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Complete Blood Count and Differential in Diagnosis of Early Onset Neonatal Revista Română de Medicină de Laborator Vol. 25, Nr. 1, Ianuarie, 2017 101 Course Notes DOI: 10.1515/rrlm-2016-0042 Complete blood count and differential in diagnosis of early onset neonatal sepsis Parametrii hemogramei complete și a formulei leucocitare în diagnosticul sepsisului neonatal cu debut precoce Maria Livia Ognean1, Adrian Boicean2, Floredana-Laura Șular3,*, Manuela Cucerea3 1Clinical County Emergency Hospital Sibiu, Romania, 2Faculty of Medicine, University Lucian Blaga, Sibiu, Romania, 3University of Medicine and Pharmacy Tîrgu Mureș, Romania Received: 2th June 2016; Accepted: 14th November 2016; Published: 21th November 2016. Neonatal sepsis - incidence, morbidity with a mortality rate that ranges from 13 to 60% and mortality (6,7) in spite of improved antibiotic therapy and care and an increased morbidity in survivors. Neonatal sepsis, one of the main causes of neo- “Suspected sepsis” is one of the most fre- natal morbidity and mortality (1), is a complex quently encountered diagnosis in neonatology clinical syndrome occurring in 1-8.6/1000 live because: a) a large number of newborns are eval- births (2) as a result of the systemic inflamma- uated for early or late sepsis based on risk factors tory response to infection during the neonatal and for fear of missing a correct diagnosis and a period (3). Early onset sepsis (EOS) is defined prompt treatment (8); b) in neonates, the clini- as sepsis occurring during the first 72 hours of cal signs of infection are not specific, late, and life as a fetal response to an ascending infection the differential diagnosis with neonatal respira- (from the birth canal) or to the hematogenous tory distress syndrome, aspiration syndromes, dissemination of a maternal infection (4). or neonatal maladaptation to extrauterine life Sepsis is a complex condition initiated by a is difficult (8-10); c) blood culture - the gold- pathogen and mediated by cytokines followed by en standard in neonatal sepsis diagnosis - pro- immune, inflammatory, and coagulation homeo- vides late information, has a poor accuracy, and stasis disturbances, its evolution being dictated is not universally available (11); and d) we do by a complicated balance between pro inflam- not have yet an ideal diagnostic tool for neonatal matory and anti inflammatory factors (5) Most infection (12). Therefore, diagnosis of neonatal of the short and long-term complications of the sepsis is still a challenge for neonatal medicine. neonatal sepsis are strictly related to inflamma- Antibiotic therapy is often initiated based upon tory mediators. Neonatal sepsis is associated clinical suspicion and/or the presence of risk * Corresponding author: Floredana-Laura Șular, University of Medicine and Pharmacy Tîrgu Mureș, Gheorghe Marinescu 38, Tîrgu Mureș, Romania e-mail: [email protected] 102 Revista Română de Medicină de Laborator Vol. 25, Nr. 1, Ianuarie, 2017 factors, leading to excessive antibiotic therapy. Current consensus of neonatal sepsis lab- Very often the diagnosis criteria for neonatal oratory diagnosis sepsis consists in documenting an infection in a newborn with severe systemic disease in which Despite hundreds of published studies, there is all possible noninfectious explanations for the still no consensus regarding the best screening patient’s altered physiological status are either test or panel of tests for rapid detection of neo- ruled out or unlikely (13). natal sepsis. Recently, new acute phase proteins, cytokines, cell surface antigens, and bacterial Blood culture - the “gold standard” test genome are used to improve the neonatal sepsis diagnosis but data are still under evaluation and The “gold standard”, definitive test for neonatal sep- most of these tests are either not clinically avail- sis is the isolation of the pathogen from blood (9). able or they are expensive (9, 16). However, its accuracy is influenced by multiple fac- tors a) contamination during sampling; b) sampling Complete blood count and differential - after antibiotic therapy was started; c) insufficient reference values and influencing factors sampling volume; d) low colony count bacteriemia (14). Accuracy of the blood culture varies between Evaluation of complete blood count (CBC) and 8 and 73% in various studies (6, 11, 15). differential was the first test used to diagnose ne- onatal sepsis, hematological indices still being Ideal markers for neonatal sepsis the most extensively used in practice, currently in association with new markers for infection As seen by experts, the ideal marker for neonatal (11, 12, 17, 18). The different rate of neutrophil sepsis must fulfill the following characteristics: release from bone marrow into circulation, the - Clinically, it must have well defined reference egress rate of the neutrophils from blood into the values that allow interlaboratory comparison, tissues, and their distribution in circulation and sensibility towards 100%, specificity over tissues are responsible for the morphological and 85%, positive predictive value over 85%, concentration abnormalities of the circulating negative predictive value over 100%, pow- neutrophils seen in neonatal sepsis (17). er to detect infection in early stages, ability Since 1979, reference values for blood neu- to differentiate between different types of trophil concentration in late preterm and term pathologic agents (viruses versus bacteria, for infants during the first 700 hours of life defined example), and allow guidance and monitoring by Manroe et al. were extensively used for of the antibiotic therapy (6, 9, 10); EOS evaluation. Mouzinho et al. (19) defined - In the laboratory, the ideal marker must be a the reference values, upper and lower limits stable product, with a time window adequate for blood neutrophil concentration in very low for sampling (sustained increase and decrease birth weight (VLBW) preterm infants. The bru- of its values within 48 hours after the onset of tal transition from the protective intrauterine the clinical manifestations), must be quantita- environment to extrauterine life is characterized tive, allow use of small sample volumes, the by extreme physiological changes required for measurement method must be simple, rapid, survival. Some of the metabolic and physiolog- with comparable results between laboratories, ical processes continue to undergo changes dur- and with a low cost (16). ing the first days of life and these may influence sometimes dramatically the results offered by Revista Română de Medicină de Laborator Vol. 25, Nr. 1, Ianuarie, 2017 103 laboratory tests. These influences must be con- some neonatal red blood cells and/or by the high sidered when interpreting the values offered by neonatal normoblast count resulting in a falsely laboratory tests (9). Therefore, beyond individ- increased number of white blood cells; incorrect ual variability, a certain value of a laboratory blood : anticoagulant ratio in small tubes may test must not be considered as static. Schmutz also give rise to errors (23, 24). et al. (18) showed that the neutrophil count in- Interpretation of the CBC parameters as nor- creases in the first hours after birth and peaks at mal or abnormal and use of different classifica- 6-8 hours for infants ≥ 28 weeks gestation, and tion systems makes the interpretation of the bor- later, at 24 hours, in those < 28 weeks gestation. derline or grossly abnormal values difficult (22). Immature/total neutrophil (I:T) ratio, one of the most valuable hematological indices, is ≤ 0.16 at Complete blood count and differential - birth and decreases to 0.12 at 72 hours of life in utility in screening for early onset sepsis healthy neonates (20). After birth, the absolute Total leukocyte count (TLC), total neutrophil immature neutrophil count follows the same pat- count, ANC, immature neutrophil count, imma- tern as the absolute neutrophil count (ANC), reg- ture/total neutrophil ratio (I:T ratio), immature/ istering a peak value at approximately 12 hours of mature neutrophil ratio (I:M ratio), neutrophil life (20). Labor and catecholamine release, as part degenerative changes (vacuolization, toxic gran- of the adaptation process to extrauterine life, may ulations, and Döhle bodies), and platelet count be responsible for the transient increase of leuko- are the most used hematological parameters for cyte and neutrophil count in the first day of life EOS evaluation (7,9). Most of the hematological (18,21). In most of the EOS cases the leukocyte screening panels for EOS use a total leukocyte count, the leukocyte characteristics, and indices count < 5000 cells/mm3 or > 20.000 cells/mm3, become abnormal around 12 hours of life (10, 22). an I:T ratio > 0.2, and total neutrophil counts The peripheral smear is useful for EOS diag- outside the normal range (7, 8). nosis as it identifies characteristic morphologic The vast majority of studies in the literature changes of the neutrophils and monocytes: ab- conclude that hematological indices have a low normal density of the nuclear chromatin, toxic sensibility and specificity in identifying EOS, granulations, vacuolization, Döhle bodies, left being more useful in identifying newborns with shift (23). However, the method is time consum- low risk for sepsis. Six to 12 hours are necessary ing, requires manual examination and experi- before the effect of the inflammatory response ence, the results are biased by subjective inter- on the number and ratio of immature and mature pretation, reduced reproducibility, and it is based neutrophil occurs (9, 17, 22). An extensive
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