INTRODUCTION
Neonatal sepsis (NS) is the leading cause of morbidity and mortality, especially in the middle- and lower-income countries.[1] Worldwide, it is responsible for 38% of neonatal deaths. Because of the overlapping of signs and symptoms, the diagnosis of NS is always challenging. Based on the time period, NS can be early-onset sepsis (EOS) and late-onset sepsis (LOS); different Gram-positive and Gram-negative bacteria are responsible for NS.[2]
Thrombocytopenia is a common complication in NS, which occurs because of endothelial damage, adhesion, and removal.[3] Thrombocytopenia is reported up to 50% of all neonates admitted in the neonatal intensive care unit (NICU).[4] There was severe thrombocytopenia with a culture positive (CP) status in NS. Because of increased administration of maternal antibiotics, there was low rate of CP in NS.[5] There were no ideal benchmarks in the diagnosis of NS; blood culture is the gold standard. However, the utility of blood culture is limited because of low positivity and a prolonged time period for reporting.[67]
The roles of different platelet indices (PIs) such as mean platelet volume (MPV), platelet volume distribution width (PDW), and plateletcrit (PCT) were extensively studied in adults.[8] However, there are limited data from Telangana state, especially in the diagnosis of NS. With this, a study was undertaken to evaluate thrombocytopenia and variations in PIs such as MPV, PDW, and PCT (MPV X platelet count) in the diagnosis of NS.
METHODS
This was a prospective, observational study, conducted in the Department of Pediatrics, Kakatiya Medical College, Warangal. The study was conducted from October 2019 to July 2021. The study protocol was approved by the institutional Ethics committee.
Neonates aged <28 days with signs and symptoms of sepsis like poor feeding, lethargy, tachypnea, hypothermia, convulsions, and so on were included in the study. Newborns with neonatal hyperbilirubinemia because of the causes other than sepsis like physiological jaundice, ABO incompatibility, TTN, and MAS without clinical or laboratory suspicion of sepsis were excluded from the study.
The study protocol was explained to the parents of the neonates in vernacular language, and all the doubts were clarified beyond the knowledge. The details of the disease process, options of treatment, ultimate outcome, possible effects, complications, and chances of recurrence in both procedures were explained, and a written informed consent was obtained before enrolment. They were informed about their right to withdraw from the study at any stage. The detailed history was collected from the parents of the neonates and recorded in the study proforma along with age and gender. Physical as well as systemic examination was conducted, and the findings were recorded. Telephone contact was also recorded to avoid gaps in follow-up.
Immediately after admission, 3 ml blood sample was collected, processed for blood culture, C-reactive protein (CRP), and PIs. Based on the clinical and laboratory findings, the study members were divided into sepsis proven (SP), probable infection, and non-infected (NI) categories; these were blood CP, culture-negative but strong evidence of infection with one or two clinical symptoms of sepsis with at least two laboratory signs of sepsis and negative blood culture with at least two clinical signs of sepsis, respectively.
RESULTS
A total of 110 neonates were included in this research. The majority (46; 41.8%) were SP, followed by probable infection (33; 30%) and NI (31; 28.1%); statistically, there was no significant difference [Table 1]. The male–female ratio was 1.3. In the <3 CRP category, 32.3% (11) were SP and 55.8% (19) were NI, whereas in the >3 CRP category, 46% (35) were SP and 15.8% (12) were NI; statistically, there was significant difference [Table 1].
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Table 1: Correlation between diagnosis and CRP among the study participants, n (%)
Age-wise, the majority (32; 36.36%) were 2–7 days age group, followed by 8–14 days (31; 28.1%). Gender-wise, 20% were male and 16.36% were female [Table 2]. Klebsiella pneumoniae (14; 12.73%) was the leading causative agent of NS, followed by Acinetobacter (6; 5.45%).
Table 2: Distribution of the study members according to the age and gender
Severe thrombocytopenia was diagnosed in 18.2% (20), followed by moderate (52.7%; 58) and mild (29.1%; 32). Of these, in severe thrombocytopenia, 13 (65%) were blood CP; 17 (29%) were CP in moderate and 16 (50%) in mild thrombocytopenia.
In mild thrombocytopenia infants, an increased MPV was observed in 32.25% (10); this was 39.65% (23) and 70% (14), respectively, in moderate and severe thrombocytopenia. The PDEs were increased 43.75% (14), 51.7% (30), and 75% (15), respectively, in mild, moderate, and severe thrombocytopenia. However, plateletcrit was decreased in 34.37% (11), 36.2% (21), and 65% (13) in mild, moderate, and severe thrombocytopenia, respectively [Table 3].
Table 3: Correlation between platelet levels and platelet indices among the study members, n (%)
DISCUSSION
In this research, 41% (46) were SP, 30% (33) were probable infection, and 28.1% (31) were NI study participants; statistically, there was no significant difference [Table 1]. Poor suckling was found to be the common clinical symptom, followed by temperature instability and respiratory disorder. In a study by Mussap M et al.,[9] the majority (33%) were probable infection, whereas 52% were SP as per Nora Hofer et al.[10] A total of 61 (55.45%) were male and 49 (44.55%) were female infants; the male–female ratio was 1.24. In a study by M. Jeeva Sankar et al.,[11] 62% were male infants and 38% were female participants. Gender-wise, it was 55% and 45%, respectively, as per the report of Black RE et al.[12]
The majority (71; 64.5%) of the infants of this study were in the 2–14 days age group, and the male–female ratio was 0.97 (35 and 36, respectively). In the 2–7 days group, 22 (20%) were male and 18 (16.36%) were female infants. However, in the 8–14 days group, 13 (11.8%) were male and 18 (16.3%) were female infants. In a study by Mussap M et al.,[9] the majority of males (34%) were in the 2–14 days age group and 28% of females were in the 2–8 days group. In a study by Black RE et al.,[12] around 45% female neonates were in the 2–12 days age group, followed by 20% male infants in the 2–14 days age group.
In this research, 20% of full-term infants did not have any infection, whereas sepsis was diagnosed in 11.82%; 30% pre-term infants reported sepsis and 27.7% reported probable infection. In a study by Richard A. Polin et al.,[13] 34% full-term study infants did not report any infection and sepsis was diagnosed in 30% of pre-term babies. As per Nora Hofer et al.[10] study, 43% of full-term infants did not report any infection and probable infection was detected in 32% of pre-term infants. According to the type of sepsis, 52.73% were LOS and 47.27% were EOS. As per the studies, the majority of sepsis were diagnosed to be late onset[1314] and Klebsiella was reported to be the leading cause of sepsis.[141516] Guclu et al.[17] concluded that individuals with >18% PDW are at a higher risk of death.
MPV is the average size of platelets, which is inversely proportional to platelet count in normal individuals. In this research, there was a significant increase in MPV; this was 70% among the infants with severe thrombocytopenia. A systematic review on NS also reported similar findings.[18] PDW is an indicator of variation in platelet size; there was a significant increase in PDW and maximum among the neonates with severe thrombocytopenia, with 43.75% (14), 51.7% (30), and 75% (15), respectively, in mild, moderate, and severe thrombocytopenia. Plateletcrit indicates the volume of circulating platelets in a unit volume of blood, deceased with thrombocytopenia, with 34.37% (11), 36.2% (21), and 65% (13) in mild, moderate, and severe thrombocytopenia, respectively [Table 3]. MPV and PDW were also reported to be useful in the diagnosis of NS at an early stage.[19] However, PIs have high specificity in the diagnosis of bacterial NS with low sensitivity.[20]
CONCLUSION
We conclude that there was severe thrombocytopenia in NS and Klebsiella is the common causative agent. There was an increase in PIs as well as CRP in NS. Hence, this combination can be used in the diagnosis of NS at the early stage.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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