title: Clinical signs to identify late-onset sepsis in preterm infants.
abstract: Late-onset neonatal sepsis (LOS) in preterm infants is an important cause of morbidity and mortality in preterm infants. Since presenting symptoms may be non-specific and subtle, early and correct diagnosis is challenging. We aimed to develop a nomogram based on clinical signs, to assess the likelihood of LOS in preterms with suspected infection without the use of laboratory investigations. We performed a prospective cohort study in 142 preterm infants <34 weeks admitted to the neonatal intensive care unit with suspected infection. During 187 episodes, 21 clinical signs were assessed. LOS was defined as blood culture-proven and/or clinical sepsis, occurring after 3 days of age. Logistic regression was used to develop a nomogram to estimate the probability of LOS being present in individual patients. LOS was found in 48 % of 187 suspected episodes. Clinical signs associated with LOS were: increased respiratory support (odds ratio (OR) 3.6; 95 % confidence interval (CI) 1.9-7.1), capillary refill (OR 2.2; 95 %CI 1.1-4.5), grey skin (OR 2.7; 95 %CI 1.4-5.5) and central venous catheter (OR 4.6; 95 %CI 2.2-10.0) (area under the curve of the receiver operating characteristic curve 0.828; 95 %CI 0.764-0.892).
  
  
  CONCLUSIONS
  Increased respiratory support, capillary refill, grey skin and central venous catheter are the most important clinical signs suggestive of LOS in preterms. Clinical signs that are too non-specific to be useful in excluding or diagnosing LOS were temperature instability, apnoea, tachycardia, dyspnoea, hyper- and hypothermia, feeding difficulties and irritability.
authors.affiliation: Princess Amalia Department of Pediatrics, Isala Klinieken, Dr van Heesweg 2, PO Box 10400, 8000 GK Zwolle, The Netherlands. j.bekhof@isala.nl
authors.forename: Jolita
authors.initials: J
authors.lastname: Bekhof
authors.forename: Johannes B
authors.initials: JB
authors.lastname: Reitsma
authors.forename: Joke H
authors.initials: JH
authors.lastname: Kok
authors.forename: Irma H L M
authors.initials: IH
authors.lastname: Van Straaten
mesh_terms: D017668:Age of Onset; D019540:Area Under Curve; D015331:Cohort Studies; D003428:Cross Infection / Q000175:diagnosis*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D007235:Infant, Premature, Diseases / Q000097:blood / Q000175:diagnosis* / Q000453:epidemiology; D007363:Intensive Care Units, Neonatal; D016015:Logistic Models; D008297:Male; D049451:Nomograms; D018805:Sepsis / Q000097:blood / Q000175:diagnosis* / Q000453:epidemiology; D063189:Symptom Assessment / Q000379:methods*