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ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 3  |  Page : 1018-1022

Evaluation of serum albumin level among preterm septicemic newborn infants


1 Department of Pediatrics, Faculty of Medicine, Menoufyia University, Menoufyia, Egypt
2 Department of Pediatrics, Sirs El-Lian Hospital, Sirs El-Lian, Egypt

Date of Submission29-Oct-2017
Date of Acceptance17-Dec-2017
Date of Web Publication31-Dec-2018

Correspondence Address:
Heba M Mostafa
Abd El-Monem Reyad Street, Sirs El-Lian City 32717, Menoufia Government
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_725_17

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  Abstract 


Objective
The objective of this study was to evaluate the clinical value of serum albumin levels for the evaluation and prognosis of preterm infants with neonatal sepsis.
Background
Neonatal sepsis is considered a leading cause of morbidity and mortality in preterm newborn infants, as the mortality rates due to neonatal sepsis range between 3 and 50%, particularly with Gram negative pathogens. Nowadays, serum albumin has been suggested to be a valuable marker for prognosis of neonatal septicemia.
Patients and methods
This study was conducted on 85 preterm neonates, 46 male and 39 female, admitted within 24 h of life to neonatal intensive care unit in the period from March 2016 to January 2017. Patients were grouped according to their serum albumin level (≥3, 2.5–3, or ≤2.5 g/dl) or according to their discharge diagnosis (sepsis, neonatal infection, or no infection).
Results
There was a highly significant difference between discharge diagnosis groups as regards their serum albumin levels, and also there was a significant correlation between serum albumin level and both clinical and hematological sepsis scores.
Conclusion
Albumin was proven to be a marker in the diagnosis of neonatal septicemia.

Keywords: neonatal sepsis, prognosis, serum albumin


How to cite this article:
El-Lahony DM, El-Sayed HM, Mostafa HM. Evaluation of serum albumin level among preterm septicemic newborn infants. Menoufia Med J 2018;31:1018-22

How to cite this URL:
El-Lahony DM, El-Sayed HM, Mostafa HM. Evaluation of serum albumin level among preterm septicemic newborn infants. Menoufia Med J [serial online] 2018 [cited 2019 Jun 19];31:1018-22. Available from: http://www.mmj.eg.net/text.asp?2018/31/3/1018/248762




  Introduction Top


Certainly, neonatal sepsis is considered a leading cause of morbidity and mortality in preterm newborn infants, as the mortality rates due to neonatal sepsis range between 3 and 50%, particularly by Gram negative pathogens[1].

Sepsis is defined as a systemic inflammatory response to infections, and is diagnosed by isolation of bacteria from the blood[2].

Numerous studies were conducted on various markers, such as hematological indices, acute-phase reactants, C-reactive protein (CRP), procalcitonin, cytokines, and cell surface markers[3], to evaluate their clinical value for diagnosis of sepsis.

In ill preterm neonates admitted to the neonatal intensive care unit (NICU), the plasma albumin level is routinely measured and is found to be low[4].

There was a relation between a low albumin level and morbidity and mortality rates in preterm neonates as reported in several studies[5].

There was an association between low serum albumin levels in critically ill patients and the intensity of inflammatory response to infections[6].

Our study aimed to evaluate the clinical value of serum albumin levels for the evaluation and prognosis of preterm neonates with neonatal sepsis.


  Patients and Methods Top


This study was conducted on 85 preterm neonates, 46 male and 39 female, admitted within 24 h of life to NICU at Menoufyia University Hospital in the period from March 2016 to January 2017.

An informed consent was taken from the parents before their enrollment in the study, which was approved by ethical committee Faculty of Medicine, Menoufyia University.

The exclusion criteria included the following: newborn infants who received any serum or blood products before the blood samples were collected, maternal fetal blood group was incompatible, and the mother received plasma paresis during pregnancy, congenital malformations, chromosomal disorders, and suspected genetic metabolic disorders.

All patients were subjected to the following.

Full assessment of medical history was done including past history (previous sibling death, previous admission to NICU, etc.), maternal history (diabetes mellitus, maternal fever >38°C, maternal antibiotics, maternal urinary tract infection, preeclampsia, etc.), natal history (baby sex, gestational age, birth weight, mode of delivery, premature rupture of membrane, maternal fever, prolonged second stage of labor, etc.), postnatal history (low Apgar score at 1 and 5 min, aggressive resuscitation, respiratory distress, cyanosis, fever, jaundice, neonatal morbidity, and death), and present history, which included most common symptoms of sepsis.

Thorough clinical examination was performed including gestational age assessment using new Ballard score, birth weight measurement, and detection of clinical signs of sepsis.

Laboratory investigations were performed that included complete blood count, CRP, serum albumin, and blood culture.

Complete blood count was analyzed by Symex XT-1800i Automated Hematology Analyzer (Symex, Kobe, Japan).

CRP and serum albumin levels were assessed by COBAS INTEGRA 400 plus (Roche Diagnostics, Rotkreus, Switzerland).

Blood culture was performed by BacT/ALERT 3D blood culture system (bioMerieux, Marcy I'Etoile, France).

Albumin level less than or equal to 2.5 g/dl was the criteria used to define hypoalbuminemia[7].

Patients were grouped according to their serum albumin levels into three groups: more than or equal to 3 g/dl (17 neonates), 2.5–3 g/dl (17 neonates), or less than or equal to 2.5 g/dl (51 neonates) for high, moderate, or low, respectively, or according to their discharge diagnosis into three groups: neonatal sepsis (50 neonates), neonatal infection (15 neonates), or no infection (20 neonates).

Neonatal sepsis was diagnosed by clinical sepsis score of 3 or more[8], hematological score more than 3[9], and blood culture.

Statistical analysis

The data collected were tabulated and analyzed by statistical package for the social sciences, version 22.0 (SPSS; IBM Corp., Armonk, New York, USA).

We used two types of statistical analysis: descriptive statistics – for example, expressed in number, mean, and SD – and analytic statistics – for example, Fisher's exact and Pearson's χ2-tests; arithmetic mean was used as an average describing central tendency of observation, and SD was used. P value less than 0.05 was considered significant.


  Results Top


Our study included 85 neonates, 46 male and 39 female, including 31 neonates delivered vaginally and 54 neonates by cesarean section; 19 neonates were one of twins. Maternal complication occurred in 53 neonates including 17 neonates with preeclampsia, seven neonates with fetal distress, 27 neonates with premature rupture of membrane, and two neonates with gestational diabetes. Neonatal sepsis was diagnosed in 50 neonates, 15 neonates were diagnosed with neonatal infection without sepsis and 20 neonates were without infection, 19 neonates required mechanical ventilation, and six neonates died. Hypoalbuminemia (albumin ≤2.5 g/dl) was observed in 51 neonates [Table 1].
Table 1: Characteristics of the preterm newborn infant (n=85)

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There was a highly statistically significant difference between albumin level groups as regards their platelet count and CRP level (P < 0.001) [Table 2].
Table 2: Laboratory test results in different albumin level groups

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There was a highly statistically significant difference between discharge diagnosis groups as regards their albumin level (P < 0.001), but no statistically significant difference was found between them as regards neonatal mortality [Table 3].
Table 3: Albumin level and mortality in the newborn infants according to discharge diagnosis

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A total of 51 neonates had low albumin levels (≤2.5 g/dl) including 41 neonates with neonatal sepsis, six neonates with neonatal infection, and four neonates without infection. Seventeen neonates had moderate albumin level (2.5–3 g/dl) including seven neonates with neonatal sepsis, four neonates with neonatal infection, and six neonates without infection. Seventeen neonates had high albumin levels (≥3 g/dl) including two neonates with neonatal sepsis, five neonates with neonatal infection, and 10 neonates without infection. There was a highly significant difference between albumin level groups as regards their discharge diagnosis (P < 0.001) [Table 4]).
Table 4: Relation between discharge diagnosis and albumin level groups

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Albumin level was significantly different from clinical sepsis score (P < 0.05), as albumin level decreased with increased clinical sepsis score [Table 5].
Table 5: Albumin level in different clinical sepsis scores in septic neonates (n=50)

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Albumin level was significantly different from hematological sepsis score (P < 0.05), as albumin level decreased with increased hematological sepsis score [Table 6].
Table 6: Albumin level with hematological sepsis score (n=50)

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  Discussion Top


Our study was performed to clarify the role of serum albumin level in diagnosis and prognosis of neonatal septicemia.

On clinical evaluation, we had 50 neonates with neonatal sepsis; the most common clinical finding among them was poor feeding owing to weak suckling in 46 neonates followed by respiratory distress in 38 neonates, lethargy in 34 neonates, cyanosis in 19 neonates, and hypotonia was the least frequent finding in only one neonate, and this agrees with the study by El-Kerdani et al.[10] who stated that weak reflexes, lethargy, and respiratory distress were the most frequent clinical signs in septicemic neonates.

However, Ipek et al.[11] found that 90% had weak suckling, 70% were lethargic, and 25% had respiratory distress. Ottoline et al.[12] found that the most common clinical findings in neonatal sepsis were tachypnea in 58%, cyanosis in 25%, and lethargy in 20% of patients.

These differences may be due to the difference in the causative organisms and the course of sepsis or owing to the nonspecific clinical symptoms and signs of neonatal sepsis.

As regards hematological scoring system, we found that 36 neonates from 50 septicemic neonates had low platelet count (≤150 × 103/μl) and this is in agreement with Manucha et al.[13], who found that thrombocytopenia is reported in sepsis and the severity of thrombocytopenia is proportional to the severity of neonatal sepsis.

Our study also shows that 34 neonates from 50 septicemic neonates had abnormal leukocyte count either leukocytosis (≥25 × 103/μl) or leukopenia (≤5 × 103/μl), 29 neonates had increased immature neutrophil count, and 17 neonates had neutropenia.

This is in agreement with Mathai et al.[14] who stated that total leukocyte count of less than 5 × 103/μl and total neutrophil count of less than 1 × 103/μl have been associated with an increased risk for bacterial infection.

In contrast, Adams-Chapman and Stool[15] recorded that normal white blood cell counts were observed in about 50% of culture-proven sepsis patients.

In our study, 41 neonates from 50 neonates with neonatal sepsis had positive blood culture, which is in agreement with the study by Ipek et al.[11] who found that positive blood culture is a microbiological confirmation to diagnose sepsis and also in agreement with the study of Hassan et al.[16] who found positive culture in 63% of patients.

In all, 31 positive blood cultures were caused by Gram negative organisms, seven cultures were caused by Gram positive organisms, and three cultures were caused by fungal sepsis.

This comes nearly in agreement with the study of Mondal et al.[17], in which about 70% of the positive blood cultures were caused by Gram negative organisms.

In our study, there was a highly significant difference between albumin level groups as regards their platelet count and CRP, as the platelet count was lower in low albumin level group and CRP was higher in low albumin level group. In addition, there was a difference between albumin level groups in WBC count but it was nonsignificant.

This is in agreement with Yang et al.[7] and Sun et al.[18] who divided their cases into four groups according to albumin level, and they found that the difference between these groups regarding CRP and platelet count was significant.

Albumin level was highly significantly correlated with sepsis as it was lower in the septic group than in others.

This is in agreement with the study of Sun et al.[18], who reported that sepsis is accompanied by hypoalbuminemia, which is caused by decreased hepatic synthesis, increased leakage into the interstitial compartment, and persistent catabolism[19].

In our study, the neonates were grouped according to albumin level into low, moderate, and high albumin level (≤2.5, 2.5–3, and ≥3 g/dl, respectively), and there was a highly significant correlation between albumin level group and final diagnosis, as 41 neonates of low albumin level group (51 neonates) were diagnosed with sepsis but only two neonates of high albumin level group (17 neonates) were diagnosed with sepsis.

Furthermore, there was a highly significant correlation between albumin level and mechanical ventilation requirement, as 16 neonates from those who required mechanical ventilation (19 neonates) had low albumin level and the albumin level was higher in neonates who survived than those of patient neonates who died.

This is in agreement with Sun et al.[18], who stated that the hospital mortality and mechanical ventilation requirement in low albumin level group were significantly higher than those of the other groups and also in agreement with Yang et al.[7] who stated that the mortality was higher in the neonatal sepsis group compared with the other two groups.


  Conclusion Top


Albumin was proven to be a marker in the diagnosis of neonatal septicemia. CRP is a very valuable tool for follow-up of sepsis and response to therapy. Blood culture has the most valuable role in diagnosis of neonatal sepsis. However, blood culture results are not available within 48–72 h of onset of sepsis. It is recommended to use a combination of two or more of the studied parameters for laboratory diagnosis of neonatal sepsis in conjunction with the clinical presentation of the newborn.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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El-Kerdani TA, Abd El-Wahed MA, Aly GS, Abd El Basset FZ, El-Barbary MN. The values of neutrophil CD11b expression, 1L-6 and soluble receptor of tumor necrosis factor in early diagnosis of neonatal sepsis. Egy J Neonatal 2001; 2:115–125.  Back to cited text no. 10
    
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Ipek IO, Saracoglu M, Bozaykut A. α1-Acid glycoprotein for the early diagnosis of neonatal sepsis. J Matern Fetal Neonatal Med 2010; 23:617–621.  Back to cited text no. 11
    
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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. Pediat Infect Dis J 2003; 22:430–434.  Back to cited text no. 12
    
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Manucha V, Rusia U, Sikka M, Faridi MM, Madan N. Utility of hematological parameter and C-reactive protein in detection of neonatal sepsis. J Paediatr Child Health 2002; 38:459–464.  Back to cited text no. 13
    
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Mathai E, Christopher U, Mathai M, Jana AK, Rose D, Bergstrom S. Is C-reactive protein level useful in differentiating infected from uninfected neonates among those at risk of infection? Indian Pediatr 2004; 41:895–900.  Back to cited text no. 14
    
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Adams-Chapman I, Stool BJ. Neonatal infections and long term neurodevelopmental outcome in preterm infants. Curr Opin Infect Dis 2006; 19:290-297.  Back to cited text no. 15
    
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Hassan HR, Gohil JR, Desai R, Metha RR, Chaudhary VP. Correlation of blood culture results with the sepsis score and sepsis screan in the diagnosis of early-onset neonatal septicemia. J Clin Neonatol 2016; 5:193–198.  Back to cited text no. 16
    
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Mondal SK, Nag DR, Banyopadhyay R, Chakraborty D, Sinha SK. Neonatal sepsis: role of a battery of immunohematological tests in early diagnosis. Int J App Basic Med Res 2012; 2:43-47.  Back to cited text no. 17
    
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Sun JK, Li WQ, Ke L, Tong ZH, Ni HB, Li G, et al. Early enteral nutrition prevents intra-abdominal hypertension and reduces the severity of severe acute pancreatitis compared with delayed enteral nutrition: a prospective pilot study. World J Surg 2013; 37:2053–2060.  Back to cited text no. 18
    
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Gatta A, Verardo A, Bolognesi M. Hypoalbuminemia. Intern Emerg Med 2012; 7(Suppl 3):S193–S199.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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