|Year : 2013 | Volume
| Issue : 3 | Page : 110-113
Hematologic scoring system (HSS): A guide to decide judicious use of antibiotics in neonatal septicemia in developing countries
Arijit Majumdar, Angshuman Jana, Anirban Jana, Soumali Biswas, Swagata Bhattacharyya
Department of Pathology, Dr. Bidhan Chandra Roy Post Graduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
|Date of Web Publication||19-Dec-2013|
Charaktala, P. O. Andul, Howrah 711 302, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Septicemia is one of the major causes of neonatal morbidity and mortality. Objective- The objective of our study was to determine the role of hematologic scoring system (HSS) in early diagnosis of neonatal septicemia and provide an effective guideline in decision making regarding judicious use of antibiotics.
Materials and Methods: The study was done taking 60 neonates admitted in the hospital. The hematological parameters were studied in all of them. Blood cultures were performed as gold standard for diagnosing septicemia.
Results: Analysis of the hematologic profiles in the light of the HSS found that an abnormal immature to total neutrophil (I:T) ratio followed by an abnormal immature to mature neutrophil (I:M) ratio were the most sensitive indicators in identifying infants with sepsis. The study also found that the higher the score the greater the certainty of sepsis being present. The score ≥ 4 was more reliable as a screening tool than any individual hematological parameter.
Conclusion : HSS is rapid, easy to perform, cost-effective screening tool for early diagnosis of neonatal sepsis and thereby helps in making of decisions regarding judicious use of antibiotics.
Keywords: Antibiotics, hematologic scoring system, neonatal septicemia
|How to cite this article:|
Majumdar A, Jana A, Jana A, Biswas S, Bhattacharyya S. Hematologic scoring system (HSS): A guide to decide judicious use of antibiotics in neonatal septicemia in developing countries. J Appl Hematol 2013;4:110-3
|How to cite this URL:|
Majumdar A, Jana A, Jana A, Biswas S, Bhattacharyya S. Hematologic scoring system (HSS): A guide to decide judicious use of antibiotics in neonatal septicemia in developing countries. J Appl Hematol [serial online] 2013 [cited 2019 Nov 18];4:110-3. Available from: http://www.jahjournal.org/text.asp?2013/4/3/110/123310
| Introduction|| |
Systemic infection in the newborn is the commonest cause of neonatal mortality.  Neonatal septicemia is characterized by clinical signs and symptoms accompanied by bacteremia in the 1 st month of life.  The newborn especially the premature are prone to serious infections because most of the time the signs of these infections may be absent or subtle and hard to detect. Thus, fatal septicemia may occur with little warning.  Hence, the timely diagnosis of sepsis in neonates is critical as the illness can be rapidly progressive and in some instances fatal.  Though Group B beta hemolytic Streptococci are the commonest cause of neonatal sepsis in the western countries, the gram negative rods are the leading ones in the developing countries like ours.  Blood culture is the gold standard for diagnosing bacteremia, but it is time consuming (requires minimum 48-72 h), gives positive results in 10-60% cases and the facilities are not available in under-resourced laboratories. The present study was undertaken to assess the role of hematologic scoring system (HSS) in early diagnosis of neonatal septicemia in a cost-effective manner particularly in developing countries like India.
| Materials and Methods|| |
The present study is a prospective analysis of the hematologic profiles of 60 neonates admitted in the neonatal care unit of this hospital between November 2011 and October 2012. Infants were enrolled in the study if there were predisposing perinatal factors or if there was clinical suspicion of sepsis. Neonates who were severely jaundiced due to blood group incompatibilities were excluded from this study. After taking a careful history specified questionnaire was designed and the detailed information was recorded by the investigator. For comparison neonates reporting to the department for immunization or attending well baby clinics were taken as controls. Blood sample was obtained by peripheral venipuncture in an ethylenediaminetetraacetic acid (EDTA) vial. The total leukocyte counts were counted on a Sysmex counter (Sysmex K21) and corrected for nucleated red blood cells. Differential counts were performed on Leishman stained blood smears by counting at least 200 cells. A band was defined as a neutrophil in which the nucleus was indented by more than one half, but in which the isthmus between the lobes was wide enough to reveal two distinct margins with nuclear material between.  All films were reviewed by a pathologist blinded to the infection status of the infants. Degenerative morphologic changes in neutophils were graded 0 to 4+ according to Zipursky et al.  Immature neutrophils include promyelocyte, myelocyte, metamyelocytes, and band form. Degenerative changes in neutrophils include vacuolization, toxic granulations, and Dohle bodies [Figure 1] and [Figure 2] The hematological findings were analyzed according to the hematologic scoring system (HSS) of Rodwell et al.  The HSS assigns a score of one for each of the seven criteria found to be significantly associated with sepsis [Table 1] with one exception. An abnormal total count is assigned a score of 2 instead of 1, if no mature polymorphs are seen on the peripheral smear to compensate for the low I:M ratio. Sensitivity, specificity, and positive and negative predictive values (PPVs and NPVs) were evaluated for each of the seven criteria of HSS using standard statistical methods.
|Figure 1: Band form: Leishman stained smear under oil immersion objective (×1000)|
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|Figure 2: Cytoplasmic vacuolation: Leishman stained smear under oil immersion objective (×1000)|
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The blood required for culture sensitivity was sent to the Department of Microbiology in the conventional blood culture bottles and the reports were obtained after 72 h.
The diagnosis of sepsis was made when there were positive findings on blood culture. Infant were classified as having probable infection when the blood culture was negative, but there was a strong clinical history for infection. Infants were considered to be normal when the blood culture was negative and there was no strong clinical evidence of infection.
Standard statistical methods were used in evaluation and P < 0.05 was considered as statistical significant difference.
Informed consent was taken from each and every patient party before including the patients in our study. There was no patient party refused to participate in the study.
The research work was approved by the institutional ethical committee.
| Results|| |
Based on the clinical history and laboratory investigations, the study population (60 neonates) was divided into three groups: Sepsis (n = 20), probable infection (n = 30), and non-infection (n = 10) [Table 2]. The patients having culture positivity were within the sepsis group. The patients with clinical suspicion, but no culture positivity were probable infection and the patients having neither positive culture report nor clinical features of sepsis were termed as non-infective.
In our study, the male-female ratio was (M:F) 1:1, but among the children with sepsis (n = 20) the ratio was 2:1.
The blood culture reports of 20 confirmed sepsis cases (33.33%) reveal the commonest organism is Escherichia More Details coli followed by Klebsiella, Pseudomonas, beta-hemolytic Streptococci.
[Table 3] shows performance of individual hematological findings in 20 proven cases of sepsis. This reveals each of an I:T ratio >0.2 and an I:M ratio >0.3 is having sensitivity 100%. Platelet count <1,00,000/mm 3 is of specificity 85% and NPV 92%. The degenerative changes of neutrophils had no significant association with sepsis.
|Table 3: Performance of hematologic scoring system in 20 proven cases of sepsis |
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| Discussion|| |
Neonatal diagnosis may be difficult as the early signs of sepsis may be subtle and different at different gestational ages.  The definitive diagnosis of septicemia is made by a positive blood culture, which requires a minimum of 48-72 h and yields a positive result in only 10-60% of cases. 
Inability to adequately exclude the diagnosis of neonatal sepsis can result in unnecessary and prolonged exposure of the newborn to antibiotics. Thus, laboratory tests that assist the clinician in diagnosis of infection in neonates have considerable relevance. ,
Aggarwal et al., reported that sepsis was the commonest cause of neonatal mortality and was responsible for 30-50% of the total neonatal deaths each year in developing countries. The incidence of neonatal sepsis was reported to be 38 per 1,000 live births in tertiary care institutions. 
Dulay et al., studied neonatal hematological indices and assessed sepsis categorization in all 68 neonates. Laboratory criteria were based on modification of the criteria of Rodwell et al. He found that early-onset neonatal sepsis (EONS) and white blood cell (WBC) count and absolute neutrophil count (ANC) were not significant. In contrast, the associations with absolute band count (ABC), hematocrit, hemoglobin, bandemia, lymphocytes, and I:T ratio continued to remain significant. 
Shirazi et al., studied 138 neonates with suspected sepsis. They evaluated the usefulness of white blood cell count and C-reactive protein as an early indicator of neonatal septicemia. The advantage of HSS is that it is easy to perform and applicable to all infants, including those who have received antibiotics. 
The findings of our study regarding individual hematological parameters were in consistent with the others. From our study we see the total leukocyte count has little significance in diagnosing sepsis because of its wide variation in values. Total polymorphonuclear (PMN) count, immature PMN had low specificity and PVV. So, these should not be considered alone as a diagnostic test. Considering the morbidity and mortality the tests having high sensitivity and NPV (I:T >0.2 and I:M >0.3) are the most desirable as all neonatal sepsis cases should be identified. However, no single test is adequate to diagnose neonatal sepsis, but when the individual hematological parameters were counted in the form of HSS, a very effective screening method was developed. Though the score ≥3 is highly sensitive, but considering the higher specificity and PPV the score ≥4 is considered as the more reliable screening tool for the diagnosis of sepsis.
| Conclusion|| |
The HSS increases the diagnostic accuracy of the complete blood cell count as a screening test for sepsis and simplifies and standardizes its interpretation. The early diagnosis of neonatal sepsis with the help of HSS may provide a guideline to decisions regarding antibiotic therapy and thereby minimize the risk of emergence of resistant organisms due to misuse of antibiotics.
Besides small sample size and shorter duration the other limitation of our study is that readily achievable complete blood count and leukocyte differential assays have relatively poor specificity for diagnosing sepsis. The associated band count and leftward shift of myeloid immaturity measurements may improve diagnostic yield, but their subjective measurement is problematic. Therefore, the need persists for improved diagnostic indicators of neonatal sepsis. Here we did not include the other parameters of the sepsis screen such as micro-erythrocyte sedimentation rate (ESR) and test for C-reactive protein. Moreover, recently the light has been started thrown on the leukocyte surface marker like CD 64 quantitation. But in the developing country like ours, the role of hematologic scoring system is still present.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]