|Year : 2014 | Volume
| Issue : 2 | Page : 230-233
Should a neonate with possible late-onset sepsis always have lumbar puncture?
Ahmed A Khattab, Dalia M El-Lahony, Shimaa Abdallah
Department of Pediatrics, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
|Date of Submission||16-Feb-2013|
|Date of Acceptance||11-Aug-2013|
|Date of Web Publication||26-Sep-2014|
Neonatal Intensive Care Unit, Benha Children Hospital
Source of Support: None, Conflict of Interest: None
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.
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.
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.
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 2020 Feb 26];27:230-3. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/230/141649
| Introduction|| |
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 .
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 .
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) .
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 .
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 .
A total of 15-55% of patients who have meningitis (positive CSF culture) have negative blood cultures .
| Patients and methods|| |
This study was carried out in the neonatal ICU in Benha Children Hospital over 60 neonates presenting with late-onset neonatal septicemia.
Babies with signs and symptoms of sepsis after 72 h of labor:
- Apnea, tachypnea, respiratory distress, cyanosis.
- Bradycardia, tachycardia.
- Hypotonia, seizures.
- Poor skin color, poor perfusion.
- Irritability, lethargy, poor feeding.
- Hepatomegaly, splenomegaly, abdominal distension.
- Hypothermia, hyperthermia.
Babies with the following signs and symptoms:
- Congenital infection.
- Early neonatal sepsis.
- Perinatal asphyxia.
- Congenital anomalies.
- Intracranial hemorrhage.
- Maternal drug abuse.
Neonates in our study were subjected to the following:
- History taking : Prenatal, natal and family history, stressing on the sex, the gestational age, the postnatal age, and the mode of delivery.
- 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.
- Laboratory investigations performed were as follows:
- Complete blood picture with a differential count for the assessment of hematological sepsis scores.
- Blood culture.
- Lumbar puncture and CSF analysis.
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:
- Complete blood count including blood indices using Sysmex KX21 (Roche Diagnostics, Manheim, Germany).
- Blood culture (aerobic and anaerobic) using BACTEC 9050 blood culture automated system by Kemet (USA).
Lumbar puncture was carried out under complete aseptic conditions.
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|| |
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|| |
Neonatal sepsis is defined as a clinical syndrome of bacteremia with signs and symptoms of infection in the first 4 weeks of life . 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 . 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 . 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. .
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. . In our study, the most common gram-negative bacteria causing septicemia during the neonatal period was Klebsiella spp., which is in agreement with Sriram .
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. , but was in agreement with Smith et al. .
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.  [Table 1],[Table 2],[Table 3],[Table 4] and [Table 5].
|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|| |
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|| |
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]