Biomarkers for the

Diagnosis of Neonatal
Sepsis
a, b
Joseph B. Cantey, MD, MPH *, John H. Lee, BS

KEYWORDS
 Biomarker  C-reactive protein  Complete blood count  Neonate  Procalcitonin
 Sepsis

KEY POINTS
 Early, accurate diagnosis of neonatal sepsis improves time to effective therapy for infants
with sepsis while minimizing antibiotic exposure in uninfected infants.
 An ideal biomarker for neonatal sepsis should become abnormal before clinical signs
develop and have near-perfect sensitivity and a rapid turnaround time.
 At present, no biomarker (including complete blood count with differential, C-reactive pro-
tein, and procalcitonin) has sufficient sensitivity to preclude the need for empiric antibiotic
treatment of infants with suspected sepsis.
 Existing biomarkers have mediocre specificity, which has contributed to unnecessary
antibiotic therapy for infants with culture-negative sepsis.
 Research efforts in partnership with biomedical engineers may identify novel biomarkers,
including ones that can be detected via noninvasive sensors.

INTRODUCTION

Neonatal sepsis remains a substantial cause of morbidity and mortality in the nursery
setting.1 Sepsis in neonates and young infants is challenging to diagnose, because in-
fants manifest nonspecific clinical signs in response to sepsis (eg, respiratory distress,
hypotension, apnea) that could indicate noninfectious conditions. Furthermore, time
to antibiotics affects neonatal sepsis outcome; therefore, there are both clinical and
compliance motivations for identifying and treating neonates with sepsis expedi-
tiously.2,3 As a result, clinicians commonly use serum biomarkers to measure inflam-
mation and infection and assess the infant’s risk of sepsis. This article reviews the
current state of neonatal sepsis diagnostics, highlights the uses and limitations of

a
Department of Pediatrics, Division of Allergy, Immunology, and Infectious Diseases, University
of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA; b Department
of Pediatrics, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX
78229, USA
* Corresponding author.
E-mail address: cantey@[Link]

Clin Perinatol 48 (2021) 215–227

[Link] [Link]
0095-5108/21/ª 2021 Elsevier Inc. All rights reserved.
216 Cantey & Lee

current biomarkers, and discusses the characteristics and development pathway of a

theoretic ideal biomarker for neonatal sepsis.

DEFINITIONS

Neonatal sepsis has been loosely defined as an infection of a sterile site (eg, blood,
urine, cerebrospinal fluid) and clinical signs of illness. Infection in the first 72 hours
of life is defined as early-onset sepsis (EOS) and is generally associated with perinatal
risk factors such as intrauterine infection and inflammation (ie, chorioamnionitis), pro-
longed rupture of membranes, and maternal group B Streptococcus colonization.4,5
For infants cared for in the nursery or neonatal intensive care unit (NICU) setting, infec-
tion beyond age 72 hours is defined as late-onset sepsis (LOS) and is associated with
health care–associated transmission.6 Infections among infants aged more than
72 hours who have been discharged is generally associated with community-
acquired pathogens and is referred to by a variety of names, including invasive bac-
terial infection, fever without a source, and serious bacterial infection.7,8 However, a
discussion of sepsis diagnostics for young infants presenting to care from the commu-
nity with suspected sepsis is beyond the scope of this article.
Sepsis in adults is defined as life-threatening organ dysfunction as a result of a dys-
regulated response to infection.9 Since the early 1990s, the diagnosis of sepsis has
been based on a group of clinical findings designed to measure organ dysfunction
systemic inflammatory response syndrome (SIRS). SIRS criteria have poor sensitivity
and specificity for neonatal sepsis. Coggins and colleagues10 evaluated SIRS criteria
in a case-control study of infants with LOS in their NICU; the sensitivity and specificity
of SIRS criteria were 42% and 74%, respectively. Concerningly, most septic infants
who developed organ dysfunction did not meet SIRS criteria at the time cultures
were obtained. The current diagnostic definition, the Third International Consensus
Definitions for Sepsis and Septic Shock (Sepsis-3), mark an intentional shift away
from SIRS.9 The Sepsis-3 task force created the Sequential Organ Failure Assessment
(SOFA). SOFA uses a variety of objective clinical components, including fraction of
inspired oxygen; mean arterial pressure, including need for vasopressors; Glasgow
coma scale score; need for mechanical ventilation; and bilirubin, platelet, and creati-
nine concentrations. The neonatal-specific SOFA score can be used to improve pre-
diction of mortality in neonatal sepsis but is not intended as a diagnostic tool.11,12
However, experts have called for specific consensus definitions of sepsis for preterm
and term infants.13

CHALLENGES IN SEPSIS DIAGNOSTICS

The diagnosis of neonatal sepsis is difficult (Fig. 1). Distinguishing the individual com-
ponents of sepsis from a dysregulated response to the infection is challenging. The 3
primary issues in neonatal sepsis diagnosis are (1) the myriad of clinical findings that
mimic sepsis rather than represent it, and, as a direct result, (2) concern for falsely
negative bacterial cultures, also known as culture-negative sepsis, and (3) the need
to treat empirically for a minimum of 24 to 48 hours while cultures incubate. A further
complication is that the initiation of antimicrobial therapy before cultures are obtained
can sterilize subsequent cultures and decrease the opportunity for accurate diagnosis
of sterile site infections.
Neonatal sepsis is rare; conditions that mimic sepsis are collectively common. For
example, apnea, respiratory distress, and hypotension are all 10 to 100 times more
common than EOS in very-low-birthweight (<1500 g) infants.14 Transient tachypnea
of the newborn, which also mimics EOS, is approximately 200 times more common
 Sepsis Biomarkers 217

Fig. 1. Although a formal consensus definition of neonatal sepsis has not been developed, it
is generally defined as an infection causing organ dysfunction because of a dysregulated
response. As shown, there are many causes of organ dysfunction in infants, particularly
those who are premature. Therefore, a careful evaluation for infection and organ dysfunc-
tion is indicated before assigning sepsis as the cause of these clinical signs.

than EOS (w60 per 1000 live births vs 0.3 per 1000 live births) and results in unnec-
essary evaluation and treatment of sepsis.15,16 Respiratory distress syndrome affects
most preterm infants, including virtually all infants less than 30 weeks’ gestation, and is
clinically and radiographically indistinguishable from pulmonary manifestations of
EOS.17 Clinicians appreciate the urgency of a neonatal sepsis diagnosis and institution
of therapy, but identifying the 1 infant who is septic out of the many who have nonin-
fectious presentations is challenging. Schulman and colleagues18 evaluated antibiotic
use in 116 California nurseries and found that the median number of infants treated for
EOS for each proven case was 95 (range, 11–336). Antibiotic use for EOS did not
correlate with the incidence of EOS at that center.18 Similar studies in both well-
baby nurseries and in NICUs have shown that antibiotic use does not correlate with
infant or maternal risk factors.19,20 Diagnostic subjectivity and inefficiency are major
contributors to unnecessary antibiotic use in the nursery setting and have spurred ef-
forts to develop objective sepsis biomarkers.21
Appropriately obtained bacterial cultures (usually blood culture alone for EOS and
blood, urine, and cerebrospinal fluid for LOS) are the gold standard for the diagnosis
of neonatal sepsis.22 Cultures should be obtained before antibiotic therapy is initiated.
Blood culture sensitivity is directly linked to volume; a weight-based approach is rec-
ommended by the American Academy of Pediatrics.23,24 For most term neonates, this
equates to 1 mL. The sensitivity of blood cultures approaches 100% if 1 mL of blood is
obtained and the culture is processed correctly.25–27 However, many clinicians caring
for neonates with suspected sepsis incorrectly view the sensitivity of blood cultures as
poor. In many situations, preanalytical issues such as inadequate blood volume or
218 Cantey & Lee

contamination are responsible for the absence of detection of a pathogen or detection

of an organism that is not considered to be a pathogen. This problem results in the far-
too-common practices of either providing prolonged antibiotic therapy to infants with
sterile cultures for culture-negative sepsis or treating a contaminant organism as a true
pathogen.28–30 These practices are unnecessary at best and harmful at worst, leading
to increased dysbiosis, adverse short-term and long-term outcomes, and antimicro-
bial resistance.31 A full discussion of culture-negative sepsis is beyond the scope of
this article, but it is an important contributor to the need for better sepsis biomarkers.
Although the sensitivity of a properly obtained blood culture is excellent to detect
bacterial causes of neonatal sepsis, these cultures require incubation for hours to
days to detect growth.32 Most clinical microbiology laboratories incubate blood cul-
tures for 3 to 7 days.33 Identification of the causative bacteria for neonatal sepsis
can be achieved in more than 99% of patients by 36 hours in LOS, and recent data
suggest that as little as 24 hours may be sufficient to detect pathogens associated
with EOS.34–38 However, even if empiric antibiotics are discontinued after 24 hours
of administration, infants are still exposed to at least 1 dose of aminoglycosides
and/or multiple doses of b-lactams or vancomycin. Even a single dose of antibiotic
is capable of causing significant dysbiosis that can persist for months and cause
increased susceptibility to infection and autoimmune disease.39–41
These real and perceived limitations to culture-based approaches have fueled inter-
est in developing rapid, accurate biomarkers for neonatal sepsis. Jörn-Hendrik Weit-
kamp42 has described the ideal neonatal sepsis biomarker as needing near-perfect
sensitivity and a rapid turnaround time. This combination would allow clinicians to delay
the initiation of antibiotics for infants with a negative biomarker test. However, at pre-
sent there is no test for neonatal sepsis that meets the criteria of an ideal biomarker.

CURRENT BIOMARKERS

The most frequently used laboratory parameters as neonatal sepsis biomarkers

include complete blood counts (CBCs) with differential, C-reactive protein (CRP),
and procalcitonin. However, numerous other assays have been investigated and are
discussed briefly later. In general, the laboratory tests currently in use as sepsis bio-
markers for neonates and young infants share common characteristics. Most have
reasonably good sensitivity and therefore reasonable negative predictive value
(NPV). However, specificity and positive predictive value (PPV) are generally poor.
These characteristics mean that normal results can be reassuring, but abnormal re-
sults are less meaningful because many inflammatory conditions can affect these
values in the absence of neonatal sepsis, including maternal preeclampsia, chorioam-
nionitis, hypoxic-ischemic injury, and in utero growth restriction.43–47 The negative
sequelae of relying on biomarkers with poor PPV to direct therapy may mean that un-
infected neonates with sterile cultures are subject to prolonged antibiotic exposure,
for culture-negative sepsis.48,49 In addition, the excellent NPV must be interpreted
within the context of the relative rarity of EOS and LOS, and therefore a low pretest
probability. Schulman and colleagues18 showed an incidence of 1.1% for EOS and
w5% for LOS in infants evaluated for sepsis. Using these low pretest probabilities,
even a coin flip has excellent NPV (exceeding 95%).50 The authors are reminded of
the classic Simpsons episode51 in which Lisa Simpson teaches her father about
such specious reasoning. Lisa picks up a rock and facetiously claims that it keeps ti-
gers away. Homer asks how, and a frustrated Lisa explains that it does not actually
work, being just a rock, but there are no tigers in the neighborhood! Homer considers
this for a moment, and then tries to buy the rock from his exasperated daughter.
 Sepsis Biomarkers 219

In order to safely delay the initiation of antibiotic therapy from an infant with sus-
pected sepsis, clinicians need a fast, accurate test with a negligible number of
false-negatives, not a meaningful number of false-negatives buried in an avalanche
of true-negatives. However, many current biomarkers perform well because of the
low pretest probability of sepsis and are, in fact, little better than Lisa Simpson’s rock.

COMPLETE BLOOD COUNT

White blood cells and their differential count is the oldest biomarker for neonatal
sepsis, predating the widespread use of automated blood culture systems. The orig-
inal description of vacuolization of the neutrophil as a specific finding in neonatal
sepsis was published in 1966.52 The use of the CBC as an adjunctive test for neonatal
sepsis has become fairly widespread; a national survey published in 2017 found that
95% of nurseries use a CBC as part of their sepsis evaluations.53 The exact use of
CBCs varies widely; approaches include obtaining CBC at a single time point or seri-
ally, evaluating the total white blood cell count, neutrophil count, immature-to-total ra-
tio, temporal trends, and evaluation of red blood cell and platelet size and morphology
in addition to leukocytes.54–56 Receiver-operator curves can be generated for these
different values. Specific findings of sepsis (>75%) include low absolute leukocyte
counts, severe neutropenia, and increased immature-to-total ratio (25%). However,
specificity comes at the cost of poor sensitivity for EOS and LOS, where the CBC has
less than 50% sensitivity.57 In a large retrospective cohort using the Pediatrix admin-
istrative database, the highest area under the curve (AUC) Hornik and colleagues58
could generate using different combinations of CBC values was 0.686, and most in-
fants with EOS had normal CBCs. The investigators concluded that the poor sensitivity
of CBCs makes them poor diagnostic markers, and that the practice of obtaining a
CBC as part of a sepsis evaluation is not supported.58

C-REACTIVE PROTEIN

CRP, an acute phase reactant made in the liver in response to inflammatory cytokines,
has attracted widespread and prolonged interest as a neonatal sepsis biomarker.
Studies evaluating the CRP for the diagnosis of EOS have consistently reported sen-
sitivities of 50% to 70% with unacceptably high false-positives.59,60 CRP levels in-
crease naturally over the first 1 to 2 days of life to levels that approach abnormal.61
A meta-analysis by Brown and colleagues62 of 22 studies evaluating the accuracy
of CRP to detect LOS showed that, at median specificity (74%), the sensitivity of
CRP was 62%. Together, these data show that CRP is not a useful tool in the diag-
nosis of neonatal sepsis.

PROCALCITONIN

Current evidence does not support the use of procalcitonin rather than CRP, because
both have significant limitations of sensitivity and specificity. Retrospective studies
suggest a range of sensitivity and specificity for procalcitonin that is on par with or
slightly superior to CBC and CRP, in the 65% to 85% range.60,63–67 Meta-analysis
of 39 studies comparing procalcitonin with CRP for EOS and LOS found a slightly su-
perior sensitivity (77% vs 66%) and no difference in specificity (w80%–82%) for pro-
calcitonin compared with CRP. In the neonatal procalcitonin intervention study
(NeoPInS), which investigated antibiotic use, Stocker and colleagues68 showed an
AUC of 0.921 for procalcitonin at age 36 hours, which was slightly inferior to the
AUC of CRP in the same study. Meta-analyses of 17 studies and 1086 neonates
220 Cantey & Lee

showed that, at the median sensitivity of 85%, the specificity of procalcitonin was
54%.69 Despite initial excitement, the data do not support the use of procalcitonin
as an ideal sepsis biomarker.

OTHERS

Numerous other serum biomarkers have been considered for the identification of
neonatal sepsis.70 These include, but are not limited to, interleukin-6,71 presepsin,72
cluster of differentiation (CD) 64,73 CD11b,74 serum amyloid A,75 S100 protein A12,76
lipopolysaccharide binding protein,77 volatile organic compounds,78 and soluble trig-
gering receptor expressed on myeloid cell-1.79 In addition, microbiome monitoring80
and the application of mass spectroscopy to serum samples during sepsis evalua-
tions81 are novel approaches for biomarkers. Noninvasive biomarkers, such as heart
rate characteristic (HRC) monitoring in preterm infants, have also been studied. In a ran-
domized controlled trial of HRC monitoring for very-low-birthweight infants, Moorman
and colleagues82 saw a reduction in mortality following sepsis for infants receiving HRC
monitoring compared with controls (10% vs 16.1%, absolute risk reduction of 6.1%,
P 5 .01). A larger follow-up study showed a similar reduction in mortality among
extremely low birthweight infants (<1000 g) receiving HRC monitoring.83 This effect,
presumably, is caused by HRC alerting clinicians about impending deterioration and
improving time to sepsis evaluation and initiation of effective antimicrobial therapy.
Biosensing, in which a detector is used to directly sense the presence of 1 or more
circulating biomolecules, is an exciting emerging field in sepsis diagnostics.84 A vari-
ety of techniques, including electrochemical, optical, bioluminescent, and thermal,
can be used to amplify and identify different circulating factors. Previous work has
used biosensors to measure the biomarkers discussed earlier, such as CRP and inter-
leukin-6.85 However, more recent studies have turned toward direct identification of
bacterial components such as lipopolysaccharide or bacterial ribosomal RNA.86 Op-
tical biosensors can measure a variety of physiologic changes via transcutaneous
capture, including creatinine, bilirubin, or nitric oxide concentration.87 If these technol-
ogies can be combined and optimized, it is possible that a wrist probe might be able to
accurately detect an increased concentration in biomolecules caused by sepsis
before clinical signs develop.

OPTIMAL CURRENT PRACTICE

In the absence of a fast, accurate sepsis biomarker with excellent sensitivity, how
should clinicians approach infants with suspected sepsis? As endorsed by the Amer-
ican Academy of Pediatrics, the most effective current strategy for neonatal sepsis is
the use of objective clinical risk factors to determine the pretest probability of sepsis,
in combination with serial observation for equivocal or low-risk infants.23 Several
studies investigating the impact of observation-based instead of laboratory-based ap-
proaches have shown similar safety outcomes with reduced need for sepsis evalua-
tions and antibiotic exposure. Cantoni and colleagues88 performed a 2-year study in
northeastern Italy that included 15,239 infants. In the first year, infants with 1 or
more risk factors for EOS were evaluated with blood culture and CBC with differential.
In the second year, infants were evaluated with serial physical examination alone and
cultured only if clinical signs of illness developed. The investigators saw no difference
in EOS incidence, time to antibiotic initiation, or mortality. However, they did see a
58% reduction in antibiotic use in the cohort evaluated during the second study
year. A similar 4-year study from Norway evaluated a change in practice in which cli-
nicians relied on serial physical examination and limited laboratory diagnostics and
 Sepsis Biomarkers 221

found a 60% reduction in antibiotic use with no change in EOS incidence.89 The most
common tool to help guide objective risk assessment in term and late-preterm infants
is the Neonatal Sepsis Calculator,90 which has been validated in numerous studies
and has been shown to reduce sepsis evaluations and unnecessary antibiotic
use.91–93 In addition, instead of using 0.3 to 0.5 mL of blood on imperfect and generally
unhelpful biomarkers, providers should add that blood to the culture bottle in order to
optimize volume. This method improves the sensitivity of the gold standard test and
minimizes confusing or inaccurate biomarker results.

FUTURE RESEARCH

Imagine for a moment a future in which the ideal biomarker has been identified. This
mythological test, the SeptiCheck (Cantey Fantasy Industries, San Antonio, TX) is a
rapid point-of-care test that requires 0.3 mL of blood and results in a qualitative
yes/no result within 10 minutes. It has 99.3% sensitivity and 99% specificity for
neonatal sepsis. Infants with suspected sepsis who have a negative SeptiCheck
can be observed closely; infants whose SeptiCheck is positive, which occurs infre-
quently because sepsis is rare and the excellent specificity of the test minimizes
false-positives, cultures are obtained and the infant is started on empiric antibiotic
therapy pending cultures. Sepsis evaluations and unnecessary antibiotic exposure
plummet, and morbidity and mortality from proven sepsis decrease with faster time
to initiation of antibiotic therapy.
How do clinicians get there from here? First and foremost, clinicians and re-
searchers must not be discouraged by the middling utility of current sepsis bio-
markers, but instead should continue the search for biomarkers that are informative.
Translational studies that enroll neonates before they develop clinical illness will be
needed to identify biomarkers with early, predictive kinetics: a test that becomes
abnormal before clinical illness, peaks concomitantly with sepsis, and decreases
with disease resolution. Novel approaches such as microbiome monitoring, mass
spectroscopy, and others should be applied to well and sick neonates to generate
novel biomarker targets for formal hypothesis testing. In addition, continued partner-
ships with engineers will be critical. The ideal biomarker, if it exists, cannot be found
without collaboration with biomedical, electrical, chemical, and computer science en-
gineers. The ultimate goal for clinicians is not to shorten antibiotic duration for infants
with suspected sepsis but to have a rapid, sensitive test that supports initiation of an-
tibiotics only when needed. Until that day comes, clinicians should reconsider how
laboratory parameters can be optimally used in combination with the prenatal history
and physical examination applying diagnostic and antimicrobial stewardship.

CLINICS CARE POINTS

 Early diagnosis of neonatal sepsis improves time to effective therapy, but current biomarkers
are insufficiently sensitive or specific to be clinically useful.
 There is currently no consensus definition of neonatal sepsis, and extrapolation of sepsis
criteria from older children or adults is highly inaccurate.
 The most evidence-based clinical role for current biomarkers (complete blood count, C-
reactive protein, or procalcitonin) is to help providers discontinue empiric antibiotics at
24-48 hours when cultures are sterile.
 Abnormal biomarkers are not an indication to continue antibiotic therapy in a well-
appearing infant whose cultures are sterile.
222 Cantey & Lee

 Management guided by serial examination and objective risk factors is non-inferior to

biomarker-based management and can reduce unnecessary blood draws and antibiotic
exposure.

Best practices

What is the current practice for diagnosing neonatal sepsis?

 Neonatal sepsis is frequently suspected when infants have clinical signs consistent with
sepsis, or for well-appearing infants with risk factors for sepsis.
 Bacterial cultures of blood (and urine, cerebrospinal fluid, or other sterile sites for late-onset
sepsis) are the reference standard for neonatal sepsis.
 Serum biomarkers (e.g., complete blood count with differential, C-reactive protein,
procalcitonin) are frequently obtained to help make the diagnosis of neonatal sepsis.
 Current biomarkers are insufficiently sensitive or specific to be consistently useful in the
diagnosis of neonatal sepsis.
 The ideal biomarker would have near-perfect sensitivity, rapid turnaround time, and the
ability to identify sepsis before clinical signs develop.
 Continued collaboration between clinicians, informaticists, and biomedical engineers is
essential to develop novel biomarkers that meet these criteria.
What changes in current practice are likely to improve outcomes?
 Providing education for clinicians regarding the limitations of current sepsis biomarkers
 Re-emphasizing the importance of culture- or molecular-based technologies in the diagnosis
of neonatal sepsis
Major recommendations
 The systematic use of current sepsis biomarkers should be discouraged; instead, that blood
volume should be added to the blood culture to optimize sensitivity of the reference
standard.
 Nurseries should have process improvement methods in place to ensure that adequate (1
mL) blood volume is inoculated into culture media.
 Perform collaborative, exploratory studies that incorporate novel approaches such as mass
spectrometry and other biomedical engineering approaches, aimed at identifying novel
biomarkers that can be adapted for clinical use.
Rating for strength of the evidence: Quality of evidence moderate, strength of recommenda-
tion moderate.

DISCLOSURE

The authors have nothing to disclose.

REFERENCES

1. Shane AL, Sanchez PJ, Stoll BJ. Neonatal sepsis. Lancet 2017;390:1770–80.

2. Weinberger J, Rhee C, Klompas M. A critical analysis of the literature on time-to-

antibiotics in suspected sepsis. J Infect Dis 2020;222:S110–8.

3. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international
guidelines for the management of septic Shock and sepsis-associated organ
dysfunction in children. Pediatr Crit Care Med 2020;21:e52–106.
 Sepsis Biomarkers 223

4. Simonsen KA, Anderson-Berry AL, Delair SF, et al. Early-onset neonatal sepsis.
Clin Microbiol Rev 2014;27:21–47.
5. Stoll BJ, Puopolo KM, Hansen NI, et al. Early-onset neonatal sepsis 2015 to 2017,
the rise of Escherichia coli, and the need for novel prevention strategies. JAMA
Pediatr 2020;174:e200593.
6. Greenberg RG, Kandefer S, Do BT, et al. Late-onset sepsis in extremely prema-
ture infants: 2000-2011. Pediatr Infect Dis J 2017;36:774–9.
7. Aronson PL, Shabanova V, Shapiro ED, et al. A prediction model to identify
Febrile infants </560 Days at low risk of invasive bacterial infection. Pediatrics
2019;144.
8. Aronson PL, Wang ME, Shapiro ED, et al. Risk stratification of Febrile infants 60
Days old without routine lumbar puncture. Pediatrics 2018;142:e20183604.
9. Singer M, Deutschman CS, Seymour CW, et al. The Third international consensus
definitions for sepsis and septic Shock (Sepsis-3). JAMA 2016;315:801–10.
10. Coggins S, Harris MC, Grundmeier R, et al. Performance of pediatric systemic
inflammatory response syndrome and organ dysfunction criteria in late-onset
sepsis in a quaternary neonatal intensive care unit: a case-control study.
J Pediatr 2020;219:133–9.e131.
11. Kurul S, Simons SHP, Ramakers CRB, et al. Association of inflammatory bio-
markers with subsequent clinical course in suspected late onset sepsis in pre-
term neonates. Crit Care 2021;25:12.
12. Wynn JL, Polin RA. A neonatal sequential organ failure assessment score pre-
dicts mortality to late-onset sepsis in preterm very low birth weight infants. Pediatr
Res 2020;88:85–90.
13. Wynn JL, Wong HR, Shanley TP, et al. Time for a neonatal-specific consensus
definition for sepsis. Pediatr Crit Care Med 2014;15:523–8.
14. Dempsey EM, Barrington KJ. Diagnostic criteria and therapeutic interventions for
the hypotensive very low birth weight infant. J Perinatol 2006;26:677–81.
15. Weintraub AS, Cadet CT, Perez R, et al. Antibiotic use in newborns with transient
tachypnea of the newborn. Neonatology 2013;103:235–40.
16. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of
delivery at term: influence of timing of elective caesarean section. Br J Obstet Gy-
naecol 1995;102:101–6.
17. Leonidas JC, Hall RT, Beatty EC, et al. Radiographic findings in early onset
neonatal group b streptococcal septicemia. Pediatrics 1977;59(Suppl):1006–11.
18. Schulman J, Benitz WE, Profit J, et al. Newborn antibiotic exposures and associ-
ation with proven bloodstream infection. Pediatrics 2019;144:e20191105.
19. Cordero L, Ayers LW. Duration of empiric antibiotics for suspected early-onset
sepsis in extremely low birth weight infants. Infect Control Hosp Epidemiol
2003;24:662–6.
20. Spitzer AR, Kirkby S, Kornhauser M. Practice variation in suspected neonatal
sepsis: a costly problem in neonatal intensive care. J Perinatol 2005;25:265–9.
21. Cantey JB. The spartacus problem: diagnostic inefficiency of neonatal sepsis.
Pediatrics 2019;144:e20192576.
22. Cantey JB, Patel SJ. Antimicrobial stewardship in the NICU. Infect Dis Clin North
Am 2014;28:247–61.
23. Puopolo KM, Benitz WE, Zaoutis TE, et al. Management of neonates born at 35
0/7 Weeks’ gestation with suspected or proven early-onset bacterial sepsis. Pe-
diatrics 2018;142:e20182894.
224 Cantey & Lee

24. Puopolo KM, Benitz WE, Zaoutis TE, et al. Management of neonates born at 34
6/7 Weeks’ gestation with suspected or proven early-onset bacterial sepsis. Pe-
diatrics 2018;142:e20182896.
25. Schelonka RL, Chai MK, Yoder BA, et al. Volume of blood required to detect com-
mon neonatal pathogens. J Pediatr 1996;129:275–8.
26. De SK, Shetty N, Kelsey M. How to use... blood cultures. Arch Dis Child Educ
Pract Ed 2014;99:144–51.
27. Connell TG, Rele M, Cowley D, et al. How reliable is a negative blood culture
result? Volume of blood submitted for culture in routine practice in a children’s
hospital. Pediatrics 2007;119:891–6.
28. Klingenberg C, Kornelisse RF, Buonocore G, et al. Culture-negative early-onset
neonatal sepsis - at the crossroad between efficient sepsis care and antimicrobial
stewardship. Front Pediatr 2018;6:285.
29. Greenberg RG, Chowdhury D, Hansen NI, et al. Prolonged duration of early anti-
biotic therapy in extremely premature infants. Pediatr Res 2019;85:994–1000.
30. Cantey JB, Sanchez PJ. Prolonged antibiotic therapy for "culture-negative" sepsis
in preterm infants: it’s time to stop! J Pediatr 2011;159:707–8.
31. Cantey JB, Baird SD. Ending the culture of culture-negative sepsis in the neonatal
ICU. Pediatrics 2017;140:e20170044.
32. Kirn TJ, Weinstein MP. Update on blood cultures: how to obtain, process, report,
and interpret. Clin Microbiol Infect 2013;19:513–20.
33. Bourbeau PP, Foltzer M. Routine incubation of BacT/ALERT FA and FN blood cul-
ture bottles for more than 3 days may not be necessary. J Clin Microbiol 2005;43:
2506–9.
34. Kumar Y, Qunibi M, Neal TJ, et al. Time to positivity of neonatal blood cultures.
Arch Dis Child Fetal Neonatal Ed 2001;85:F182–6.
35. Lefebvre CE, Renaud C, Chartrand C. Time to positivity of blood cultures in in-
fants 0 to 90 Days old presenting to the emergency department: is 36 hours
enough? J Pediatr Infect Dis Soc 2017;6:28–32.
36. Theodosiou AA, Mashumba F, Flatt A. Excluding clinically significant bacteremia
by 24 hours in otherwise well Febrile children younger than 16 years: a study of
more than 50,000 blood cultures. Pediatr Infect Dis J 2019;38:e203–8.
37. Kuzniewicz MW, Mukhopadhyay S, Li S, et al. Time to positivity of neonatal blood
cultures for early-onset sepsis. Pediatr Infect Dis J 2020;39:634–40.
38. Marks L, de Waal K, Ferguson JK. Time to positive blood culture in early onset
neonatal sepsis: a retrospective clinical study and review of the literature.
J Paediatr Child Health 2020;56:1371–5.
39. Niu X, Daniel S, Kumar D, et al. Transient neonatal antibiotic exposure increases
susceptibility to late-onset sepsis driven by microbiota-dependent suppression of
type 3 innate lymphoid cells. Sci Rep 2020;10:12974.
40. Singer JR, Blosser EG, Zindl CL, et al. Preventing dysbiosis of the neonatal
mouse intestinal microbiome protects against late-onset sepsis. Nat Med 2019;
25:1772–82.
41. Ng KM, Aranda-Diaz A, Tropini C, et al. Recovery of the gut microbiota after an-
tibiotics depends on host diet, community context, and environmental reservoirs.
Cell Host Microbe 2020;28:628.
42. Weitkamp JH. The role of biomarkers in suspected neonatal sepsis. Clin Infect
Dis 2020.
43. Marins LR, Anizelli LB, Romanowski MD, et al. How does preeclampsia affect ne-
onates? Highlights in the disease’s immunity. J Matern Fetal Neonatal Med 2019;
32:1205–12.
 Sepsis Biomarkers 225

44. Amarilyo G, Oren A, Mimouni FB, et al. Increased cord serum inflammatory
markers in small-for-gestational-age neonates. J Perinatol 2011;31:30–2.
45. Zanardo V, Peruzzetto C, Trevisanuto D, et al. Relationship between the neonatal
white blood cell count and histologic chorioamnionitis in preterm newborns.
J Matern Fetal Neonatal Med 2012;25:2769–72.
46. Rath S, Narasimhan R, Lumsden C. C-reactive protein (CRP) responses in neo-
nates with hypoxic ischaemic encephalopathy. Arch Dis Child Fetal Neonatal
Ed 2014;99:F172.
47. Howman RA, Charles AK, Jacques A, et al. Inflammatory and haematological
markers in the maternal, umbilical cord and infant circulation in histological cho-
rioamnionitis. PLoS One 2012;7:e51836.
48. Gyllensvard J, Ingemansson F, Hentz E, et al. C-reactive protein- and clinical
symptoms-guided strategy in term neonates with early-onset sepsis reduced
antibiotic use and hospital stay: a quality improvement initiative. BMC Pediatr
2020;20:531.
49. Cantey JB, Wozniak PS, Sanchez PJ. Prospective surveillance of antibiotic use in
the neonatal intensive care unit: results from the SCOUT study. Pediatr Infect Dis J
2015;34:267–72.
50. Cantey JB, Bultmann CR. C-reactive protein testing in late-onset neonatal sepsis:
hazardous Waste. JAMA Pediatr 2020;174:235–6.
51. Much apu about nothing. in Dietter S: the Simpsons. 1996.
52. Zieve PD, Haghshenass M, Blanks M, et al. Vacuolization of the neutrophil. An aid
in the diagnosis of septicemia. Arch Intern Med 1966;118:356–7.
53. Mukhopadhyay S, Taylor JA, Von Kohorn I, et al. Variation in sepsis evaluation
across a national network of nurseries. Pediatrics 2017;139:e20162845.
54. Mikhael M, Brown LS, Rosenfeld CR. Serial neutrophil values facilitate predicting
the absence of neonatal early-onset sepsis. J Pediatr 2014;164:522–8, e521-523.
55. Weinberg AG, Rosenfeld CR, Manroe BL, et al. Neonatal blood cell count in
health and disease. II. Values for lymphocytes, monocytes, and eosinophils.
J Pediatr 1985;106:462–6.
56. Cornbleet PJ. Clinical utility of the band count. Clin Lab Med 2002;22:101–36.
57. Newman TB, Puopolo KM, Wi S, et al. Interpreting complete blood counts soon
after birth in newborns at risk for sepsis. Pediatrics 2010;126:903–9.
58. Hornik CP, Benjamin DK, Becker KC, et al. Use of the complete blood cell count in
early-onset neonatal sepsis. Pediatr Infect Dis J 2012;31:799–802.
59. Yochpaz S, Friedman N, Zirkin S, et al. C-reactive protein in early-onset neonatal
sepsis - a cutoff point for CRP value as a predictor of early-onset neonatal sepsis
in term and late preterm infants early after birth? J Matern Fetal Neonatal Med
2020;1–6.
60. Eschborn S, Weitkamp JH. Procalcitonin versus C-reactive protein: review of ki-
netics and performance for diagnosis of neonatal sepsis. J Perinatol 2019;39:
893–903.
61. Macallister K, Smith-Collins A, Gillet H, et al. Serial C-reactive protein measure-
ments in newborn infants without evidence of early-onset infection. Neonatology
2019;116:85–91.
62. Brown JVE, Meader N, Wright K, et al. Assessment of C-reactive protein diag-
nostic test accuracy for late-onset infection in newborn infants: a systematic re-
view and meta-analysis. JAMA Pediatr 2020;174:260–8.
63. Liu C, Fang C, Xie L. Diagnostic utility of procalcitonin as a biomarker for late-
onset neonatal sepsis. Transl Pediatr 2020;9:237–42.
226 Cantey & Lee

64. Frerot A, Baud O, Colella M, et al. Cord blood procalcitonin level and early-onset
sepsis in extremely preterm infants. Eur J Clin Microbiol Infect Dis 2019;38:
1651–7.
65. Mohsen AH, Kamel BA. Predictive values for procalcitonin in the diagnosis of
neonatal sepsis. Electron Physician 2015;7:1190–5.
66. Morad EA, Rabie RA, Almalky MA, et al. Evaluation of procalcitonin, C-reactive
protein, and interleukin-6 as early markers for diagnosis of neonatal sepsis. Int
J Microbiol 2020;2020:8889086.
67. Stocker M, van Herk W, El Helou S, et al. C-reactive protein, procalcitonin, and
white blood count to rule out neonatal early-onset sepsis within 36 hours: a sec-
ondary analysis of the neonatal procalcitonin intervention study. Clin Infect Dis
2020.
68. Stocker M, van Herk W, El Helou S, et al. Procalcitonin-guided decision making
for duration of antibiotic therapy in neonates with suspected early-onset sepsis:
a multicentre, randomised controlled trial (NeoPIns). Lancet 2017;390:871–81.
69. Pontrelli G, De Crescenzo F, Buzzetti R, et al. Accuracy of serum procalcitonin for
the diagnosis of sepsis in neonates and children with systemic inflammatory syn-
drome: a meta-analysis. BMC Infect Dis 2017;17:302.
70. Hincu MA, Zonda GI, Stanciu GD, et al. Relevance of biomarkers currently in use
or research for practical diagnosis approach of neonatal early-onset sepsis. Chil-
dren (Basel) 2020;7:309.
71. Chiesa C, Pacifico L, Natale F, et al. Fetal and early neonatal interleukin-6
response. Cytokine 2015;76:1–12.
72. Parri N, Trippella G, Lisi C, et al. Accuracy of presepsin in neonatal sepsis: sys-
tematic review and meta-analysis. Expert Rev Anti Infect Ther 2019;17:223–32.
73. Dai J, Jiang W, Min Z, et al. Neutrophil CD64 as a diagnostic marker for neonatal
sepsis: meta-analysis. Adv Clin Exp Med 2017;26:327–32.
74. Qiu X, Li J, Yang X, et al. Is neutrophil CD11b a special marker for the early diag-
nosis of sepsis in neonates? A systematic review and meta-analysis. BMJ Open
2019;9:e025222.
75. Bourika V, Hantzi E, Michos A, et al. Clinical value of serum amyloid-A protein,
high-density lipoprotein cholesterol and apolipoprotein-A1 in the diagnosis and
follow-up of neonatal sepsis. Pediatr Infect Dis J 2020;39:749–55.
76. Tosson AMS, Glaser K, Weinhage T, et al. Evaluation of the S100 protein A12 as a
biomarker of neonatal sepsis. J Matern Fetal Neonatal Med 2020;33:2768–74.
77. Mussap M, Noto A, Fravega M, et al. Soluble CD14 subtype presepsin (sCD14-
ST) and lipopolysaccharide binding protein (LBP) in neonatal sepsis: new clinical
and analytical perspectives for two old biomarkers. J Matern Fetal Neonatal Med
2011;24(Suppl 2):12–4.
78. Berkhout DJC, Niemarkt HJ, Andriessen P, et al. Preclinical detection of non-
catheter related late-onset sepsis in preterm infants by Fecal volatile compounds
analysis: a prospective, multi-center cohort study. Pediatr Infect Dis J 2020;39:
330–5.
79. Bellos I, Fitrou G, Daskalakis G, et al. Soluble TREM-1 as a predictive factor of
neonatal sepsis: a meta-analysis. Inflamm Res 2018;67:571–8.
80. Agudelo-Ochoa GM, Valdes-Duque BE, Giraldo-Giraldo NA, et al. Gut microbiota
profiles in critically ill patients, potential biomarkers and risk variables for sepsis.
Gut Microbes 2020;12:1707610.
81. Chatziioannou AC, Wolters JC, Sarafidis K, et al. Targeted LC-MS/MS for the eval-
uation of proteomics biomarkers in the blood of neonates with necrotizing entero-
colitis and late-onset sepsis. Anal Bioanal Chem 2018;410:7163–75.
 Sepsis Biomarkers 227

82. Moorman JR, Carlo WA, Kattwinkel J, et al. Mortality reduction by heart rate char-
acteristic monitoring in very low birth weight neonates: a randomized trial.
J Pediatr 2011;159:900–906 e901.
83. Schelonka RL, Carlo WA, Bauer CR, et al. Mortality and neurodevelopmental out-
comes in the heart rate characteristics monitoring randomized controlled trial.
J Pediatr 2020;219:48–53.
84. Balayan S, Chauhan N, Chandra R, et al. Recent advances in developing bio-
sensing based platforms for neonatal sepsis. Biosens Bioelectron 2020;169:
112552.
85. Sun LP, Huang Y, Huang T, et al. Optical microfiber reader for enzyme-linked
immunosorbent assay. Anal Chem 2019;91:14141–8.
86. Kurundu Hewage EMK, Spear D, Umstead TM, et al. An electrochemical
biosensor for rapid detection of pediatric bloodstream infections. SLAS Technol
2017;22:616–25.
87. Doulou S, Leventogiannis K, Tsilika M, et al. A novel optical biosensor for the early
diagnosis of sepsis and severe Covid-19: the PROUD study. BMC Infect Dis
2020;20:860.
88. Cantoni L, Ronfani L, Da Riol R, et al. Physical examination instead of laboratory
tests for most infants born to mothers colonized with group B Streptococcus: sup-
port for the Centers for Disease Control and Prevention’s 2010 recommendations.
J Pediatr 2013;163:568–73.
89. Vatne A, Klingenberg C, Oymar K, et al. Reduced antibiotic exposure by serial
physical examinations in term neonates at risk of early-onset sepsis. Pediatr
Infect Dis J 2020;39:438–43.
90. Permanente K. Neonatal early-onset sepsis calculator. Kaiser Permanente Divi-
sion of Research; 2021.
91. Kuzniewicz MW, Puopolo KM, Fischer A, et al. A quantitative, risk-based
approach to the management of neonatal early-onset sepsis. JAMA Pediatr
2017;171:365–71.
92. Benitz WE, Achten NB. Technical assessment of the neonatal early-onset sepsis
risk calculator. Lancet Infect Dis 2020.
93. Deshmukh M, Mehta S, Patole S. Sepsis calculator for neonatal early onset sepsis
- a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2019;
34(11):1832–40.