title: A prospective study of the sensitivity, specificity and diagnostic performance of soluble intercellular adhesion molecule 1, highly sensitive C-reactive protein, soluble E-selectin and serum amyloid A in the diagnosis of neonatal infection.
abstract: BACKGROUND
  Diagnosis of neonatal infection is difficult, because of it's non-specific clinical presentation and the lack of reliable diagnostic tests. The purpose of this study was to examine the potential diagnostic value of serum soluble intercellular adhesion molecule-1 (sICAM-1), soluble E-selectin (sE-selectin), highly sensitive C-reactive protein (hsCRP) and serum amyloid A (SAA) measurements, both individually and in combination in the setting of a neonatal intensive care unit.
  
  
  METHODS
  219 consecutive serum samples were taken from 149 infants undergoing sepsis work up in a neonatal intensive care unit. Clinical diagnosis was established in a prospective manner, blind to the results of the study measurements. Infants were classified by an experienced paediatrician as infected or not-infected, one week after presentation. Classification was based on clinical presentation, routine laboratory and radiological investigations and response to therapy. The infected group were sub-classified as (a) culture positive infection or (b) culture negative infection. sICAM-1, sE-selectin, hsCRP and SAA levels were determined from stored serum samples after diagnosis was established. Further sub-group analysis of results was undertaken according to early or late onset of infection and preterm or term status. Statistical analysis utilised Mann Whitney U test and ROC curve analysis.
  
  
  RESULTS
  There were significantly increased serum levels of sICAM-1, hsCRP, E selectin (p < 0.001) and SAA (p = 0.004) in infected infants compared with non-infected. ROC curve analysis indicated area under the curve values of 0.79 (sICAM-1), 0.73 (hsCRP), 0.72 (sE-selectin) and 0.61 (SAA). ROC curve analysis also defined optimum diagnostic cut-off levels for each measurement. The performance characteristics of sICAM-1, hsCRP and sE-selectin included a high negative predictive value (NPV) for culture positive infection and this was enhanced by combination of all 4 measurements. Clinical subgroup analysis suggested particularly high NPV for early onset symptoms, however further studies are required to elucidate this finding.
  
  
  CONCLUSIONS
  All four study measurements demonstrated some diagnostic value for neonatal infection however sICAM-1, hsCRP and sE-selectin demonstrated the highest NPV individually. The optimum diagnostic cut off level for hsCRP measurement in this study was much lower than currently used in routine clinical practice. Use of a combination of measurements enhanced diagnostic performance, demonstrating sensitivity of 90.3% and NPV of 91.3%. This study suggests there may be value in use of several of these markers, individually and in combination to assist in excluding neonatal infection. Further work is needed to confirm a specific role in the exclusion of early onset infection.
authors.affiliation: Regional Immunology Service, Royal Hospitals, The Belfast Trust, & School of Medicine, Dentistry & Biomedical Sciences, Queen's University Belfast, Northern Ireland. david.edgar@belfasttrust.hscni.net
authors.forename: J David M
authors.initials: JD
authors.lastname: Edgar
authors.forename: Vanessa
authors.initials: V
authors.lastname: Gabriel
authors.forename: J Ruth
authors.initials: JR
authors.lastname: Gallimore
authors.forename: Stanley A
authors.initials: SA
authors.lastname: McMillan
authors.forename: Judith
authors.initials: J
authors.lastname: Grant
mesh_terms: D002097:C-Reactive Protein / Q000378:metabolism*; D003937:Diagnosis, Differential; D019040:E-Selectin / Q000097:blood*; D004739:England; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000097:blood* / Q000175:diagnosis; D007239:Infections / Q000097:blood / Q000175:diagnosis*; D007363:Intensive Care Units, Neonatal; D018799:Intercellular Adhesion Molecule-1 / Q000097:blood*; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D012680:Sensitivity and Specificity; D018805:Sepsis / Q000175:diagnosis; D000685:Serum Amyloid A Protein / Q000378:metabolism
chemical_list: D019040:E-Selectin; D000685:Serum Amyloid A Protein; D018799:Intercellular Adhesion Molecule-1; D002097:C-Reactive Protein
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