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Journal Club Presentation

Journal Club Presentation. Organized by: DEPARTMENT OF NEONATOLOGY (NU – I) MMCH. Chairperson Dr. Md. Anwar Hossain MBBS, M Phil, MCPS (Pediatrics) FCPS (Pediatrics), MD (Neonatology) Assistant Professor Department of Neonatology Mymensingh Medical College. Speaker Dr. Md. Abu Taher

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Journal Club Presentation

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  1. Journal Club Presentation Organized by: DEPARTMENT OF NEONATOLOGY (NU – I) MMCH

  2. ChairpersonDr. Md. Anwar HossainMBBS, M Phil, MCPS (Pediatrics)FCPS (Pediatrics), MD (Neonatology)Assistant ProfessorDepartment of NeonatologyMymensingh Medical College Speaker Dr. Md. Abu Taher Assistant Registrar Neonatology(U-1), MMCH

  3. Title Role of micro-ESR and I/T ratio in the early diagnosis of Neonatal Sepsis.

  4. Source: • Mymensingh Medical Journal 2009 Jan ; 18(1): 56-61 • Authors: Walliullah SM, Islam MN, Siddika M, Hossain MA, Chowdhury AK. • Study period: 19 months (15th March’05 –15th Octeber’06) Study place: Dhaka Shishu Hospital, Dhaka.

  5. Objective of the study: • Objective of this study is to find out the sensitivity and specificity of Micro-ESR and I/T ratio separately and combined in early diagnosis of neonatal sepsis.

  6. Introduction: • Septicemia is one of the major cause of neonatal mortality and morbidity. • Despite considerable progress in hygiene condition, introduction of newer antimicrobials , advanced techniques for early diagnosis of sepsis, supportive measures for critically ill neonates, sepsis remains one of the important cause of morbidity and mortality in this age group.

  7. Cont.. • The outcome of a neonate with sepsis largely depends on its • early identification and • prompt management. • Delay in treatment until signs and symptoms of sepsis are obvious cause greater risk of preventable mortality.

  8. Cont.. • Globally about 130 million baby’s born every year . • Among them 4 million die in the first 4 weeks of life due to infection, prematurity, and perinatal asphyxia.

  9. Cont.. • Recognition of infection is difficult in most infected neonates as clinical manifestations mimic other conditions like asphyxia , hypoglycemia , prematurity etc. • Combination of clinical and laboratory examination can be used, though their predictive accuracy , sensitivity and specificity are variable.

  10. Cont.. • No Single laboratory test has been found to have enough specificity and sensitivity • But combination of hematological profiles shows high sensitivity and specificity. • The gold standard for diagnosis of neonatal septicemia is a positive blood culture. • A positive blood culture is found in 10-60% of neonatal sepsis cases.

  11. Cont.. • In developing countries like Bangladesh, blood culture facilities are non- existent in the district hospitals and UHCs. • But TLC, DLC, PBF, can easily be done even in health centers. • Among the hematological profiles , the micro –ESR is a popular and simple screening test to detect neonatal sepsis and has been recognized as a valid investigation tool.

  12. Cont.. • Micro-ESR is also possible to be done as bed side test by heparinized capillary tube which is not very costly and very small amount of blood is required. • In spite of simplicity it is not practiced routinely in our country due to less availability of heparinized capillary tube. • In this study a normal value of micro-ESR in 1st hours is calculated as age of baby in days plus 3 mm to maximum15 mm.

  13. Cont.. • Band cell count increases significantly beyond normal range in new born babies with bacterial infection. • All band cells and cells less mature than the band cells were classified together as immature neutrophil.

  14. Cont.. • I/T Ratio: Immature to total neutrophil count ratio can be calculated from peripheral blood film. • Immature cell count more than 20% of total neutrophil count (that is I/T ratio >0.2) is a useful marker of bacterial infection in newborn.

  15. Cont.. • So micro ESR & I/T ratio can be done as a part of simple routine screening test for the early diagnosis of neonatal sepsis. • As a simple method the present study was carried out to assess the role of micro-ESR and I/T ratio in the early diagnosis of neonatal sepsis

  16. Methods: • Study type: Prospective cross sectional study • Study population: 110 neonates (definite sepsis 30, probable sepsis 50, control 30 )

  17. Inclusion criteria : For Case: Neonates present with: (one or more) • Lethargy • Reluctant to feed • Abdominal distension • Vomiting • Respiratory distress • Fever

  18. Cont… For Control: • No sign symptom of sepsis but admitted due to other problems like- • Physiological Jaundice • Delayed passage of urine • Feeding problem

  19. Exclusion criteria : • IDM • Perinatal asphyxia • Congenital cyanotic heart disease.

  20. Result: In this study out of 80 clinically suspected cases of neonatal septicemia: • 30 positive blood culture were taken as definite sepsis • 50 with negative blood culture but one or more abnormal hematological profiles suggestive of sepsis were taken as probable sepsis . • 30 neonates with no signs and symptoms of septicemia were taken as control group.

  21. Cont.. • Out of 80 cases 51 (63.75%) were male , and 29(36.25%) were female. • Incidence of sepsis is higher in low birth weight neonates in comparison to normal birth weight neonates (67% in definite sepsis and 70% in probable sepsis are LBW ).

  22. Table: 1 : Micro-ESR in cases and control

  23. Table: 2 : I/T ratio in cases and control

  24. Cont.. In this study more than normal level of micro-ESR was found: • 63.3% in definite sepsis • 40% in probable sepsis and also • 6.7% in control Which was statistically significant(P value <0.05).

  25. Cont….. In this study I/T ratio was positive in: • 70% cases of definite sepsis • 44% cases in probable sepsis • 6.7% in control Which was statistically significant ( p value <.05).

  26. Table-3: Sensitivity ,specificity, positive and negative predictive values of micro-ESR in definite sepsis &probable sepsis.

  27. Table-4: Sensitivity ,specificity, positive and negative predictive values of micro-ESR in definite sepsis & control.

  28. Table-5: Sensitivity ,specificity, positive and negative predictive values of I/T ratio in definite sepsis & probable sepsis.

  29. Table-6: Sensitivity ,specificity, positive and negative predictive values of I/T ratio in definite sepsis & control.

  30. cont…. • When it was compared between definite and probable sepsis sensitivity of micro-ESR was 63.3% ,specificity 60% and negative predictive value was 73.2% . • But When it was compared between definite sepsis and control specificity was high (93.3%) ,positive predictive value 90.5%

  31. cont…. • When I/T ratio was compared between definite and probable sepsis sensitivity was 70% ,specificity 56% and negative predictive value was 75.7% . • But When it was compared between definite sepsis and control specificity was high (93.3%) ,positive predictive value 91.3%.

  32. Table7: Sensitivity, specificity, positive and negative predictive values of Combined Micro ESR and I/T ratio between definite sepsis and Probable sepsis In this study sensitivity and specificity of combined micro-ESR and I/T ratio was 80% and 70% respectively, when compared between definite sepsis and probable sepsis.

  33. Table 8: Sensitivity, specificity, positive and negative predictive values of Combined Micro ESR and I/T ratio between definite sepsis and control In this study sensitivity and specificity of combined micro-ESR and I/T ratio was 83.3% and 96.7% respectively, when compared between definite sepsis and probable sepsis.

  34. Discussion • As tools for early diagnosis of neonatal septicemia, micro-ESR and I/T ratio were analyzed in this study to see the role of these parameters in all the neonates of both cases and control groups . • The incidence of sepsis is higher in low birth weight neonates in comparison to normal weight babies . 67% of neonate in definite sepsis and 70% of neonate in probable sepsis group were of low birth weight. Nearly similar observation was mentioned by Bhakoo ON , Singh M (perinatal risk factors in neonatal bacterial sepsis. Indian J Pediatr. 1988;55:941-946.)

  35. cont.. Common clinical features of sepsis were reluctant to feed(96.7%),lethargy(73.3%), abdominal distention (70%), jaundice(50%) and hypothermia (40%). This observation was similar to the observations by Hoque MM ,Ahmed ASM N, Ahmed S, Chowdhury MAKA (Clinical manifestation and bacteriological profile of septicemia in preterm neonates :Experience from a tertiary level pediatric hospital . BJMSc 2004;10(1):29-33) and Chowdhury MAKA, Rahman MM, Karim AQMR (Characteristic of septicemia in newborne in Dhaka Shishu Hospital.DSHJ.1998:14(2):9-12)

  36. cont.. • In this study for Micro-ESR Sensitivity and Specificity of Micro-ESR in definite sepsis was 63.3% and 60% respectively . Misra et al. showed high sensitivity (79%) and specificity (92%). Sharma et al. Showed Micro ESR was relatively low sensitivity (60%) and specificity (62.5%).Okolo et al. showed high sensitivity 96.9% and specificity 90%

  37. cont.. • In this study sensitivity and specificity of I/T ratio in definite sepsis was 80% and 70% respectively. . Misra et al. showed high sensitivity (92%) and specificity (79%). Sharma et al. Showed Micro ESR was relatively low sensitivity (60%) and specificity (62.5%).Sing et al. observed low specificity 48%.Chandna et al. showed specificity was much lower 31%

  38. cont.. • In this study sensitivity and specificity of combined micro-ESR and I/T ratio was 80% and 70% respectively. Misra et al. showed sensitivity 75% and specificity 85%. Sharma et al. Showed relatively low sensitivity 66.7% and specificity 70%. Okolo et al. showed high sensitivity 84.4% and specificity 85%.

  39. Limitations: • 1. This study is a single hospital based study. • 2. Sample size is small.

  40. Key message: • Micro-ESR and I/T ratio can be used as reliable test in the early diagnosis of neonatal sepsis with high degree of sensitivity and specificity specially where blood culture facility is not available .

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