advanced techniques for early diagnosis of sepsis, supportive measures for critically ill neonates, sepsis remains one of the important cause of morbidity and mortality in this age group.

Cont..

 The outcome of a neonate with sepsis largely depends on its  early identification and  prompt management.  Delay in treatment until signs and symptoms of sepsis are obvious cause greater risk of preventable mortality.

Cont..

 Globally about 130 million baby’s born every year .

 Among them 4 million die in the first 4 weeks of life due to infection, prematurity, and perinatal asphyxia.

Cont..

 Recognition of infection is difficult in most infected neonates as clinical manifestations mimic other conditions like asphyxia , hypoglycemia , prematurity etc.  Combination of clinical and laboratory examination can be used, though their predictive accuracy , sensitivity and specificity are variable.

Cont..

 No Single laboratory test has been found to have enough specificity and sensitivity  But combination of hematological profiles shows high sensitivity and specificity.  The gold standard for diagnosis of neonatal septicemia is a positive blood culture.  A positive blood culture is found in 10-60% of neonatal sepsis cases.

Cont..

 In developing countries like Bangladesh, blood culture facilities are non- existent in the district hospitals and UHCs.  But TLC, DLC, PBF, can easily be done even in health centers.  Among the hematological profiles , the micro –ESR is a popular and simple screening test to detect neonatal sepsis and has been recognized as a valid investigation tool.

Cont..

 Micro-ESR is also possible to be done as bed side test by heparinized capillary tube which is not very costly and very small amount of blood is required.  In spite of simplicity it is not practiced routinely in our country due to less availability of heparinized capillary tube.  In this study a normal value of micro-ESR in 1 st hours is calculated as age of baby in days plus 3 mm to maximum15 mm.

Cont..

 Band cell count increases significantly beyond normal range in new born babies with bacterial infection.

 All band cells and cells less mature than the band cells were classified together as immature neutrophil.

Cont..

 I/T Ratio: Immature to total neutrophil count ratio can be calculated from peripheral blood film.  Immature cell count more than 20% of total neutrophil count (that is I/T ratio >0.2) is a useful marker of bacterial infection in newborn.

Cont..

 So micro ESR & I/T ratio can be done as a part of simple routine screening test for the early diagnosis of neonatal sepsis.  As a simple method the present study was carried out to assess the role of micro-ESR and I/T ratio in the early diagnosis of neonatal sepsis



Methods: Study type:

Prospective cross sectional study 

Study population:

110 neonates (definite sepsis 30, probable sepsis 50, control 30 )

Inclusion criteria :

For Case:

Neonates present with: (one or more)  Lethargy  Reluctant to feed  Abdominal distension  Vomiting  Respiratory distress  Fever

Cont…

For Control:

 No sign symptom of sepsis but admitted due to other problems like  Physiological Jaundice  Delayed passage of urine  Feeding problem

Exclusion criteria :

 IDM  Perinatal asphyxia  Congenital cyanotic heart disease.

Result:

In this study out of 80 clinically suspected cases of neonatal septicemia:  30 positive blood culture were taken as definite sepsis  50 with negative blood culture but one or more abnormal hematological profiles suggestive of sepsis were taken as probable sepsis .

 30 neonates with no signs and symptoms of septicemia were taken as control group.

Cont..

 Out of 80 cases 51 (63.75%) were male , and 29(36.25%) were female.  Incidence of sepsis is higher in low birth weight neonates in comparison to normal birth weight neonates (67% in definite sepsis and 70% in probable sepsis are LBW ).

Table: 1 : Micro-ESR in cases and control

Micro ESR

>

Normal Normal Total Probable Sepsis No.(%) Control No.(%) Definite sepsis No.(%) Definite sepsis vs Probable sepsis Definite sepsis vs Control 20 (40%) 30 (60%) 50 02 (6.7%) 28 (93.3%) 30 19 (63.3%) 11 (36.7%) 30 P=0.043

Chi = 4.09

P=0.001

Chi = 21.17

Table: 2 : I/T ratio in cases and control

I/T ratio Probable Sepsis No.(%) Control No.(%) Definite sepsis No.(%) Definite sepsis vs Probable sepsis Definite sepsis vs Control >0.2

<0.2

22 (44%) 28 (56%) 02 (6.7%) 28 (93.3%) 21 (70%) 09 (30%) P =0.001 P=0.001

Chi = 14.44

Chi = 25.45

Total 50 30 30

Cont..

In this study more than normal level of micro ESR was found:  63.3% in definite sepsis  40% in probable sepsis and also  6.7% in control Which was statistically significant(P value <0.05).

Cont…..

In this study I/T ratio was positive in:  70% cases of definite sepsis  44% cases in probable sepsis  6.7% in control Which was statistically significant ( p value <.05).

Table-3: Sensitivity ,specificity, positive and negative predictive values of micro-ESR in definite sepsis &probable sepsis.

Test Defini te sepsis Proba ble sepsis Tot al Sensitiv ity (%) Specific ity (%) Accur acy PP V NPV (%) (%) (%)

> norma l norma l total

19 11 30 20 30 50 39 41 63.3

60 61.3

48.7

73.2

Table-4:

Sensitivity ,specificity, positive and negative predictive values of micro-ESR in definite sepsis & control .

test

>normal

Definite sepsis control

19 02

total Sensitivi ty (%) Specific ity y (%) PP V Accuracy (%) (%) N PV (%)

21

Normal

11

total

30 28 30 39 63.3 93.3 78.3

90.5 71.8

Table-5:

Sensitivity ,specificity, positive and negative predictive values of I/T ratio in definite sepsis & probable sepsis.

test Definit e sepsis Probab le sepsis total Sensiti vity (%) Specifi cit y (%) Acuracy (%) Pp V (%) N PV (%)

>0.2

21 22 43

<0.2

9 28 37 70.0 56 61.3

48.

8 75.

7

total

30 50

Table-6:

Sensitivity ,specificity, positive and negative predictive values of I/T ratio in definite sepsis & control.

test

>0.2

<0.2

Definit e sepsis control

21 9 02 28

total Sensiti vity (%) Specifi cit y (%) Acuracy (%)

23 37 70.0 93.3 81.7

PP V (%)

91.

3

total

30 30

N PV (%)

75.

7

cont….

 When it was compared between definite and probable sepsis sensitivity of micro-ESR was 63.3% ,specificity 60% and negative predictive value was 73.2% .

 But When it was compared between definite sepsis and control specificity was high (93.3%) ,positive predictive value 90.5%

cont….

 When I/T ratio was compared between definite and probable sepsis sensitivity was 70% ,specificity 56% and negative predictive value was 75.7% .

 But When it was compared between definite sepsis and control specificity was high (93.3%) ,positive predictive value 91.3%.

Table7

: Sensitivity, specificity, positive and negative predictive values of

Combined

Micro ESR and I/T ratio between definite sepsis and Probable sepsis

Validity Sensitiv test ity

Percent age 80.0

Specific ity

70.0

Accura cy

73.8

PPV

61.5

In this study sensitivity and specificity of combined micro-ESR and I/T ratio was 80% and 70% respectively, when compared between definite sepsis and probable sepsis.

NPV

85.4

Table 8

: Sensitivity, specificity, positive and negative predictive values of

Combined

Micro ESR and I/T ratio between definite sepsis and control

Validit y test Sensiti vity Specifi city Accur acy PPV NPV

Percent age 83.3

96.7

90.0

96.2

85.3

In this study sensitivity and specificity of combined micro ESR and I/T ratio was 83.3% and 96.7% respectively, when compared between definite sepsis and probable sepsis.

Discussion

 As tools for early diagnosis of neonatal septicemia, micro-ESR and I/T ratio were analyzed in this study to see the role of these parameters in all the neonates of both cases and control groups .

 The incidence of sepsis is higher in low birth weight neonates in comparison to normal weight babies . 67% of neonate in definite sepsis and 70% of neonate in probable sepsis group were of low birth weight. Nearly similar observation was mentioned by Bhakoo ON , Singh M (

perinatal risk factors in neonatal bacterial sepsis. Indian J Pediatr. 1988;55:941-946.)

cont..

Common clinical features of sepsis were reluctant to feed(96.7%),lethargy(73.3%), abdominal distention (70%), jaundice(50%) and hypothermia (40%). This observation was similar to the observations by Hoque MM ,Ahmed ASM N, Ahmed S, Chowdhury MAKA (Clinical manifestation and bacteriological profile of septicemia in preterm neonates :Experience from a tertiary level pediatric hospital . BJMSc 2004;10(1):29-33) and Chowdhury MAKA, Rahman MM, Karim AQMR (Characteristic of septicemia in newborne in Dhaka Shishu Hospital.DSHJ.1998:14(2):9-12)

In this study :

Study

I/T ratio Micro – ESR Combination of Micro- ESR &I/T ratio Misra et al : Sharma et al : Okolo et al : Sing et al : Chandana et al : I/T ratio Micro- ESR (> 8mm) I/T ratio Micro-ESR (> 10mm) I/T ratio Micro-ESR Micro-ESR (> 14mm) I/T ratio 70% 70% 63.3% 63.3% 80% 83.3% 92% 75% 60% 66.7% 96.9% 84.5% 55% - 56% 93.3% 60% 93.3% 70% 96.7% 79% 85% 62.5% 70% 90% 85% 82% 31%

cont..

 In this study for Micro-ESR Sensitivity and Specificity of Micro-ESR in definite sepsis was 63.3% and 60% respectively .

Misra et al. showed high sensitivity (79%) and specificity (92%). Sharma et al. Showed Micro ESR was relatively low sensitivity (60%) and specificity (62.5%).Okolo et al. showed high sensitivity 96.9% and specificity 90%

cont..

 In this study sensitivity and specificity of I/T ratio in definite sepsis was 80% and 70% respectively. .

Misra et al. showed high sensitivity (92%) and specificity (79%). Sharma et al. Showed Micro ESR was relatively low sensitivity (60%) and specificity (62.5%).Sing et al. observed low specificity 48%.Chandna et al. showed specificity was much lower 31%

cont..

 In this study sensitivity and specificity of combined micro-ESR and I/T ratio was 80% and 70% respectively.

Misra et al. showed sensitivity 75% and specificity 85%. Sharma et al. Showed relatively low sensitivity 66.7% and specificity 70%. Okolo et al. showed high sensitivity 84.4% and specificity 85%.

Limitations:

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1. This study is a single hospital based study.



2. Sample size is small.

Key message:



Micro-ESR and I/T ratio can be used as reliable test in the early diagnosis of

neonatal sepsis with high degree of sensitivity and specificity specially where blood culture facility is not available .