Estrategias para el diagnóstico de sepsis neonatal tardía
Palabras clave:
SEPSIS, RECIÉN NACIDO
Resumen
La sepsis neonatal es una enfermedad frecuente y muy grave en los neonatos internados que requiere un diagnóstico rápido para tomar una conducta adecuada.
Se plantea como objetivos del presente trabajo la evaluación de variables clínicas y paraclínicas para mejorar el diagnóstico de sepsis neonatal tardía mediante la razón de verosimilitud (RV) y de la probabilidad posprueba. En un estudio retrospectivo se analizaron 47 historias de neonatos con el diagnóstico clínico de sospecha de sepsis. Las variables estudiadas para mejorar el diagnóstico fueron: antecedentes de cirugía, acidosis metabólica progresiva en pacientes bien ventilados y hepatomegalia como datos clínicos; hiperglucemia, número de glóbulos blancos y plaquetas como información rápida de laboratorio. Se aceptó como definición de sepsis la información clínica con la que se hizo el diagnóstico de sepsis más el hemocultivo positivo. Se calculó para cada una de ellas la RV. Usando el nomograma de Fagán se estimó cómo mejoraba el diagnóstico cuando una de las variables estaba presente.
Para una prevalencia de sepsis en la unidad de 34% se encontró que las variables estudiadas mejoraban la probabilidad de sepsis. El antecedente quirúrgico, la acidosis y la leucopenia alcanzan una probabilidad de 62,6%, la hepatomegalia 57% y la hiperglucemia, la leucocitosis y la plaquetopenia 45%. Se concluye que frente a un neonato con clínica de sospecha de sepsis que presente algunas de las variables que se estudian, tiene 50% o más de probabilidades de tener una sepsis y se aconseja tomar una conducta activa.
Citas
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24) Gabay C, Kushner I. Acute-fase proteins and other systemic responses to inflammation. N Engl J Med 1999; 340(6): 448-54.
25) Aoki N, Xing Z. Use of citokines in infection. Expert Opin Emerg Drugs 2004; 9(2): 223-36.
26) Black S, Kushner I, Samols D. C-reactive protein. J Biol Chem 2004; 279(47): 48487-92.
27) Rodwell RL, Leslie AL, Tudehope DI. Early diagnosis of neonatal sepsis using a hematologic scoring system. J Pediatr 1988; 112(5): 761-7.
28) Fowlie PW, Schmidt B. Diagnostic tests for bacterial infection from birth to 90 days: a sistematic review. Arch Dis Child Fetal Neonatal Ed 1998; 78(2): F92-8.
29) Wagle S, Grauaug A, Kohan R, Evans SF. C-reactive protein as a diagnostic tool of sepsis in very immature babies. J Paediatr Child Health 1994; 30(1): 40-4.
30) Ng PC, Cheng SH, Chui KM, Fok TF, Wong MY, Wong W, et al. Diagnosis of late onset neonatal sepsis with cytokines, adhesion molecule, and C-reactive protein in preterm very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 1997; 77(3): F221-7.
31) NG PC, Li K, Wong RP, Chui KM, Wong E, Fok TF. Neutrophil CD64 expression: a sensitive diagnostic marker for late-onset nosocomial infection in very low birthweight infants. Pediatr Res 2002; 51(3): 296-303.
32) de-Bont ES, Martens A, van-Raan J, Samson G, Fetter WP, Okken A, et al. Diagnostic value of plasma levels of tumor necrosis factor á(TNF á) and interleukin-6(IL-6) in newborn with sepsis. Acta Paediatr 1994; 83(7): 696-9.
33) Küster H, Weiss M, Willeitner AE, Detlefsen S, Jeremias E, Zbojan J, et al. Interleukin-1 receptor antagonist and interleukin-6 for early diagnosis of neonatal sepsis 2 days before clinical manifestation. Lancet 1998; 352(9136): 1271-7.
34) Benitz WE, Han MY, Madan A, Ramachandra P. Serial serum C-reactive protein levels in the diagnosis of neonatal infection. Pediatrics 1998; 102(4): E 41.
35) Kawamura M, Nishida H. The usefulness of serial C-reactive protein measurement in managing neonatal infection. Acta Paediatr 1995: 84(1):10-3.
36) Jordan JA, Durso MB. Comparison of 16S rRNA gene PCR and BACTEC 9240 for detection of neonatal bacteremia. J Clin Microbiol 2000; 38(7): 2574-8.
2) Stoll JB, Gordon T, Korones SB, Shankaran S, Tyson JE, Bauer CR, et al. Late-onset sepsisin very low birth weight neonates: a report from the National Institute of Child Health and Human Development Neonatal Research Network. J Pediatr 1996; 129(1): 63-71.
3) Klein JO. Bacterial sepsis and meningitis. In: Remington and Klein. Infectious Diseases of the Fetus and Newborn Infants. 5th ed. Philadelphia: WB Saunders, 2001: 943-98.
4) Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, et al. To tap or no to tap: high likelihood of meningitis without sepsis among very low birth weight infants. Pediatrics 2004; 113(5): 1181-6.
5) Stoll BJ, Hansen NI, Adams-Chapman I, Fanaroff AA, Hintz SR, Vohr B, et al. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. JAMA 2004; 292(19): 2357-65.
6) Murphy DJ, Hope PL, Johnson A. Neonatal risk factors for cerebral palsy in very preterm babies: case-control study. BMJ 1997; 314(7078): 404-8.
7) Kaufman D, Fairchild KD. Clinical microbiology of bacterial and fungus sepsis in very-low-birth-weight infants. Clin Microbiol Rev 2004; 17(3): 638-80.
8) Kilpatrick L, Harris MC. Cytokines and inflamatory response in the fetus and neonate. In: Polin RA, Fox WW, Abman SH. Fetal and neonatal physiology. 3rd ed. Philadelphia: WB Saunders, 2004: 1555-72.
9) Fanaroff AA, Korones SB, Wright LL, Verter J, Poland RL, Bauer CR, et al. Incidence, presenting features, risk factors and significance of late onset septicemia in very low birth weight infants. Pediatr Infect Dis J 1998; 17(7): 593-8.
10) Bonadio WA, Hennes H, Smith D, Ruffing R, Melzer-Lange M, Lye P, et al. Reliability of observation variables in distinguishing infectious outcome of febril young infants. Pediatr Infect Dis J 1993; 12(2): 111-4.
11) Singh AS, Dutta S, Narang A. Predictive clinical scores for diagnosis of late onset neonatal septicemia. J Trop Pediatr 2003; 49(4): 235-9.
12) Gordon A, Isaacs D. Late-onset infection and the role of antibiotic prescribing policies. Curr Opin Infect Dis 2004; 17(3): 231-6.
13) Moyer VA, Kennedy KA. Understanding and using diagnostic tests. Clin Perinatol 2003; 30(2): 189-204.
14) Kellogg JA, Ferrentino FL, Goodstein MH, Liss J, Shapiro SL, Bankert DA. Frequency of low level bacteremiain infants from birth to two months of age. Pediatr Infect Dis J 1997; 16(4): 381-5.
15) Vecchio TJ. Predictive value of a single diagnostic testin unselected populations. N Engl J Med 1966; 274(21): 1171-3.
16) Altman DG. Practical Statistics for medical research. London: Chataman & Hall, 1995: 415.
17) Ingelfinger JA, Mosteller F, Thibodeau LA, Ware JH. Biostatistics in Clinical Medicine. New York: Macmillan, 1983: 1.
18) Katz MA. A probability graph describing the predictive value of highly sensitive diagnostic test. N Engl J Med 1974; 291(21): 1115-6.
19) Fagan TJ. Nomogram for Bayes’s Theorem. N Engl J Med 1975; 293(5): 257.
20) Motulsky H, Stannard P, Neubig R, Ploatt M, Pilkington J, Searle P. GraphPad Prism. Versión 2.0. San Diego: GraphPad Software, 1994.
21) Martell M, Fescina RH, Nieto F, Martínez G, Martínez M, Delgado L, et al. Introducción a la metodología de la investigación científica.2ª ed. Montevideo: Oficina del Libro FEFMUR, 2003: 121.
22) Fitzgerald MJ, Goto M, Myers TF, Zeller WP. Early metabolic effects of sepsisin the preterm infant: lactic acidosis and increased glucose requirement. J Pediatr 1992; 121(6): 951-5.
23) Mizock BA, Falk JL. Lactic acidosis in critical illness. Crit Care Med 1992; 20(1): 80-93.
24) Gabay C, Kushner I. Acute-fase proteins and other systemic responses to inflammation. N Engl J Med 1999; 340(6): 448-54.
25) Aoki N, Xing Z. Use of citokines in infection. Expert Opin Emerg Drugs 2004; 9(2): 223-36.
26) Black S, Kushner I, Samols D. C-reactive protein. J Biol Chem 2004; 279(47): 48487-92.
27) Rodwell RL, Leslie AL, Tudehope DI. Early diagnosis of neonatal sepsis using a hematologic scoring system. J Pediatr 1988; 112(5): 761-7.
28) Fowlie PW, Schmidt B. Diagnostic tests for bacterial infection from birth to 90 days: a sistematic review. Arch Dis Child Fetal Neonatal Ed 1998; 78(2): F92-8.
29) Wagle S, Grauaug A, Kohan R, Evans SF. C-reactive protein as a diagnostic tool of sepsis in very immature babies. J Paediatr Child Health 1994; 30(1): 40-4.
30) Ng PC, Cheng SH, Chui KM, Fok TF, Wong MY, Wong W, et al. Diagnosis of late onset neonatal sepsis with cytokines, adhesion molecule, and C-reactive protein in preterm very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 1997; 77(3): F221-7.
31) NG PC, Li K, Wong RP, Chui KM, Wong E, Fok TF. Neutrophil CD64 expression: a sensitive diagnostic marker for late-onset nosocomial infection in very low birthweight infants. Pediatr Res 2002; 51(3): 296-303.
32) de-Bont ES, Martens A, van-Raan J, Samson G, Fetter WP, Okken A, et al. Diagnostic value of plasma levels of tumor necrosis factor á(TNF á) and interleukin-6(IL-6) in newborn with sepsis. Acta Paediatr 1994; 83(7): 696-9.
33) Küster H, Weiss M, Willeitner AE, Detlefsen S, Jeremias E, Zbojan J, et al. Interleukin-1 receptor antagonist and interleukin-6 for early diagnosis of neonatal sepsis 2 days before clinical manifestation. Lancet 1998; 352(9136): 1271-7.
34) Benitz WE, Han MY, Madan A, Ramachandra P. Serial serum C-reactive protein levels in the diagnosis of neonatal infection. Pediatrics 1998; 102(4): E 41.
35) Kawamura M, Nishida H. The usefulness of serial C-reactive protein measurement in managing neonatal infection. Acta Paediatr 1995: 84(1):10-3.
36) Jordan JA, Durso MB. Comparison of 16S rRNA gene PCR and BACTEC 9240 for detection of neonatal bacteremia. J Clin Microbiol 2000; 38(7): 2574-8.
Publicado
2005-12-30
Cómo citar
1.
Perotti E, Cazales C, Martell M. Estrategias para el diagnóstico de sepsis neonatal tardía. Rev. Méd. Urug. [Internet]. 30 de diciembre de 2005 [citado 17 de noviembre de 2024];21(4):314-20. Disponible en: http://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/796
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