Pediatrics Table 6. Clinical Score Clinical sign
Score
Lethargy
1
Tachycardia
1
Fever
1
Abdominal distension
1
Increased prefeed aspirate
1
Chest retraction
1
Grunting
2
The clinical signs showing LR+ >1 were considered for clinical score, score-1 was given for signs with LR+ between 1 & 2 and score 2 for signs with LR+ >2.
Table 7. Statistical Analysis of Clinical Score Score Sensitivity (%)
Specificity (%)
PPV (%)
NPV (%)
LR+
2
47
77
45
78
2
3
13
92
40
73
1.6
4
3
99
100
72
3
and 10 (6.2%) weighed >2.5 kg at birth with mean birth weight (mean ± SD) = 1,378 ± 507 g. The frequency of occurrence of apnea is maximum followed by lethargy and tachycardia. However, tachycardia, increased prefeed aspirates, increased respiratory rate and abdominal distension were more common in definite sepsis, whereas, refusal to feed, sick looking and hypothermia were more common in probable sepsis. But in no sepsis group, refusal to feed, increased prefeed aspirate and tachycardia predominated. In this study, central cyanosis, sclerema, seizures and bradycardia were not present in any group (Tables 2 and 3). It is found that, with respect to the symptomatic events (n = 210), two clinical signs were present in 94 events (44.8%), followed by one sign in 62 events (29.5%), three clinical signs in 34 events (16.2%) and ≥4 signs in 20 (9.5%) events, respectively. And out of 210 symptomatic events; in 60 (28.5%) events, blood culture was positive (definite Sepsis), in 34 (16%) events, sepsis screen was positive only (probable sepsis) and in 116 (55.5%) events, no sepsis was found. The sensitivity of clinical signs varied from 3 to 47% and specificity from 51 to 97%. The positive predictive value (PPV) ranges from 8.3 to 50%. Grunting is the only sign
having LR+ of >2. It showed that the combined clinical score of 2 and 3 had PPV of 45 and 40%, respectively. However, a clinical score of 4 gave a maximum PPV of 100% and LR+ of 3. So, this predictive ability is significantly more than any of the clinical signs in isolation. DISCUSSION Infections are the single largest cause of neonatal deaths globally. Klebsiella pneumoniae and Staphylococcus aureus were the two most common organisms isolated. Based on the onset, neonatal sepsis is classified into two major categories: Early-onset sepsis, which usually presents with respiratory distress and pneumonia within 72 hours of age and late-onset sepsis that usually presents with septicemia and pneumonia after 72 hours of age. Clinical features of sepsis are nonspecific in neonates and a high index of suspicion is required for timely diagnosis. Although blood culture is the gold standard for the diagnosis of sepsis, culture reports would be available only after 48-72 hours. In our study, there is male preponderance, which is due to the prevalent custom of taking male babies preferentially to healthcare institutions and also because female babies are immunologically more competent.9,10 Gerdes et al11 reported that male infants are four times vulnerable to sepsis than females. Also majority of this study group are preterms, which may be attributed to the occurrence of more number of premature deliveries in our institution hence they are more prone for sepsis.2 It is found that the mean age of onset of symptomatic events is 10.7 ± 6.8 days. Majority occurred between 4-7 days of life. This is in accordance with other studies.13 Also apnea, lethargy and tachycardia were the common clinical signs present in babies at enrollment for evaluation of sepsis which is similar to the study by Fanaroff et al.14 Any illness in neonates is bound to present with a constellation of clinical signs, hence, majority of symptomatic events presented with two clinical signs per event. Sixty (28.5%) events belong to the culture-positive group hence classified under definite sepsis category, which correlates with the report by Singh et al.15 Gram-negative sepsis predominates in our study (Table 4) with Klebsiella being the most frequent gramnegative isolate and S. aureus the gram-positive one. Kuruvilla et al16 reported similar isolates in his study in 1998. However, the incidence of CoNS is low in our set up. It is seen from Table 4 that the sensitivity of
Indian Journal of Clinical Practice, Vol. 23, No. 10 March 2013
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