To the Editor:
We read the study of Khalil et al (1) about hepatobiliary dysfunction in neonatal septicaemia with a high interest. They reported cholestatic jaundice with a rate of 42.5% in Gram-negative septicaemia.
We retrospectively reviewed our 5-year (2006–2011) data of neonates with Gram-negative septicaemia. Seventy of 92 infants with Gram-negative confirmed sepsis were included in the study. The remaining were excluded because of comorbitidities associated with cholestasis. The responsible pathogens were determined as Escherichia coli (n = 22), Klebsiella pneumoniae (n = 18), Klebsiella oxytoca (n = 7), Pseudomonas aeruginosa, (n = 8), Serratia marcescens (n = 4), and Acinetobacter baumannii (n = 11). Mean gestational age was 33.5 weeks (25.9–40.2) with a mean birth weight 2085 g (560–4500). A total of 26 (37.1%) infants did not survive to discharge. Cholestasis (direct bilirubin >20% of total with a minimum level of 2 mg/dL) was present in 18 (25.7%) infants with a median 7 days (2–90) of gestational age. The prevalence of cholestasis was comparable between survivors and nonsurvivors (23% vs 27.2%, P > 0.05). Mean conjugated bilirubin level was 1.5 ± 2.5 mg/dL and 1.2 ± 1.8 mg/dL in survivors and nonsurvivors, respectively (P > 0.05); however, mean total bilirubin level was significantly higher in survivors as compared with nonsurvivors (12.1 ± 10 mg/dL vs 7.5 ± 4 mg/dL, P = 0.001). As the nature of the retrospective study, the time of bilirubin obtaining is not identical; however, median total and direct bilirubin sampling times were similar in survivors and deaths (6 days vs 7 days, P > 0.05) in the present study. Bilirubin levels and liver function tests were normal, 3 months after the onset of cholestasis in all of the infants.
Our results support previous reports that neonatal cholestasis caused by Gram-negative sepsis is frequent, mild, transient (1,2), and has an early onset (1,3). Cholestasis and the level of conjugated bilirubin did not influence the prognosis, which is in contrast with Khalil et al (1), whereas higher total bilirubin levels are associated with a higher rate of the survival in our study. We support the hypothesis that bilirubin has a beneficial effect on the prognosis of Gram-negative sepsis.
1. Khalil S, Shah D, Faridi MM, et al. Prevalence and outcome of hepatobiliary dysfunction in neonatal septicaemia. J Pediatr Gastroenterol Nutr
2. Shamir R, Maayan-Metzger A, Bujanover Y, et al. Liver enzyme abnormalities in gram-negative bacteremia of premature infants. Pediatr Infect Dis J
3. Tiker F, Tarcan A, Kilicdag H, et al. Early onset conjugated hyperbilirubinemia in newborn infants. Indian J Pediatr