C-reactive protein and immature-to-total neutrophil ratio have no utility in guiding lumbar puncture in suspected neonatal sepsis

Christopher D. Goldfinch, Tony Korman, Despina Kotsanas, David P. Burgner, Kenneth Tan

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Aim: Meningitis may complicate neonatal sepsis, but there is scant evidence to inform the decision to perform a lumbar puncture (LP) and considerable variation in practice. We investigated whether inflammatory markers − C-reactive protein (CRP) and immature-to-total neutrophil ratio (ITR) – were predictive of meningitis or significant cerebrospinal fluid (CSF) pleocytosis and useful in guiding the decision to perform a LP. Methods: We studied all inpatients in a single tertiary neonatal unit who were <6 months of age who had a LP performed between March 2011 and October 2014. We categorised CSF results as follows: (i) culture-positive meningitis; (ii) probable culture-negative meningitis but meeting a priori criteria for significant CSF leucocytosis; or (iii) no evidence of meningitis. CRP and ITR obtained within 48 h of LP were analysed. We assessed the test performance of CRP and ITR by area under receiver operating characteristic curves. Results: A total of 757 (male 471, 62.2%) infants were included. The median (interquartile range) gestational age was 38.4 weeks (30–40.3), and birthweight was 2940 g (1330–3560). Ten (1.3%) infants had culture-positive meningitis; 71 (9.4%) were classified as probable culture-negative meningitis and 676 (89.3%) as non-meningitis. The area under receiver operating characteristic curve for culture-positive and probable culture-negative meningitis was 0.43 for CRP (95% confidence interval 0.36–0.51) and 0.58 for ITR (0.51–0.65). At a CRP threshold of 30 mg/L, there was a positive likelihood ratio (LR) of 0.77 and a negative LR of 1.44. Conclusions: CRP and ITR perform poorly in identifying infants with confirmed or probable meningitis. The decision to perform an LP should be more focused on clinical grounds and/or a positive blood culture and less on inflammatory or haematological markers in isolation.

Original languageEnglish
Pages (from-to)848-854
Number of pages7
JournalJournal of Paediatrics and Child Health
Volume54
Issue number8
DOIs
Publication statusPublished - 1 Aug 2018

Keywords

  • C-reactive protein
  • immature-to-total neutrophil ratio
  • inflammatory markers
  • lumbar puncture
  • meningitis

Cite this

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title = "C-reactive protein and immature-to-total neutrophil ratio have no utility in guiding lumbar puncture in suspected neonatal sepsis",
abstract = "Aim: Meningitis may complicate neonatal sepsis, but there is scant evidence to inform the decision to perform a lumbar puncture (LP) and considerable variation in practice. We investigated whether inflammatory markers − C-reactive protein (CRP) and immature-to-total neutrophil ratio (ITR) – were predictive of meningitis or significant cerebrospinal fluid (CSF) pleocytosis and useful in guiding the decision to perform a LP. Methods: We studied all inpatients in a single tertiary neonatal unit who were <6 months of age who had a LP performed between March 2011 and October 2014. We categorised CSF results as follows: (i) culture-positive meningitis; (ii) probable culture-negative meningitis but meeting a priori criteria for significant CSF leucocytosis; or (iii) no evidence of meningitis. CRP and ITR obtained within 48 h of LP were analysed. We assessed the test performance of CRP and ITR by area under receiver operating characteristic curves. Results: A total of 757 (male 471, 62.2{\%}) infants were included. The median (interquartile range) gestational age was 38.4 weeks (30–40.3), and birthweight was 2940 g (1330–3560). Ten (1.3{\%}) infants had culture-positive meningitis; 71 (9.4{\%}) were classified as probable culture-negative meningitis and 676 (89.3{\%}) as non-meningitis. The area under receiver operating characteristic curve for culture-positive and probable culture-negative meningitis was 0.43 for CRP (95{\%} confidence interval 0.36–0.51) and 0.58 for ITR (0.51–0.65). At a CRP threshold of 30 mg/L, there was a positive likelihood ratio (LR) of 0.77 and a negative LR of 1.44. Conclusions: CRP and ITR perform poorly in identifying infants with confirmed or probable meningitis. The decision to perform an LP should be more focused on clinical grounds and/or a positive blood culture and less on inflammatory or haematological markers in isolation.",
keywords = "C-reactive protein, immature-to-total neutrophil ratio, inflammatory markers, lumbar puncture, meningitis",
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C-reactive protein and immature-to-total neutrophil ratio have no utility in guiding lumbar puncture in suspected neonatal sepsis. / Goldfinch, Christopher D.; Korman, Tony; Kotsanas, Despina; Burgner, David P.; Tan, Kenneth.

In: Journal of Paediatrics and Child Health, Vol. 54, No. 8, 01.08.2018, p. 848-854.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - C-reactive protein and immature-to-total neutrophil ratio have no utility in guiding lumbar puncture in suspected neonatal sepsis

AU - Goldfinch, Christopher D.

AU - Korman, Tony

AU - Kotsanas, Despina

AU - Burgner, David P.

AU - Tan, Kenneth

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N2 - Aim: Meningitis may complicate neonatal sepsis, but there is scant evidence to inform the decision to perform a lumbar puncture (LP) and considerable variation in practice. We investigated whether inflammatory markers − C-reactive protein (CRP) and immature-to-total neutrophil ratio (ITR) – were predictive of meningitis or significant cerebrospinal fluid (CSF) pleocytosis and useful in guiding the decision to perform a LP. Methods: We studied all inpatients in a single tertiary neonatal unit who were <6 months of age who had a LP performed between March 2011 and October 2014. We categorised CSF results as follows: (i) culture-positive meningitis; (ii) probable culture-negative meningitis but meeting a priori criteria for significant CSF leucocytosis; or (iii) no evidence of meningitis. CRP and ITR obtained within 48 h of LP were analysed. We assessed the test performance of CRP and ITR by area under receiver operating characteristic curves. Results: A total of 757 (male 471, 62.2%) infants were included. The median (interquartile range) gestational age was 38.4 weeks (30–40.3), and birthweight was 2940 g (1330–3560). Ten (1.3%) infants had culture-positive meningitis; 71 (9.4%) were classified as probable culture-negative meningitis and 676 (89.3%) as non-meningitis. The area under receiver operating characteristic curve for culture-positive and probable culture-negative meningitis was 0.43 for CRP (95% confidence interval 0.36–0.51) and 0.58 for ITR (0.51–0.65). At a CRP threshold of 30 mg/L, there was a positive likelihood ratio (LR) of 0.77 and a negative LR of 1.44. Conclusions: CRP and ITR perform poorly in identifying infants with confirmed or probable meningitis. The decision to perform an LP should be more focused on clinical grounds and/or a positive blood culture and less on inflammatory or haematological markers in isolation.

AB - Aim: Meningitis may complicate neonatal sepsis, but there is scant evidence to inform the decision to perform a lumbar puncture (LP) and considerable variation in practice. We investigated whether inflammatory markers − C-reactive protein (CRP) and immature-to-total neutrophil ratio (ITR) – were predictive of meningitis or significant cerebrospinal fluid (CSF) pleocytosis and useful in guiding the decision to perform a LP. Methods: We studied all inpatients in a single tertiary neonatal unit who were <6 months of age who had a LP performed between March 2011 and October 2014. We categorised CSF results as follows: (i) culture-positive meningitis; (ii) probable culture-negative meningitis but meeting a priori criteria for significant CSF leucocytosis; or (iii) no evidence of meningitis. CRP and ITR obtained within 48 h of LP were analysed. We assessed the test performance of CRP and ITR by area under receiver operating characteristic curves. Results: A total of 757 (male 471, 62.2%) infants were included. The median (interquartile range) gestational age was 38.4 weeks (30–40.3), and birthweight was 2940 g (1330–3560). Ten (1.3%) infants had culture-positive meningitis; 71 (9.4%) were classified as probable culture-negative meningitis and 676 (89.3%) as non-meningitis. The area under receiver operating characteristic curve for culture-positive and probable culture-negative meningitis was 0.43 for CRP (95% confidence interval 0.36–0.51) and 0.58 for ITR (0.51–0.65). At a CRP threshold of 30 mg/L, there was a positive likelihood ratio (LR) of 0.77 and a negative LR of 1.44. Conclusions: CRP and ITR perform poorly in identifying infants with confirmed or probable meningitis. The decision to perform an LP should be more focused on clinical grounds and/or a positive blood culture and less on inflammatory or haematological markers in isolation.

KW - C-reactive protein

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