Laboratory Diagnosis in Newborn Infectious Disease & Neonatal Sepsi

7/25/2019 Laboratory Diagnosis in Newborn Infectious Disease & Neonatal Sepsi

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Laboratory Diagnosisin Newborn InfectiousDisease

& Neonatal SepsisClinical Pathology Department,

Faculty of Medicine Universitas Gadjah Mada /

Dr. ardjito !ospital


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SCCM Consensus Denition


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Infection


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Sepsis

"nfection, plus # or more "$ criteria


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Severe Sepsis


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Septic Shock


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Infection

Parasite

irus

!ungus

"acteria

#rau$a

"urnsSepsis

"$

SevereSepsis

%dapted from CCM/%CCP Consensus Guidelines

shock

"SIPancreatitis

%thers

Multi

Organ

Dysfunction

syndrome


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Greg Martin, David mennino,et al.

& 'ngl ( Med, vol )*+, &o ) - ept #, ## - 000.nejm.or


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Mortality rate 1 increases 0ith increased severity

+2 in patients 0ith "$ 2 in patients 0ith epsis #2 in patients 0ith evere epsis *2 in patients 0ith eptic hoc3

$angel1Frausto, et al 4(%M% 5567


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Neonatal mortality ASEAN countries

Country Life birth(000)

Perinatalmortality

Earlyneonatal

death

Neonatalmortality

Singaore !" ! # #

Malaysia $!% " ! $

&runei ' % !

hailand #0'* *0 % #

Philiines *0*% * #* #$

+ietnam #$% " # #$

,ndonesia!$-! 0 #! #'

Laos #%$ $" *- $

Cambodia !-# -- # !0

Myanmar ##%! -$ 0 !0

WHO Data : Neonatal and perinatal mortality : country, regional and global estimates. 200


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Cause of neonatal death in SEA


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Neonatal Major Infection

!n"ection No. o" cases #ase $atality%ate &'( No. o" Deat)

*cute +ung!n"

2.00.000 -0 0.000

/etanusneonatal -1.000 1 -2.000

epsis 0.000 0 -00.000

Diar)ea 2.000.000 0. 30.000

Meningitis 32.000 0 0.00

Stoll BJ : The global impact of infection Clin Pernatol1997 24:1-21


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Diagnostic criteria for sepsis

"nfection, documented or suspected, and some of thefollo0ing8

General varia9les

Fever 4: );.) achypnea 4increased respiratory rate7%ltered mental statusigni?cant edema or positive @uid 9alance 4: # mA/3g over#* hrs7!yperglycemia 4plasma glucose :# mg/dA or +.+ mmol/A7 inthe a9sence of dia9etes

%CCP/CCM Consensus De?nition, Crit Care Med #)


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Ina$$atory variables

Leukocytosis '("C count ) *+,---.uL/

Leukopenia '("C count 0 1,---.uL/Nor$al ("C count with ) *-2 i$$ature for$s3levate4 plas$a C5reactive protein 'C6P/3levate4 plas$a procalcitonin 'PC#/

7e$o4yna$ic variables

8rterial hypotension 'S"P 0 9- $$7g, M8P 0 :-, or anS"P 4ecrease ) 1- $$7g in a4ults or 0 + SD belownor$al for age/Sv%+) :-2Car4iac In4e; ) $in5*M5+here is no speci?c pathognomonic clinicalor la9oratory parameter of sepsis

'arly detection and timely therapeuticintervention is crucial for improvedoutcome of patients 0ith sepsis

'arly diagnosis of sepsis is 3ey forimproved survival

>he diagnosis of sepsis is dicult and notrelia9le 9ased on general signs andsymptoms such as fever, tachycardia andtachypnea


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Laboratory tests i$portant in i4entifying the infectious agent

Infectious agent


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"n one recent, prospective study, positive9lood cultures 0ere found in8

+2 of patients 0ith sepsis, #62 0ith severe sepsis, 52 0ith septic shoc3.


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>0o major reasons8

>he patients are indeed septic 0ith9acteremia 9ut the organisms did not

gro0 under normal circumstances in theculture medium

>he septic state may have resulted notfrom 9acteremia 9ut from pyrogenic

cyto3ine activation


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Gram1negative organisms the mostcommon isolates from 9lood cultures

Echerichia coli,

!lebiella pne"moniae, Enterobacter cloacae,

the epidemiology of sepsis has changedin thelast # decades gram positive


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Gram1positive organisms accounted formore than 62 of all positive 9loodcultures from septic patients

Coagulase1negative staphylococci, Staph#lococc" a"re", Enterococc" faecali


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everal reasons for the increasing num9erof Gram1positive infections8 election of resistant Gram1positive organisms

from empiric anti9iotic therapy directed at

Gram1negative infections, "ncreased use of vascular access catheters and

implanta9le devices/prostheses, hared anti9iotic resistance 9et0een Gram1

positive organisms, and increased virulence ofGram1positive pathogens.

9ecause of advances in medicaltechnology


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Gram1negative 9acteria

Microbial factors in sepsis


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Cohen, Nature: 2002 420:885


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Bhat microorganisms cause severeinfections and sepsis in 9a9iesE

Prenatal During Delivery %fter irth

$u9ella4German

measles7

Group

streptococcus4G7

$espiratory

syncytial virus4$7

Cytomegalovirus4CM7

'. Coli Candida

aricella1Hoster virus4chic3enpoI virus7

!erpessimpleI virus

!aemophilus in@uenHae type 94!i97

Aisteriamonocytogenes

1 'nterovirus
http://www.healthline.com/adamcontent/rubellahttp://www.healthline.com/adamcontent/acute-cytomegalovirus-cmv-infectionhttp://www.healthline.com/adamcontent/chickenpoxhttp://www.healthline.com/adamcontent/herpes-simplexhttp://www.healthline.com/adamcontent/herpes-simplexhttp://www.healthline.com/galecontent/haemophilus-influenzae-type-bhttp://www.healthline.com/galecontent/haemophilus-influenzae-type-bhttp://www.healthline.com/galecontent/haemophilus-influenzae-type-bhttp://www.healthline.com/galecontent/haemophilus-influenzae-type-bhttp://www.healthline.com/adamcontent/herpes-simplexhttp://www.healthline.com/adamcontent/herpes-simplexhttp://www.healthline.com/adamcontent/chickenpoxhttp://www.healthline.com/adamcontent/acute-cytomegalovirus-cmv-infectionhttp://www.healthline.com/adamcontent/rubella


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Laboratory In4icators of Infection .Sepsis

Laboratory #est !in4ings Interpretation

Bhite 9lood cellcount

Aeu3ocytosis orleu3openia

'ndotoIemia maycause earlyleu3openia

Platelet count >hrom9ocytosis or

throm9ocytopenia

!igh value early

may 9e seen asacute1phaseresponseJ lo0platelet countsseen in overt D"C

Coagulation

cascade

Protein C

de?ciencyJantithrom9inde?ciencyJelevated D1dimerlevelJ prolonged P>and P>>

%9normalities can

9e o9served 9eforeonset of organfailure and 0ithoutfran3 9leeding.

Creatinine level 'levated from

9aseline

Dou9lingKindicates

acute renal injury


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Laboratory #est !in4ings Interpretation

Aactic acid level Aactic acid : *

mmol/A 4) mg/dA7

"ndicates tissue

hypoIiaAiver enHyme levels 'levated al3aline

phosphatase, %>,%A>, 9iliru9in levels

"ndicates acutehepatocellular injurycaused 9yhypoperfusion

erum phosphatelevel

!ypophosphatemia "nversely correlated0ithproin@ammatorycyto3ine levels4>&F, "A1, "A1#receptors7

C1reactive protein4C$P7 level

'levated %cute1phaseresponse

Procalcitonin level 'levated DiLerentiatesinfectious "$ fromnoninfectious "$


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Fast increaseto 9e present at the onsetor even 9efore the appearance of theclinical signs of infection/sepsis

>o 9e highly sensitive and speci?c forinfection/ sepsis4diLerentiation 9et0eeninfectious and non infectious causes ofin@ammation, organ dysfunction and

shoc37 "mprove accuracy of clinical diagnosis

>o indicate the eLectiveness of therapy

(hat is e;pecte4 fro$ such a$arker ??


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Recent Laboratory Marker :

1. Existing Marker: C-Reactive Protein (CRP)

2. Emerging Marker: Procalcitonin (PCT)

3. Promising Markers:

- Interleukin 6 (IL-6)

- Protein membran : CD 64 CD !!b

- Circulating protein:

"eo#terin $n%otok&in #rotein '* ! (+i,+-mobilit,rou#-bo. !) "T-#ro*"P ("-terminal #ro-brain natriuretic

#e#ti%e)


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CREAC!I"E #R$!EIN %CR#&: %'&

Intro%uce% in !/0 analitcal met+o%e +a&%evelo#e% &ince !/41 a& inection marker

Tec+nolo, 3+i,+ &en&itive ultra &en&itive

+a& analitcal &en&itivit: 001 u,mL (m,L)Pro#ert (!):

7: !20-!40 kDalton 206 #e#ti%a can not

#a&& t+e barrier #lacenta Pro%uce% in liver tri,erin, b IL6 IL! T"89

T8 I8";


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CREAC!I"E #R$!EIN %CR#&: %(&

Pro#ert (2): Reco,nation activation ca#abilit ma

reco,nieek in%icate& atreatment ailure or %i&ea&e comorbi%it


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(hat is PC#??

PC> is the prohormone of the hormonecalcitonin 9ut are distinct proteins

Calcitonin is eIclusively produced 9y C1cells of the thyroid gland in response tohormonal stimuli, 0hereas

PC> can 9e produced 9y several cell types

and many organs in response to pro1in@ammatory stimuli, in particular 9y9acterial products


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#R$CALCI!$NIN %#C!&:

'i&tor: Intro%uce% in !/?4 a& a #ro+ormon #rotein

con&i&te% o !!6 a&am amino 7 !-!4

kDalton $ra !//0 : %evelo#e% a& a marker o bacterial

inection

Pro#ert (!): Pro%uction i& &timulate% b t+e #re&entation o

en%otok&in increa&e in 2 +r #eak in !2-24 +r

%ecrea&e &lo>l in 6-12 +r


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#R$CALCI!$NIN %#C!&: %(&

Pro#ert (2): Pro%uce% in C cell o tiroi% ,lan% un%er IL6

IL? T"89 re,ulation

"ormal con%ition : all PCT cleava,e% intocalcitonin

Inection : e.#re&&ion o ,ena Calc-! >ill

&timulate all t#e& o #arenc+m ti&&ue cell& torelea&e PCT


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#R$CALCI!$NIN %#C!&: %)&

Pro#erti :

=& &ecun%ar inlammation me%iator in+ibit

#ro&ta,lan%in trombok&an &inte&i& at

limo&it

Increa&in, level %e#an%& on t+e &ta,e o &e#&i&

"ormal: @ 005 n,mL (u,L) in bacterial

inection A 2 n,mL


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PC> reference rangesand "nterpretation of PC>serum or plasma levels


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Reeren& Level Ben&itivit B#e&ivicit

*en%er et al200? ("eonatalBettin,)

A 25 n,mL( IL 6 A 250

#,mL)

1! E ?? E

aini et al 2001(CommunitBettin,)

2!/ n,mL ?01 E 61?E

=n%reola et al2001($mer,encBettin,)

A 2 n, mL 11 F 5?4 E /? - /2 E

#erformance #C!


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$"DTJI" Li#o#ol&ac+ari%e com#onent o cell >all o

"e,ative ram *acillu& Btron, tri,,er to>ar% &e#&i& ca&ca%e

Detection:

! L=L (Limulu& =moebicte L&at):ver

&en&itive reliabel marker >it+ ,elatin L=L

%an c+romo,enic L=L

2 $== ($n%oto.in =ctivit =&&a): met+o%e

o C+emilumine&ent Level A 50 #,mL --- A

marker o ne,ative ,ram bacillu& inection


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Protein '* !: Cromo&omal nuklear #rotein 3late onset

proinflamatory cytokine. Secrete% bmakroa, culture >+ic+ &timulate% b

en%oto.in

Detection limit : 06 #,mL ($LIB=)

"$PT$RI": Derivat #teri%in in mono&itmakroa, culture

areker o inection (viral bacterial)

"T-#ro*"P:

Dierentiate : &urvivor v& non-&urvivor


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CD !!b: In ,ranula o ,ranuloct cito#la&mic --- A

e.ce&&ive activation >ill be mobilictometricCD 64: 8c-,amma rece#tor I unction to inte,rate t+e

innate a%a#tive immune reon&inection

ma up-regulation

arker netroil %etecte% b lo>ctometric

Bi&temik inectione.re&&i A2000

COMPARISON SEVERAL MARKERS


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ESR CBC CRP PCT

1 Specimen Wholeblood

(sitras)

Wholeblood

(EDTA)

Serum/Plasma

Serum/Plasma

2 Methode indirect(fibrinoen)

Directmanual

otomatic

Directmanual

otomatic

Directotomatic

! "ncreasin

Pattern

Slo#l$%

bac& tonormal in

#ee&s

'uic&%

muchinfluenced

b$ lots

conditions

'uic&%

bac& tonormal up

to no

stimuli

'uic&%

bac& tonormal up

to no

stimuli

Pea& leel s

normal

* 1%+,! * 1+,!- * . - ,

. 2-- *

Sepsis

COMPARISON SEVERAL MARKERS

ESR CBC CRP PCT


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ESR CBC CRP PCT

+ onfounder0

-se*

-ae-Plasma Protein

-Eritrosit

-etc

...

...

Tissue

necrosis

a Tiroid%

Plasmodium

3alciparum

4 AnaliticalPerform0

-Sensitiit$

-Spesifisit$

-Precisi

,Anal$tical time

Moderat

Moderat

Moderat

4- mnt

5ih

Moderat

5ih

1-,4-

mnt

5ih

5ih

5ih

6 !- mnt

5ih

5ih

5ih

6 !- mnt

7 ost lo# relatie relatie hih


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#hank @ou

Documents

Laboratory Diagnosis in Newborn Infectious Disease & Neonatal Sepsi