Multiple vital signs analysis algorithm detects systemic inflammatory response in premature infants with late-onset sepsis and necrotising enterocolitis.

Abstract

Commentary on: Mithal LB, Yogev R, Palac HL, Kaminsky D, Gur I, Mestan KK. Vital signs analysis algorithm detects inflammatory response in premature infants with late onset sepsis and necrotizing enterocolitis. Early Hum Dev. 2018 Feb; 117:83-89. https://doi.org/10.1016/j.earlhumdev.2018.01.008. Epub 2018 Jan 23. Neonatal sepsis substantially contributes to neonatal mortality and morbidity and presents a major public health challenge worldwide 1. Despite the decline in the incidence of late-onset sepsis (LOS) due to infection control measurements, it still disproportionately affects very low-birthweight (VLBW) infants causing significant morbidity, lifelong neurological impairments and prolonged hospitalisation 2, 3. The diagnosis of sepsis remains difficult due to its nonspecific clinical presentation which could be attributed to many other noninfectious aetiologies, as well as the lack of reliable laboratory biomarkers. Because of the potential dire consequences, clinicians have a low threshold for LOS treatment leading to antibiotic overuse in a large proportion of VLBW infants and its adverse effects such as increased antibiotic resistance, fungal infections, microbiota modification, necrotising enterocolitis (NEC) and death 4. NEC, defined as bowel infection, bacterial penetration and tissue destruction, presents with nonspecific signs at early stage, very often overlapping with sepsis 5. Both neonatal sepsis and NEC are associated with systemic inflammatory responses. The development of a reliable and specific method to detect an impending infection or systemic inflammatory response prior to the clinical deterioration has been of particular research interest in recent years 6, 7. Previous studies have shown that RALIS software with multiple vital signs monitoring was an effective tool in detecting sepsis 2.5 days earlier than the onset of the clinical suspicion of infection 8. The current study aimed to evaluate the performance of the revised RALIS algorithm in the detection of a systemic inflammatory response in LOS and NEC in preterm infants (23–32 GA). Vital sign data incorporated into the revised RALIS algorithm included heart rate, respiratory rate, temperature, desaturation events and bradycardia events. A score was generated (range: 0–10) and the clinical team was alerted if ≥5 for six consecutive hours. Premature infants with complete electronic vital sign data were included and classified according to the primary outcome into LOS, expanded LOS, NEC, culture-negative LOS or controls. This study consistently proved the effectiveness of the RALIS algorithm in detecting LOS and NEC with a mean alert of 33 hours before clinical suspicion, particularly emphasising its utility in excluding LOS with a high negative predictive value of 93%. Although sensitive, the positive diagnostic value in identifying LOS and NEC remained limited, showing a moderate PPV (67%) similar to that in previous reports 8. The authors note the study's limitations, mainly regarding the sample size and its retrospective nature. Thus, this study indicates the particular usefulness of the RALIS algorithm in identifying clinician concern ahead of clinical concern without consequence, which may more confidently aid the physician's decision-making with regard to withholding or discontinuing antibiotic treatment. This study adds additional data regarding the benefit of multiple sign monitoring algorithms in the prediction of neonatal infections; however, future prospective studies are warranted to investigate its association with existing or novel laboratory biomarkers, as well as its utility beyond the first month of life. https://ebneo.org/2019/05/late-onset-sepsis-necrotizing-enterocolitis/. The authors declare no financial or other conflict of interest.