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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 72-77

Comparative Study of Procalcitonin and C-Reactive Protein Concentrations as Early Marker of Neonatal Sepsis : A Hospital Based Study


1 Junior Resident, Department of Pediatrics, Kurji Holy Family Hospital, Patna, India
2 Assistant Professor, Department of Pediatrics, IGIMS, Patna, India
3 Consutant, Department of Pediatrics, Kurji Holy Family Hospital, Patna, India
4 Associate Professor, Department of Pediatrics, IGIMS, Patna, India
5 Professor & HOD, Department of Pediatrics, IGIMS, Patna, India

Date of Web Publication20-Nov-2020

Correspondence Address:
Sunil Kishore
Assistant Professor Department of Pediatrics, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Background: Neonatal sepsis is one of the important causes of neonatal morbidity and mortality particularly in the developing countries. In order to avoid unnecessary NICU admissions and antibiotic therapies, it is very important to make early diagnosis of neonatal sepsis with utmost accuracy. Blood culture though gold standard requires lot of time for diagnosis, hence it's necessary to rely on early diagnostic markers such as blood counts, micro-erythrocyte sedimentation rate(ESR), C reactive protein (CRP), Procalcitonin(PCT). Out of the early diagnostic markers available, CRP and pro-calcitonin has the highest sensitivity and specificity rates.
Methods: The present study was a hospital based prospective observational study Conducted for a period of one year from 1year (May 2016- April 2017) On neonates admitted to NICU, at Kurji Holy Family Hospital, Patna Bihar which is a tertiary care referral hospital for children. Proper consent was taken from the parents of all neonates. Specimen of blood obtained from each neonate with proper aseptic conditions and prior to commencement of antibiotics.
Results: Total of 155 neonates satisfying the inclusion criteria were taken in the study group, based on the above criteria, they were grouped into 3 categories, 93/150 neonates had clinical/no sepsis, 45/155 had probable sepsis and definite sepsis was found in 17/155 neonates. Appropriate investigations were done. Blood culture was positive in 17 neonates. Procalcitonin was negative in 96 neonates, positive (>0.5ng/ml) in 59 neonates, PCT is positive in 12/17 blood culture positive cases. CRP was positive in 43/155 cases, and negative in 112/155 cases. CRP was positive in 11/17 blood culture positive cases. Procalcitonin in comparison with CRP, sensitivity was100%, specificity was 85.72%, positive predictive value (PPV) was 72.88%, and negative predictive value (NPV) was 100%. CRP in comparison with Procalcitonin, sensitivity was 72.88%, specificity was 100%, PPV was 100%, and NPV was 85.72%.
Conclusions: Procalcitonin in comparison with CRP shows better sensitivity and negative predictive value.

Keywords: C-reactive protein ; Neonatal sepsis; Procalcitonin


How to cite this article:
Rahul K, Kishore S, Kumar D, Kumar M, Gupta Ak, Kumar A, Sharan S, Prakash J. Comparative Study of Procalcitonin and C-Reactive Protein Concentrations as Early Marker of Neonatal Sepsis : A Hospital Based Study. J Indira Gandhi Inst Med Sci 2019;5:72-7

How to cite this URL:
Rahul K, Kishore S, Kumar D, Kumar M, Gupta Ak, Kumar A, Sharan S, Prakash J. Comparative Study of Procalcitonin and C-Reactive Protein Concentrations as Early Marker of Neonatal Sepsis : A Hospital Based Study. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2021 Jan 18];5:72-7. Available from: http://www.jigims.co.in/text.asp?2019/5/1/72/301083




  Introduction: Top


Neonatal Sepsis is a clinical syndrome of bacteremia characterized by systemic signs and symptoms of infection in the first 28 days of life.[1] Sepsis is the commonest cause of neonatal mortality and it accounts for 30-50% of the total neonatal deaths per year in developing countries[1],[2]. The incidence of neonatal sepsis varies from 7.1 to 38 per 1000 live births in Asia, 6.5 to 23 per 1000 live births in Africa, from 3.5 to 8.9 per 1000 live births in South America and Caribbean and by comparison incidence in UK and Australia is 6-9 per 1000 live births[3] Diagnosis of neonatal sepsis is always a challenge. Blood culture though “gold standard”, takes a lot of time for diagnosis.[4] Although neutrophil, total white blood cell (WBC), absolute neutrophil count (ANC), and platelet counts and blood culture are ordered to screen for suspected sepsis, these values are ineligible as infection markers due to insufficient sensitivity and specificity[5]. Most hospitals commonly use C-reactive protein (CRP) levels as markers. Recently, serum procalcitonin (PCT) has been reported as a measurable laboratory marker in the inflammatory response to the infection in some studies. Procalcitonin (PCT) is a 116-amino acid protein, a precursor of calcitonin which is produced by the thyroid.

Effectiveness of procalcitonin (PCT) as an early diagnostic tool for neonatal sepsis has been reported. Research studies reported that PCT is more effective than CRP at followup, as PCT levels rise earlier and return to normal levels more rapidly than CRP levels[6],[7].

As Procalcitonin is better marker of sepsis as compared to CRP regarding sensitivity and specificity and less affected by non-infectious etiologies and can be used as monitor for response to treatment. But, procalcitonin is not yet approved as septic screen or diagnostic marker of sepsis. The aims and objective of this study is to evaluate the suitability of procalcitonin as a marker in diagnosis of neonatal Sepsis and to compare Procalcitonin level with CRP level.


  Materials and Methods: Top


A. STUDY AREA

A hospital based prospective observational study was conducted in Department of pediatrics (Neonatal division) at Kurji Holy Family Hospital, Patna Bihar which is a tertiary care referral hospital for children.

B. STUDY POPULATION

Study group comprised of all neonates admitted in our hospital who fall in our inclusion criteria.

C. SAMPLE SIZE

A total 155 neonates, fulfilling the predefined inclusion criteria were studied and divided into three groups.

  1. GROUP A: DEFINITE SEPSIS
  2. GROUP B: PROBABLE SEPSIS
  3. GROUP C: NO SEPSIS/CLINICAL SEPSIS


According to the hospital records, total neonatal sepsis cases admitted in the previous one year were 250. Using Raosoft sample size calculator and considering margin error of 5% with confidence limit of 95% sample size came 152 or more.

D. STUDY DESIGN

A hospital based prospective observational study.

E. STUDY DURATION

1 year (May 2016- April 2017).

F. INCLUSION CRITERIA:

  1. Neonates born to mothers with at least one of the following risk factors:


    1. Prolonged rupture of membranes (>18 hours).
    2. More than 3 vaginal examinations after rupture of membranes.
    3. History of maternal fever one week before delivery (>38oC).
    4. Foul-smelling liquor.
    5. Meconium stained liquor.
    6. Maternal urinary tract infection within 2 week prior to delivery.


  2. Neonates brought from outside to NICU with signs and symptoms of sepsis.


G. EXCLUSION CRITERIA

  1. New born babies with gestational age < 28 weeks.
  2. Neonates with birth weight less than<1000gm.
  3. Neonates with lethal congenital anomalies.
  4. Post-dated neonates
  5. Antibiotic therapy prior to admission.
  6. Birth asphyxia.
  7. Respiratory distress syndrome.
  8. Meconium aspiration syndrome.
  9. Maternal diabetes.


H. METHODOLOGY:

Collection of data and methodology:

After obtaining approval and clearance from the Institutional Ethical committee, this study included 155 neonates born to mother with risk factors as per inclusion criteria and followed till 72 hours from the time of birth for the development of any symptoms and signs suggestive of neonatal sepsis and if present was recorded. But, these newborn were evaluated through laboratory parameters after 4 hr of birth as per our hospital protocol. The written informed consent was obtained from parents/guardians of all the cases after explaining the study procedure to their satisfaction. A standard case record form was maintained for each subject. The following signs and symptoms suggestive of neonatal sepsis were recorded:

General: Hypothermia, poor feeding, sclerema, mottling, lethargy.

Cardiovascular System: Hypotension, poor perfusion, CRT>3 second, shock.

Respiratory System: Apnea, chest retractions, cyanosis, grunting.

Central nervous system: Bulging anterior fontanelle, hypotonia, irritability, seizures, high pitched cry, neck retractions.

Gastrointestinal system: Feed intolerence, paralytic ileus, NEC, diarrhea, vomiting, abdominal distension, hepatomegaly

Renal: Acute renal failure

Hematological: Bleeding, petechiae, purpura.

The following lab parameters were recorded:

  1. Total leukocyte count.
  2. Absolute Neutrophil count.
  3. Band cell count.
  4. Micro ESR in 1st hour.
  5. CRP.
  6. Procalcitonin.
  7. Blood culture.


Infants with <37 weeks gestational age was regarded as preterm and >37 weeks term which was be calculated by New Ballard Scoring.


  Method of Blood Sample Collection: Top


Under complete aseptic conditions, 8-10 ml of blood sample were obtained by peripheral venepuncture. Sepsis work-up involved complete blood counts, Peripheral blood smears,

C-reactive protein, Procalcitonin and blood culture. Peripheral blood smears were prepared immediately, stained with Leishman stain and examined under oil immersion lens of light microscope at a magnification of ×1000. Differential counts were performed on these smears by counting at least 200 cells. All the peripheral blood smears were analyzed by pathologists blinded to the infection status of these infants and observed manually.

Blood culture-About 1ml of blood was drawn aseptically and inoculated into a blood culture bottle containing 10 ml of Brain Heart Infusion broth, thus making a dilution of 1 in 10 to nullify the natural bacteriostatic/bacteriocidal activity of blood. The broth was distributed in to 10 ml quantity in McCartney bottles and sterilized by autoclaving at 121 degree centigrade for 15 minutes. After inoculation, the blood culture bottles were incubated at 37 degree centigrade under aerobic conditions in the incubator for 7 days. The first subculture was done after 24 hours of incubation, the second on the third day and final on the seventh day. Subcultures were done on to chocolate agar, 5% sheep blood agar and Mac Conkey agar plates. The inoculated plates were incubated aerobically in the incubator for 37 degree centigrade and the plates were observed for growth. The growth was identified by colony characteristics, grams stain and biochemical tests.

Cultures which did not yield any growth following three subcultures were reported negative at the end of 7 days.

Procalcitonin level analysis was done using CHEMI LUMINENCE IMMUNO ASSAY (CLIA) for PROCALCITONIN by ROCHE ELECSYS COBAS E-100 BRAHMS PCT KIT manufactured by ROCHE DIAGNOSTICS INDIANAPOLIS, GERMANY which was a quantitative assay where value upto 0.50 ng/ml was considered normal.

CRP analysis was done using IMMUNOTURBIDOMETRY METHOD which was a quantitative analysis where levels greater than 6mg/litre was considered as positive.

The investigator performing the Procalcitonin and CRP test was blinded to the clinical status of newborn baby.

Clinical sepsis /no sepsis

  1. Clinical signs suggestive of sepsis are present.
  2. Less than 2 parameters for sepsis screen positive.
  3. Blood culture negative.


Probable sepsis

  1. Clinical signs suggestive of sepsis are present.
  2. At least 2 parameters for sepsis screen must be positive.
  3. Blood culture negative.


Definite sepsis

  1. Clinical signs suggestive of sepsis are present.
  2. At least 2 parameters of sepsis screen must be positive.
  3. Blood culture positive


I.STATISTICAL METHODS:

The data obtained were tabulated and analysed using MS Excel SPSS version 20.0 for windows. Descriptive statistical analysis was done. Significance was assessed at 5% level of significance. Chi-square/Fisher Exact test had been used to find the significance of study parameters on categorical scale between two groups. Diagnostic statistics viz. Sensitivity, Specificity, PPV, NPV, accuracy was computed and confidence interval computed in the study.


  Observation and Results: Top


Among the 155 babies, there were 88 (56.8%) males (90% CI, 50.2-63.4) and67 (43.2%) females (90% CI, 36.3-49.8).
Table 1: Shows distribution of cases according to sex (n=155)

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Among the 155 babies, there were 47 (30.3%) with birth weight <2.5 kg (90% CI, 24.2-36.4) and 108(69.7%) with birth weight of >2.5 kg (90% CI, 63.6-75.8).
Table 2: Shows distribution of cases according to Birth weight (n=155)

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Among the babies, there were 37 (23.9%) with gestational age < 37 weeks (90% CI, 18.2-29.6) and 118 (76.1%) with gestational age of > 37 weeks (90% CI, 70.4-81.8).
Table 3: Shows distribution of cases according to Gestational age (n=155)

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Among 155 babies with maternal risk factors 84 (54.2%) had meconium stained liquor with (90% CI, 47.6-60.8), 44 (28.4%) had PROM with (90% CI, 17.8-29.0), 11 (7.1%) had maternal UTI with (90% CI, 3.7-10.5), 8 (5.2%) had more than 3 vaginal examinations with(90% CI, 2.3-8.1), 8(5.2%) had foul smelling liquor with (90% CI, 2.3-8.1), 6 (3.9%) had maternal fever with (90% CI, 1.3-6.5).
Table 4: Shows distribution of cases according to risk factors (n=155)

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With relation to risk factors, 3 (37.5%) cases with foul smelling liquor were positive, 5 (62.5%) cases with > 3 vaginal examinations were positive, 18 (41%) of cases with PROM were positive, 34 (40.5%) cases with meconium stained liquor were positive, 2 (18.2%) with maternal UTI were positive and 1 (16.7%). No statistical significance was observed between PCT and maternal characteristics
Table 5: Association of Maternal characteristics & PCT positive

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Among 155 babies, Procalcitonin is positive in 59 (38.1%) with (90% CI, 31.7-44.5) and negative in 96 (61.9%) with (90% CI, 55.5-68.3).
Table 6: Frequency distribution of PCT

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Among 155 cases CRP was positive in 43 (27.7%) with (90% CI, 21.8-33.6) and negative in 112 (72.3%) with (90% CI, 66.4-78.2)
Table 7: Frequency distribution of CRP

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Of total 155 cases, 138 (89%) of cases had blood culture negative with (90% CI, 84.9-93.1) and 17 cases are positive, of which 7 (4.5%) of cases had Klebsiella positive with (90% CI, 1.8-7.2), 4 (2.6%) cases had E. coli growth with (90% CI, 1.1-6.1), 4 (2.6%) cases had Pseudomonas growth with (90% CI, 1.1-6.1) and 2 (1.3%) case had Coagulase negative staphylococcus with (90% CI, 0.2-2.8).
Table 8: Distribution of Blood culture cases

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Among the 155 babies, Total count < 5000 was noted in 14(9%) of patients with (90% CI 5.2-12.8) and in the remaining 141(91%) was > 5000 with (90% CI 87.2-94.8).
Table 9: Distribution of cases according to TLC

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Among the 155 cases, compared with blood culture, Procalcitonin was true positive in 12 cases, false positive in 47, false negative in 5 and true negative in 91. CRP was true positive in 11, false positive in 32, false negative in 6 and true negative in 106 cases.
Table 10: Correlation of PCT & CRP in relation to blood culture An observation

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Among the 155 cases, Procalcitonin in comparison with CRP, sensitivity was100%, specificity was 85.72%, PPV was 72.88%, and NPV was 100%. CRP in comparison with Procalcitonin, sensitivity was 72.88%, specificity was 100%, PPV was 100%, and NPV was 85.72%. Procalcitonin in comparison with CRP shows better sensitivity and negative predictive value.


  Discussion: Top


Neonatal sepsis with its high mortality rate, still remains a diagnostic and treatment challenge for neonatal health care providers, developing countries have the highest incidence and mortality rates. This may be due to problems in utero by anatomical defects, infections and infected birth passage etc.

Early diagnosis of neonatal sepis helps the clinician in instituting antibiotics therapy at the earliest thereby reducing mortality in neonates. Early identification of an infected neonate also helps in avoiding unnecessary treatment of a non-infected neonate.

In the present study an attempt has been made to document the effects of intrapartum risk factors for early onset sepsis on PCT and CRP in neonates and to assess the suitability of the test in the diagnosis of neonatal sepsis.

Male babies were more than the female babies in present study, showing a ratio of 1.3:1, the results are comparable to Mathai et al [8] and closer to Tallur et al[9]. Male preponderance in the neonatal septicaemia may be linked to the x-linked immunoregulatory gene resulting in the host's susceptibility to the infection in males.

In the present study, the higher proportion of cases were with birth weight >2.5 kg. The results of other studies showed higher proportion of cases with birth weight <2.5 kg[9],[10]. As during this study, there were fewer babies with weight <2.5 kg delivered in the hospital, fewer cases were recorded.

In the present study the higher proportion of cases were found, with gestational age>37 weeks.

The results of present study are almost comparable with Raghavan et al and Tallur et al[9]. Caughey et al[12] found that the rates of immediate neonatal morbidity increased with increasing gestational age

The higher proportion of term neonates compared to the preterm neonates in present study probably reflects difference in the population characteristics and the occurrence of the predisposing factors (preterm incidence) among them.

In the present study, maternal fever as a risk factor was observed in 3.9% of cases which was almost similar to Tallurand Tower et al[9],[13]. > 3 VE after rupture of membrane as a risk factor was observed in 5.2% which was less than that observed in other studies.

FSL as a risk factor was observed in 5.2% of cases which was similar to Kuruvilla et al[14]. MSL as a risk factor was observed in 54.2% which was more than that observed in various studies but was closer to results in Raghavan et al[11]. Regarding laboratory data of neonates included in the study, there were significant higher levels of total leukocytic count in neonates with sepsis than in the control group (90% CI 87.2-94.8). This finding was comparable with that of the studies by Basu S et al.[15] and Srinivasan and Harris[16]. They concluded that TLC is useful to estimate the probability of sepsis. However, Laurent et al.[17] found that the total leukocytic count had little value in discriminating infection in neonates.

UTI as risk factor was observed in 7.1% of cases which was comparable to Betty Chacko et al[18].PROM as a risk factor was observed in 28.4% of cases which was higher than that observed in other studies. The variation in the occurrence of intrapartum risk factors probably reflects differences in the rates of occurrence of the predisposing risk factors in various studies.

In the present study, blood culture was positive in 17(11%) of cases with maternal risk factors which is comparable to studies done by Rodwell RL et al[19]. The success of isolating bacterial pathogens from blood depends upon the quantum of blood cultured, frequency of culture and duration of incubation and the volume of blood required for the isolation of the pathogen depends on the magnitude of septicemia, which is directly related to the age of the patient. All the above reason says why the blood culture positivity is low.

In the present study, procalcitonin evaluation demonstrated sensitivity of 100%, specificity of 85.72%, PPV of 72.88% and NPV of 100% which was comparable to other studies,Pavcnik-Arnol et al.[20], and Ivancevic et al.[21], In the present study, the sensitivity observed was 72.88%, specificity of 100%, PPV of 100% and NPV of 85.72% for CRP which was comparable with Emine et al[22].


  Conclusion: Top


In this study, we found PCT has high sensitivity and good negative predictive value ascompared to CRP. Thus, PCT appears to be good marker for diagnosis of neonatal sepsis. But, Blood culture remains the gold standard but its take more time. Hence, more studies need to be done to search for new marker of neonatal sepsis which is cost effective as well as has high sensitivity and specificity.

However, this study has certain limitations, that can be overcome by study with large number of cases among population groups.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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