Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : December | Volume : 3 | Issue : 6 | Page : 1847 - 1852

Outcome Of Sepsis Evaluations In Very-Low-Birth-Weight Premature Neonates

RAMESH BHAT. Y*, KUMAR N

*MD (Paed)Associate Professor,**Resident Department Of PediatricsKasturba Medical College Manipal. 576104

Correspondence Address :
Dr. Ramesh Bhat. Y,Associate Professor Department of Paediatrics Kasturba Medical College,Manipal University, Manipal-576104 Udupi District, Karnataka (INDIA)E-mail: docrameshbhat@yahoo.co.in

Abstract

Objective: We aimed to evaluate the outcome of early onset-sepsis (EOS) workups in very low birth weight (VLBW) premature neonates
Methods: Premature neonates weighing less than 1500g were evaluated for EOS. Haematological screening parameters, CRP and blood cultures were obtained in all. EOS (occurring at <72 hours of life) was the primary outcome. We analyzed the relationship between various maternal and neonatal characteristics, screening parameters, CRP and EOS.
Results: The present study included 36 premature VLBW neonates. The mean (SD) gestational age and birth weight were 31.2(2.5) weeks and 1252.9(199.9) gms, respectively. Obstetric risk factors were present in 12 (33.3%) neonates. Twenty (55.6%) neonates had EOS, 2 (5.6%) grew organisms in their blood culture and 5 (13.9%) died. EOS was slightly, but not significantly higher in neonates who were born with obstetric risk factors as compared to those who were not born without the risk factors (OR 1.18; 95%CI: 0.29-8.46; p=0.27). Choreoamnionitis, decreasing gestational age and birth weight were associated positively. Asymptomatic newborns were at a lower risk than their critically illcounterparts (33.3% Vs 62.9%; OR 0.29). The sensitivity of the haematological screening parameters and CRP varied from 10%-35%. Combination of any two parameters had a sensitivity of 40% and a negative predictive value of 50%. Neonates with EOS had a significantly longer duration of mechanical ventilation (p=0.03) and higher mortality than those without EOS (25% Vs 6.3%).
Conclusions: Blood culture proven EOS is uncommon among VLBW premature neonates, but clinical sepsis continues to be a significant problem. Infection rate in asymptomatic neonates is low. Haematological screening parameters and CRP have limited roles in distinguishing the infected neonates from the uninfected ones.

Keywords

Very low birth weight neonates, early onset sepsis, prematurity

Introduction
Bacterial infections are an important cause of morbidity and mortality among very low birth weight (VLBW) preterm neonates (1),(2). Higher rates of early-onset sepsis (EOS occurring in the first 72 hours of life) and mortality among these neonates have been described(1),[3,(4),(5),(6)The suspicion of EOS is almost universal in VLBW preterm infants and the initiation of antibiotic therapy at birth is a common practice(1). The decision to discontinue antibiotic therapy in these fragile neonates is often difficult. There are limitations to blood culture methods and it is possible for a single blood culture result to be negative when a neonate has bacterial sepsis. The reported rate of infection and treatment vary widely. About 4.4% to 10.5% of all infants born in United States were said to receive systemic antibiotics although the frequency of neonatal bacterial infections ranges from 1 to 5 per 1000 livebirths. A treatment rate of 10.9% was identified when the infection rate was 1% among asymptomatic infants (7). A study involving a large cohort of VLBW infant population reported that almost half of the VLBW neonates received antibiotic therapy for 5 or more days, despite negative blood culture results in 98% of the patients (1),(4). These findings underscored the difficulty of ruling out bacterial sepsis in sick immature neonates and the concern for possible culture-negative clinical sepsis. However, unnecessary and prolonged antibiotic therapy in VLBW neonates increases both risk and cost. In this context, we aimed to evaluate the outcome of sepsis workups in VLBW premature neonates. We examined the first evaluations performed for bacterial infection, the risk factors of the disease and its impact on the subsequent hospital course.

Material and Methods

This study was conducted prospectively in the neonatal intensive care unit of a teaching hospital between January and August 2005. The neonates were included if they were premature and weighed <1500 gms at birth. Those neonates who expired in less than 12 hours following birth and those with major congenital anomalies were excluded. The demographic data, maternal risk factors and treatment, delivery details, gestational age and birth weight were recorded. Gestational age was determined by obstetric measures and by the Ballard score. Neonatal and outcome data were collected until the discharge or death of the neonates. All neonates were subjected to haematological screening for sepsis which included the total leukocyte count (TLC), platelet count (PLT), micro ESR, C-reactive protein(CRP), band to total neutrophil ratio (B:N),cytoplasmic vaccuolations (CV) and/or toxic granulation (TG) in peripheral smears. The semi quantitative measurement of CRP was done in all. Blood culture samples included a single sample from a peripheral vein taken under aseptic conditions before commencing antibiotics. Chest X-ray and other investigations were performed whenever indicated.

Early-onset sepsis was the primary outcome. The outcome assignment was based on a positive result of the blood culture of the specimens drawn within the first 72 hours of life or on clinical sepsis. A culture proven infection is defined as an infection which is confirmed by a positive blood culture. A probable infection (clinical sepsis) is one in which the clinical course strongly suggested that infection was present, although the blood culture results were negative.

For analysis purposes, TLC (8),(9),(10) of <5000 or >20000/mm3, PLT (10) of <150000/mm3, CRP of >6mg/L, B: N ratios (9),(11) of ≥0.2 and the presence of CV or TG in the peripheral smear (12),(13), were considered abnormal. Micro ESR was considered to be positive if the readings were more than (age in days + 3) mm in the first hour (14). A neonate was considered to be critically ill if assisted ventilation (nasal continuous positive airway pressure or intermittent mandatory ventilation) and/or vasoactive drugs were administered or if a thoracotomy tube was placed. Other neonates with no abnormalities were considered to be asymptomatic.

Statistical Analysis
Statistical analyses were performed by using the Statistical Package for Social Sciences for Windows version 11.5 software. χ2 or Fisher’s exact tests were used to compare categorical variables and Student’s t tests were used to compare the mean differences of continuous variables. Multivariate analyses were performed using logistic regression. A p-value of <0.05 was considered to be significant.

Results

The present study consisted of 36 premature neonates weighing less than 1500 gms. Among them, 41.7% were born to primi mothers and 38.9% were born by Caesarean section. The mean (SD) gestational age and birth weight were 31.2(2.5) weeks and 1252.9(199.9) gms, respectively. Five (13.9%) were extremely low birth weight infants. About two third of the infants were males and one third were ‘small for gestational age (SGA) infants’ (Table/Fig 1) .Obstetric risk factors were present in 12 neonates (33.3%), choreoamnionitis in 3 and rupture of membrane >18 hours prior to delivery in 9. Ventilator support was needed in 27; intermittent mandatory ventilation in 19 (52.8 %) and CPAP alone in 8 (22.2%) neonates. Surfactant was administered in 4 (11.1%) cases.

A total of 20 (55.6%) neonates met our criteria for infection. The blood culture grew organisms in 5.6% (2/36) cases. (Table/Fig 2) shows the relationship of the infection with various maternal and neonatal characteristics. Parity of the mother and the mode of delivery did not bear a positive relationship with sepsis. The early-onset of sepsis was slightly, but not significantly higher if the neonates were born with obstetric risk factors than without them (35% Vs 33.3%; OR 1.18; 95%CI: 0.29-8.46; p=0.27). The presence of choreoamnionitis was positively associated with neonatal sepsis. There was no association between the neonate's sex and the risk of early-onset sepsis. Decreasing gestational age and birth weight were positively but not significantly associated with EOS. Asymptomatic newborns were at a lower risk for early sepsis as compared to critically ill newborns (33.3% Vs 62.9%; OR of 0.29).

(Table/Fig 3) shows the predictive values of haematological screening parameters and CRP. The sensitivity varied from 10%-35%. PLT and TG/CV had the best , but only 35%. Combination of any two parameters had a sensitivity of 40% and a negative predictive value of 50%.

(Table/Fig 4) shows the impact of EOS on the duration of mechanical ventilation and hospitalization. Neonates with early-onset sepsis had a significantly longer duration of mechanical ventilation than those who were not infected early. The mean duration of the hospital stay was not different in both groups. There was 13.9% (5/36) mortality among the study population which was attributable mainly to infection. Neonates with EOS (5/20) were at an increased risk of death as compared to uninfected neonates (1/16).

Discussion

The incidence of the early onset of bacterial infections was higher in premature VLBW neonates than in term neonates (1),(2),(3),(15),(16). A blood culture proven EOS rate of 19/ 1000 live births (or 1.9%) of VLBW infants has been reported from an analysis of 7606 infants (1). The same analysis also described variations in the rate of 13-27 per 1000 live births among participating centers. We observed a higher blood culture proven sepsis rate of 8.3% (2/24). In contrast, Kuruvilla (6) et al reported a very low rate of 0.6%.

There were some limitations in our study. We used single blood culture samples. All mothers with risk factors for neonatal sepsis received antepartum /intrapartum antibiotics. It is possible that such treatment may partly suppress bacterial growth, leading to false negative results. Further, it is also likely that the clinician may either overestimate or underestimate the infant’s risk for infection. Another possible reason for low culture yield could be the usage of conventional blood culture bottles rather than the usage of the BacT/Alert system.

The use of automated colorimetric blood culture (BacT/Alert) systems could confidently identify the presence or absence of bloodstream bacteria early and improve the positivity rate (17),(18),(19). BacT/Alert automated microbial detection systems are based on the colorimetric detection of CO2 produced by growing microorganisms. A CO2 sensor separated from the broth by a semi-permeable membrane is bonded to the bottom of each bottle. CO2 produced by growing microorganisms diffuses across the membrane into the sensor and dissolves in water, generating hydrogen ions. As the pH decreases, the blue to dark green sensor turns lighter green to yellow, which results in an increase of the reflected red light. The BacT/Alert system incubates, shakes, and scans CO2 production every 10 minutes by using a computerized database management system to record and report results. The BacT/Alert system offers several significant advantages over manual blood cultures for microbial detection (18). It is a fully automated system which eliminates repeated manipulations of bottles and consequently, reduces workload and errors. The system is non- radiometric, the detector is external to the bottles and hence, bottle cross-contamination during repeated aspirations is eliminated. The repeated automated testing of the culture bottles reduces the time needed to detect microbial growth. Shorter time to positivity(17),(19) decreases costs and medication errors. Further, the reports of Kumar et al (19) suggest that the administration of antibiotics before blood collection; including intrapartum maternal antibiotics, may not significantly compromise the growth in neonatal blood cultures.

The pathogens responsible for EOS generally reflect the predominant vaginal flora of the pregnant woman. Gram-positive organisms, especially group B streptococcus, were the most frequent pathogens identified for early-onset sepsis in many earlier studies (9),(10),(12),(15). Reports from India identified gram negative organisms (6),(13). Two blood culture isolates of the present study included pseudomonas and enterobacter species. Recent studies have reported a change in the distribution of pathogens from predominantly gram-positive to primarily gram-negative organisms (2),(20).
.
It was reported that the strong association of the mode of delivery with EOS significantly increased risk with vaginal delivery than in cesarean delivery (1). On the contrary, we did not find the association of the risk with the parity of the mother and the mode of delivery. The time from the rupture of the membrane (ROM) to birth, was identified as a strong risk factor for EOS (1). The longer the time from ROM to birth, the greater is the risk of EOS. We did not find this association. This could be due to antibiotic administration to the mother. A similar observation was made by Escobar (7) et al. We observed an increased risk with the presence of choreoamnionitis, that was similar to the reports of many authors (1),(7),(15). When the maternal variables were entered into a multivariate regression equation, none of the variables remained as statistically significant risk predictors.

We did not find increased risk in male infants unlike several studies that reported an increased risk of infection in male neonates. The equal risk of infection in VLBW male and female infants was earlier reported by Stoll BJ et al (1). In very immature neonates, factors like pathogen exposure and immaturity of the immune system that influence early-onset sepsis, may be more important than sex. Decreasing gestational age and birth weight were positively but not significantly associated with EOS. Similar results and in neonates who were born at < 28 weeks' gestation twice the risk of EOS as those who were more mature were published by earlier reports(1). The present study had only 2 neonates who were less than 28 weeks old. Asymptomatic newborns were at lower risk for early sepsis as compared to critically ill newborns (33.3% Vs 62.9%; OR of 0.29). Very low risk of bacterial infection in asymptomatic newborns was recognized (7).

The sensitivity of haematological screening parameters and CRP in the present study varied from 10%-35%. PLT and TG/CV had the best predictive value, but it was only 35%. Wide variations in the predictive ability of these parameters exist in literature (7),(8),(9),(10),(11),(12),(13),(14),(15) Kumar V (21) et al reported that none of screening parameters individually predicted the presence of bacteraemia satisfactorily. Similar observations were made earlier too (11). Benitz WE (22) et al concluded that the positive predictive value of elevated CRP levels is low, especially for culture-proven early-onset infections. Further, they described that the sensitivity of a normal CRP at the initial evaluation is not sufficient to justify withholding antibiotic therapy and suggested serial CRP levels. Escobar (7)et al did not use CRP in their evaluation because of the lack of the full assessment of its utility. They also suggested the reassessment of the complete blood count. In our study, the combination of any two parameters had a sensitivity of 40% and a negative predictive value of 50%. This was in contrast to reports of better efficacy (9),(11),(13).

Neonates with EOS had a significantly longer duration of mechanical ventilation than those who were not infected early. The mortality was higher among neonates who were infected early than uninfected neonates (25% vs. 6.3%). A longer duration on the ventilator and significantly increased mortality in early infected neonates were recognized in studies done on a large population (1),(23).

Conclusion

Blood culture proven early onset sepsis among
VLBW premature neonates is uncommon, but clinical sepsis continues to be a significant problem. An automated colorimetric blood culture system with improved positivity rate would probably narrow down this gap. The mortality among early infected neonates remains high. Increased rates of infection are likely to be associated with maternal risk factors, decreasing gestational age and birth weight. The rate of infection in asymptomatic neonates is low. However, screening, observation and rational antibiotics therapy is warranted to this group. Early identification of the truly infected neonates who require prompt antibiotic therapy remains challenging for a clinician. The sensitivity and negative predictive value of haematological screening parameters and CRP have limited roles in early-onset sepsis.

References

1.
Stoll BJ, Gordon T, Korones SB et al. Early onset sepsis in VLBW neonates. J Pediatr 1996;129:72-80
2.
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