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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 230-233

Should a neonate with possible late-onset sepsis always have lumbar puncture?


Department of Pediatrics, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt

Date of Submission16-Feb-2013
Date of Acceptance11-Aug-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
Shimaa Abdallah
Neonatal Intensive Care Unit, Benha Children Hospital
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141649

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  Abstract 

Objectives
The aim of this work was to study the incidence of neonatal meningitis among newborns with late-onset sepsis, and to determine whether it is mandatory to perform a lumbar puncture and cerebrospinal fluid (CSF) analysis in all cases of late-onset neonatal sepsis.
Background
Neonatal sepsis is an important cause of neonatal morbidity and mortality and often results in prolonged hospitalization of infants who are admitted to neonatal ICUs. A positive blood culture confirms sepsis, and when the blood culture is negative, the condition is considered as clinical sepsis. It is almost impossible to distinguish sepsis from meningitis in the neonate clinically. However, CSF that is positive for pathogenic bacteria indicates meningitis.
Patients and methods
This study was carried out in the neonatal ICU in the Benha Children Hospital over 60 neonates presenting with late-onset neonatal septicemia. All studied neonates were subjected to history taking, clinical examination stressing on points of the clinical sepsis score, routine investigations (complete blood count, C-reactive protein, blood culture), and CSF analysis and culture.
Results
All 60 neonates were positive for the clinical sepsis score: 48 cases were positive for the hematological sepsis score and 12 cases out of 60 were positive for CSF culture; among the 12 cases with positive CSF cultures, there were six cases (50%) with negative blood cultures.
Conclusion
There is a high incidence of neonatal meningitis among neonates with late-onset sepsis. Neonatal meningitis frequently occurs in the absence of bacteremia. Hence, lumbar puncture and CSF examination is mandatory in all cases with late-onset sepsis.

Keywords: Lumbar puncture, meningitis, neonatal sepsis


How to cite this article:
Khattab AA, El-Lahony DM, Abdallah S. Should a neonate with possible late-onset sepsis always have lumbar puncture?. Menoufia Med J 2014;27:230-3

How to cite this URL:
Khattab AA, El-Lahony DM, Abdallah S. Should a neonate with possible late-onset sepsis always have lumbar puncture?. Menoufia Med J [serial online] 2014 [cited 2019 Dec 7];27:230-3. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/230/141649


  Introduction Top


Blood stream infections are an important cause of neonatal morbidity and mortality and often result in prolonged hospitalization of infants who were admitted to neonatal ICUs [1].

Neonatal sepsis can be categorized as early onset and late onset depending on whether the onset of symptoms is before 72 h of life (early onset) or later (late onset). Late-onset sepsis is caused by the organisms present in the external environment of the home or the hospital [2].

Late-onset neonatal sepsis occurs in ~0.1% of all newborns and in up to 25% of very low-birth-weight infants (birth weight<1500 g) [3].

Previously, various white blood cell counts and the acute-phase reactant, C-reactive protein (CRP), have been used to diagnose neonatal sepsis. CRP is specific but less sensitive in the early stages of neonatal sepsis [4].

Positive blood culture confirms sepsis, and when the blood culture is negative, the condition is considered as clinical sepsis. It is almost impossible to distinguish sepsis from meningitis in the neonate clinically. However, cerebrospinal fluid (CSF) positive for pathogenic bacteria indicates meningitis [5].

A total of 15-55% of patients who have meningitis (positive CSF culture) have negative blood cultures [6].


  Patients and methods Top


Patients

This study was carried out in the neonatal ICU in Benha Children Hospital over 60 neonates presenting with late-onset neonatal septicemia.

Inclusion criteria

Babies with signs and symptoms of sepsis after 72 h of labor:

  1. Apnea, tachypnea, respiratory distress, cyanosis.
  2. Bradycardia, tachycardia.
  3. Hypotonia, seizures.
  4. Poor skin color, poor perfusion.
  5. Irritability, lethargy, poor feeding.
  6. Hepatomegaly, splenomegaly, abdominal distension.
  7. Hypothermia, hyperthermia.


Exclusion criteria

Babies with the following signs and symptoms:

  1. Congenital infection.
  2. Early neonatal sepsis.
  3. Perinatal asphyxia.
  4. Congenital anomalies.
  5. Intracranial hemorrhage.
  6. Maternal drug abuse.


Methods

Neonates in our study were subjected to the following:

  1. History taking : Prenatal, natal and family history, stressing on the sex, the gestational age, the postnatal age, and the mode of delivery.
  2. Complete clinical examination stressing on the gestational age, temperature, tolerance to oral feeding, abdominal distension, residual gastric aspirate, cyanosis, and others according to the sepsis score reported by the modified clinical sepsis score.



  3. Laboratory investigations performed were as follows:

    1. Complete blood picture with a differential count for the assessment of hematological sepsis scores.
    2. CRP.
    3. Blood culture.
    4. Lumbar puncture and CSF analysis.


Sample collection

A peripheral blood sample was obtained through venipuncture. The blood was collected using a sterile technique. This requires the venipuncture sites of the patients to be cleaned before collection with alcohol swabs containing 2% chlorhexidine and 70% isopropyl alcohol.

The samples were centrifuged at 3000 rpm for 10 min, and then the serum samples were stored for the following analyses:

  1. Complete blood count including blood indices using Sysmex KX21 (Roche Diagnostics, Manheim, Germany).
  2. Blood culture (aerobic and anaerobic) using BACTEC 9050 blood culture automated system by Kemet (USA).


Lumbar puncture was carried out under complete aseptic conditions.

Description

Lumbar puncture was performed by inserting the needle between the fourth and the fifth lumbar vertebrae (L4-L5). This location is used because the spinal cord stops near L2 and a needle introduced below this level will miss the cord.

Routine examination of CSF includes visual observation of the color, clarity, tests for glucose, protein, red blood cell count, white blood cell count with a differential count, Gram stain, and bacterial culture. Further tests may have to be performed depending on the results of the initial tests and the presumptive diagnosis.


  Results Top


Our results were as follows: A total of 60 neonates were positive for the clinical sepsis score. Weak sucking was the most frequent clinical finding (93%), followed by weak Moro (70%) and lethargy (53.3%). Of the neonates in our study, 48 cases were positive for the hematological sepsis score and 12 were negative. Out of 60 neonates, 30 cases had a positive blood culture and 12 cases had a positive CSF culture. The most common organism in the blood culture was Klebsiella spp., found in 12 cases, whereas the most common organism in the CSF culture was Staphylococcus aureus, found in four cases. There were six cases with positive CSF cultures, but negative blood cultures.


  Discussion Top


Neonatal sepsis is defined as a clinical syndrome of bacteremia with signs and symptoms of infection in the first 4 weeks of life [7]. Clinical features of sepsis are nonspecific in neonates and a high index of suspicion is required for the timely diagnosis of sepsis. Although blood culture is the gold standard for the diagnosis of sepsis, culture reports would be available only after 48-72 h [8]. In this study, we found that sepsis occurs more often in full-term infants [44 (73.3%)] than in preterm infants [16 (26.7%)].

Concerning the age of presentation, our study included newborns with ages ranging from 7 to 27 days, with a mean ± SD age of 13.43 ± 66.6 years.

In this study, patients were evaluated according to the estimated neonatal sepsis score [9]. Their scores ranged from 3 to 6 as all our cases were clinically septic. Overall, 22 cases (36.7%) scored 3, 10 cases (16.7%) scored 4, 20 cases (33%) scored 5, and eight cases (13.3%) scored 6, but no case scored 7.

Regarding the clinical presentation, we found that the most common clinical findings among patients with sepsis were weak sucking in 93.3% of the cases, followed by weak Moro in 70% of the cases. These results were the same as those obtained by Ottolini et al. [10].

In our study, the CRP ranged between 6 and 192 mg/dl (mean ± SD = 103.33 ± 64.11), whereas about 10% of our cases showed a negative CRP and 3.3% of them had positive blood cultures. These results were the same as those obtained by Gendrel et al. [11]. In our study, the most common gram-negative bacteria causing septicemia during the neonatal period was Klebsiella spp., which is in agreement with Sriram [12].

In this study, all neonates (60 cases) underwent a lumbar puncture and CSF analysis for cytology, chemistry (glucose and proteins), and CSF culture. The results showed that 46 cases (76.6%) had normal CSF, cells less than 5 cells/mm 3 , normal glucose and protein levels, and culture showed no growth. However, in 14 cases (23.3%), the CSF analysis showed cells ranging between 80 and 26 000 cells/mm 3 . It should be kept in mind that the interpretation of CSF findings is more difficult in neonates than in older children, especially in premature infants, in whom the more permeable blood-brain barrier causes higher levels of glucose and protein.

Concerning the CSF culture, in our study, 48 (80%) out of 60 cases showed no growth. The remaining 20% had positive CSF cultures. The most common organism was S. aureus (6.7%). In our study, we found 2/60 (3.3%) cases with CSF negative cultures to have high CSF white blood cell counts, high protein, and low glucose; these results contradicted those obtained by Garges et al. [13], but was in agreement with Smith et al. [14].

Among the 12 cases with positive CSF cultures, there were six cases (50%) with negative blood cultures and six cases (50%) with positive blood cultures. The organisms isolated were discordant in two cases (16.5%) and were the same in four cases (33.3%). This agreed with Malbon et al. [15] [Table 1],[Table 2],[Table 3],[Table 4] and [Table 5].
Table 1: Clinical sepsis scores

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Table 2: Blood culture results

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Table 3: Cerebrospinal fluid culture results

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Table 4: Correlation between the clinical score and the hematological score

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Table 5: Comparison between the cerebrospinal fluid culture and the blood culture

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  Conclusion Top


We concluded that clinical parameters such as irritability, lethargy, and a sick appearance are better indicators of meningitis.

There is high incidence of neonatal meningitis among neonates with late-onset sepsis.

Neonatal meningitis frequently occurs in the absence of bacteremia. Hence, lumbar puncture and CSF examination is mandatory in all cases with late-onset sepsis.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.[16]

 
  References Top

1.Gonzalez J, Castro A, Arribas. Trends in the epidemiology of neonatal sepsis. Acta Paediatr 2004; 91 :540-554.  Back to cited text no. 1
    
2. Sankar MJ, Agarwal R, Deorari AK, Paul VK. Sepsis in the newborn. Indian J Pediatr 2008; 75 :261-266.  Back to cited text no. 2
    
3. Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 2002; 110 :285-291.  Back to cited text no. 3
    
4. Mathers NJ, Pohlandt F. Diagnostic audit of C-reactive protein in neonatal infection. Eur J Pediatr 1987; 146 :147-151.  Back to cited text no. 4
    
5. Remington JS, Klein JO. Infectious diseases of the fetus and newborn. 5th ed. Philadelphia: WB Saunders; 2001.  Back to cited text no. 5
    
6. Heath PT, Nik Yusoff NK, Baker CJ. Neonatal meningitis. Arch Dis Child Fetal Neonatal 2003; 88 :F173-F178.  Back to cited text no. 6
    
7. Khinchi YR, Kumar A, Yadav S. Profile of neonatal sepsis. J Coll Med Sci Nepal 2010; 6 :1-6.  Back to cited text no. 7
    
8. Ipek IO, Saracoglu M, Bozaykut A. Alpha1-acid glycoprotein for the early diagnosis of neonatal sepsis. J Matern Fetal Neonatal Med 2010; 23 :617-621.  Back to cited text no. 8
    
9. Töllner U. Early diagnosis of septicemia in the newborn. Eur J Pediatr 1982; 138 :331-337.  Back to cited text no. 9
    
10.Ottolini MC, Lundgren K, Mirkinson LJ, Cason S, Ottolini MG. Utility of complete blood count and blood culture screening to diagnose neonatal sepsis in the asymptomatic at risk newborn. Pediatr Infect Dis J 2003; 22 :430-434.  Back to cited text no. 10
    
11.Gendrel D, Assicot M, Raymond J, Moulin F, Francoual C, Badoual J, et al. Procalcitonin as a marker for the early diagnosis of neonatal infection. J Pediatr 1996; 128 :570-573.  Back to cited text no. 11
    
12.Sriram R. Correlation of blood culture results with the sepsis score and the sepsis screen in the diagnosis of neonatal septicemia. Int J Biol Med Res 2011; 2 :360-368.  Back to cited text no. 12
    
13.Garges HP, Moody MA, Cotten CM, Smith PB, Tiffany KF, Lenfestey R, et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters? Pediatrics 2006; 117 :1094-1100.  Back to cited text no. 13
    
14.Smith PB, Garges HP, Cotton CM, Walsh TJ, Clark RH, Benjamin DKJ. Meningitis in preterm neonates: importance of cerebrospinal fluid parameters. Am J Perinatol 2008; 25 :421-426.  Back to cited text no. 14
    
15.Malbon K, Mohan R, Nicholl R. Should a neonate with possible late onset infection always have a lumbar puncture? Arch Dis Child 2006; 91 :75-76.  Back to cited text no. 15
    
16.Agamanolis D. The normal CSF: cerebrospinal fluid ′neuropathology′. Northeast Ohio Medical University; 2011.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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Abstract
Introduction
Patients and methods
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Acknowledgements
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