Neonatal sepsis is a clinical syndrome of bacteremia characterized by systemic signs and symptoms in first month of life. It is a common disorder affecting 1.1 to 2.7% of all neonates.
Neonatal sepsis identification is difficult through clinical presentation alone, so hematological indices and biochemical markers of inflammation, such as C-reactive protein (CRP) are now routinely used in clinical practice as they can aid in the diagnosis of neonatal sepsis. However the gold standard for diagnosis of neonatal sepsis remains blood culture despite its problems.
As neonatal sepsis can be rapidly fatal if left untreated, so once it is suspected, highly effective antibiotic therapy must be used and delay in the provision of care must be minimized.
Polyclonal intravenous immunoglobulin (IVIG) significantly reduces mortality and is a promising adjuvant in the treatment of neonatal sepsis and septic shock. However, the totality of the evidence is insufficient to support its benefit. Adjunctive therapy with monoclonal IVIGs remains experimental.
Exchange transfusion (ET) may be beneficial as a last resort in neonates with severe sepsis, particularly in those who are failing appropriate antibiotics and full supportive therapy, but the evidence is weak.
Hence, the aim of this study is to evaluate the role of intravenous immunoglobulin and exchange transfusion as an adjunctive therapy in treatment of neonatal sepsis compared to antibiotic therapy alone, aiming to set up protocol for management of neonatal sepsis in neonatal intensive care unit (NICU) of Benha University Hospital.
To achieve this target, we prospectively studied a series of 30 septic neonates born at or referred to Benha University Hospital and admitted to NICU from November 2012 to May 2013.
Sepsis was diagnosed using the hematological scoring system (HSS) and CRP. All neonates enrolled in this study received antibiotic therapy and other supportive measures then were divided into three groups: Group I: (No=10) Includes neonates who received IVIG in addition, group II: (No=10) Includes neonates who received ET with fresh whole blood in addition and group III: (No=10) Includes neonates who received antibiotics and other supportive therapy alone.
All neonates were subjected to the following: Careful history taking, full clinical examination and the following investigations: Complete blood count (CBC), CRP and blood culture.
The three groups were compared regarding: Gestational age, birth weight, sex, mode of delivery, provisional diagnosis and complications.
- Results revealed the following:
Out of these thirty neonates, there were 14 males (46.66%) and 16 females (53.33%). The mean gestational age was (36.1±2.9 weeks) of which 12 were preterm (40%) and 18 were term (60%). The mean birth weight was (2.5±0.61 kg.). The mode of delivery was normal vaginal delivery in 9 neonates (30%) and cesarean section in 21 neonates (70%). There were no significant differences regarding sex, gestational age, birth weight and mode of delivery between the three groups (P>0.05).
The age of onset of sepsis in all cases ranged from day 1 to day 30. Only one case presented with early onset sepsis (EOS), while all others presented with late onset sepsis (LOS).
All neonates were admitted in NICU with different presentations then acquired sepsis through their stay. It was observed that respiratory distress syndrome (RDS) was the commonest presentation in 13 neonates (43.3%) followed by hypoxic ischemic encephalopathy (HIE) in 8 neonates (26.6%), there were no significant differences between the three groups.
Blood culture showed that 9 cases were gram positive cocci (30%), 5 cases were gram negative bacilli (16.6%) and 5 cases were candida (16.6%), while the remaining 11cases showed no growth (36.6%), there were no significant differences between the three groups.
Cases that were subjected to exchange transfusion were critically ill. This is proved by significant higher heart rate, their need to assisted ventilation and blood transfusion and significantly high HSS and CRP.
After ET, temporary clinical improvement and significant reduction of HSS and CRP were noticed compared to antibiotic group, but the overall mortality was (80%).
IVIG treatment resulted in early clinical improvement and significant reduction of HSS and CRP compared to antibiotic group, with overall mortality (30%).
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