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PEDIATRICS Vol. 106 No. 2 August 2000, pp. 256-263
2000 Grams at Birth: A
Population-Based Study
,, and
From * Kaiser Permanente Medical Care Program, Division of
Research, Perinatal Research Unit, Oakland, California; and the
Department of Pediatrics, Kaiser Permanente Medical Center, 1425 S
Main St, Walnut Creek, California.
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ABSTRACT |
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Top
Abstract
Methods
Results
Discussion
References
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Background. Few data are available on the outcome of neonatal sepsis evaluations in an era when intrapartum antibiotic therapy is common.
Methods. We identified all newborns weighing 
2000 g at
birth who were ever evaluated for suspected bacterial infection at 6 Kaiser Permanente hospitals between October 1995 and November 1996, reviewed their records and laboratory data, and tracked them to 1 week after discharge. We analyzed the relationship between key predictors and the presence of neonatal bacterial infection.
Results. Among 18 299 newborns 2000 g without major
congenital anomalies, 2785 (15.2%) were evaluated for sepsis with a
complete blood count and/or blood culture. A total of 62 (2.2%) met
criteria for proven, probable, or possible bacterial infection: 22 (.8%) had positive cultures and 40 (1.4%) had clinical
evidence of bacterial infection. We tracked all but 10 infants (.4%)
to 7 days postdischarge. There were 67 rehospitalizations (2.4%; 2 for
group B streptococcus bacteremia). Among 1568 infants who did not
receive intrapartum antibiotics, initial asymptomatic status was
associated with decreased risk of infection (adjusted odds ratio
[AOR]: .26; 95% confidence interval [CI]: .11-.63), while
chorioamnionitis (AOR: 2.40; 95% CI: 1.15-5.00), low absolute
neutrophil count (AOR: 2.84; 95% CI: 1.50-5.38), and meconium-stained
amniotic fluid (AOR: 2.23; 95% CI: 1.18-4.21) were associated with
increased risk. Results were similar among 1217 infants who were
treated, except that maternal chorioamnionitis was not significantly
associated with neonatal infection.
Conclusions. The risk of bacterial infection in asymptomatic newborns is low. Evidence-based observation and treatment protocols could be defined based on a limited set of predictors: maternal fever, chorioamnionitis, initial neonatal examination, and absolute neutrophil count. Many missed opportunities for treating mothers and infants exist. Key words: neonatal sepsis, neonatal meningitis, neonatal intensive care, group B streptococcus, streptococcus agalactiae, antibiotic therapy, sepsis evaluations, neonatal infections.
The frequency of neonatal bacterial infections ranges from
1 to 5 per 1000 live births.1,2 However, between 4.4% and
10.5% of all infants born in the United States
(130 000-400 000/year) receive systemic
antibiotics.3-6 General agreement seems to exist with
respect to management of infants with proven infection.7,8
Controversy exists with respect to newborns whose presentations are
considered equivocal, high-risk newborns who are asymptomatic, and
newborns whose mothers received intrapartum
antibiotics.9-12
This article reports on the outcome of neonatal sepsis work-ups in
infants This project was approved by the KPMCP Institutional Review
Board for the Protection of Human Subjects. An expert panel, the Neonatal Infection Study Group, defined predictors and outcomes and
reviewed study data. The panel consisted of a pediatric infectious disease specialist, a pediatric pathologist, and 9 neonatologists.
Infants were included if they: 1) weighed Study subjects were identified prospectively. Paper and electronic
records were reviewed retrospectively. On-site research assistants
reviewed nursery logs, laboratory results, and patient records. A
complete chart review of maternal and neonatal records was performed
for all newborns who ever had a CBC and/or blood culture obtained.
The information systems of KPMCP use a common medical record number and
clinical data repository. These information systems permit multiple
linkages (eg, downloading all neonatal CBCs and linking their results
to hospitalization records). The methods used for subject
identification, data abstraction, and electronic linkage have been
described in this journal13-16 and
elsewhere.17-20
We downloaded and manually reviewed the electronic results of: 1) all
maternal genital cultures for Streptococcus agalactiae (group B streptococcus [GBS]) obtained during pregnancy; and 2) all
neonatal urine, blood, and cerebrospinal fluid (CSF) cultures obtained
on members of the study cohort. We also downloaded and manually
reviewed the following neonatal results: the first 3 CBCs; the first 3 arterial blood gas results; and the first 2 CSF cell counts.
Infants born to women who are Kaiser Foundation Health Plan, Inc
members are automatically covered for the first month of life, which
permits very high follow-up rates during the immediate neonatal
period.16 We scanned all available KPMCP electronic
databases, including those tracking out-of-plan use, to define whether
study subjects: 1) left the health plan after discharge from the birth
hospitalization; 2) were rehospitalized during the first week after
discharge from the birth hospitalization; or 3) died during the first
week after discharge from the birth hospitalization. We also contacted
the families of all study subjects by mail at 14 to 60 days
postdischarge to enquire whether their infant was hospitalized or died
during the first week after the birth hospitalization. If an infant's outcome during the first week after the birth hospitalization could not
be ascertained using the above methods, we attempted to contact the
infant's family by phone. We then reviewed electronic hospitalization
records, laboratory data, and paper charts of all rehospitalized
infants.
The ratio of immature to total neutrophils (I:T ratio) was calculated
in the same manner as described by Manroe et al21 and
Schelonka et al.22,23 Because neonatal leukocyte indices
change over time, we did not assess the predictive ability of a single
absolute neutrophil count (ANC) value. Rather, the ANC was categorized
as being abnormally high or low if it fell outside the upper and lower
10th percentiles for chronological age. We used results from recent
studies,22-30 rather than the more commonly cited study
by Manroe et al,21 to define these percentile ranges,
which are provided in the "Appendix" (available to readers on
request).
We categorized chorioamnionitis as definite if an obstetrician
documented it, supporting evidence was provided (eg, uterine tenderness
or foul smelling amniotic fluid was present), and the highest
antepartum temperature exceeded 101.9°F. The definition of probable
chorioamnionitis was similar, except that the temperature threshold
used was >100.4°F. The definition of possible chorioamnionitis only
required an obstetrician's note.
We considered an infant to be asymptomatic if no abnormalities were
recorded in the chart. An infant was defined as critically ill if any
of the following occurred: 1) assisted ventilation (nasal continuous
positive airway pressure or intermittent mandatory ventilation), 2)
chest compressions, 3) needling of the chest or thoracostomy tube
placement, 4) continuous infusion of vasoactive drugs, and/or 5)
transport to a higher level of care (eg, for refractory persistent
pulmonary hypertension).
Screening for GBS
Screening for GBS is not routinely performed in the KPMCP, whose
obstetricians endorsed a risk factor-based strategy in
1994.31,32 Screening is performed based on the discretion
of individual clinicians. Intrapartum therapy uses either ampicillin or
a cephalosporin.
Outcome Assignment
Outcome assignment was based on culture results or clinical
factors (eg, results of physical examinations or chest roentgenograms). To avoid circular reasoning, we did not use CBC results or treatment decisions to define outcome. A culture-proven infection is defined as
an infection confirmed by a positive culture from a normally sterile
site. A probable infection is one in which the clinical course strongly
suggested that infection was present, although culture results were
negative. An example of a probable infection (meningitis) is an infant
with clinical signs and CSF pleocytosis (defined as having >30 white
blood cells and <45 000 red blood cells in the CSF33). A
possible infection is one in which an infant had negative cultures and
equivocal clinical findings but infection could not be excluded. An
example of this category is an infant who required assisted ventilation
and had only a single chest radiograph showing lung infiltrates. An
infection was considered nosocomial if it could be ascribed to care
processes (eg, Staphylococcus epidermidis sepsis after
prolonged intubation). Rehospitalization was defined as admission
within 7 days after an infant first went home.
Statistical Methods
Statistical analyses were performed using SAS (SAS, Cary,
NC).34 A total of 19 043 birth hospitalizations occurred at the 6 study
sites. We excluded 744 infants for the following reasons: 589 weighed
<2000 g at birth and 155 had major anomalies. Of the remaining 18 299
infants, 15 391 never had a CBC or blood culture obtained during the
birth hospitalization. Among the 2908 infants who had a CBC during the
birth hospitalization, medical record review showed that the CBC was
obtained for reasons other than to rule out sepsis in 123 cases: 5 were
born out of asepsis; 78 had a CBC as part of a jaundice evaluation; 4 had a CBC and blood culture obtained as part of a syphilis and/or human
immunodeficiency virus evaluation; and 36 had a CBC performed for some
other reason. Table 1 summarizes
characteristics of the remaining 2785 infants, who constitute the study
cohort.
TABLE 12000 g at birth in an era of widespread intrapartum antibiotic treatment. We focused on the first evaluation performed for
perinatally acquired non-nosocomial bacterial sepsis shortly after
birth. Our setting was the Kaiser Permanente Medical Care Program
(KPMCP), a mature managed care organization with integrated information
systems.
METHODS
Top
Abstract
Methods
Results
Discussion
References
2000 g at birth; 2) were
born in the hospital at the KPMCP Hayward, Oakland, Sacramento, San
Francisco, Santa Clara, and Walnut Creek facilities between October
1995 and November 1996; 3) were ever evaluated for bacterial infection
during the birth hospitalization; and 4) did not meet exclusion
criteria. An infant was considered to have been evaluated if a complete
blood count (CBC) and/or a blood culture was obtained. Infants were
excluded if: 1) a major congenital anomaly was present; 2) the first
evaluation was for suspected nosocomial infection; 3) the infant was
born outside the hospital; 4) the first evaluation occurred after
discharge home; 5) a CBC was performed for other reasons (eg,
jaundice); or 6) the CBC was obtained to evaluate for syphilis,
gonorrhea, or human immunodeficiency virus infection.
2 or Fischer's exact
tests were used to compare categorical predictors and
Student's t tests were used to compare mean
differences of continuous predictors. Least-square adjusted means were
produced using analysis of variance. Multivariate analyses were
performed using logistic regression after stratification by maternal
treatment. The area under the receiver operator characteristic curve
was calculated using the method of Hanley and McNeil.35
RESULTS
Top
Abstract
Methods
Results
Discussion
References
Description of Study Cohort
A total of 67 infants met our criteria for infection. Table 2 summarizes these infections and shows that 62 were non-nosocomial, 2 were nosocomial, and 3 were not under a caregiver's control. The 62 infants with non-nosocomial infections, thus, constitute the numerator for this study. Of these 62 infants, 12 were either asymptomatic or had transient clinical signs (ie, they seemed to have bacteremia rather than sepsis) and 2 of these 12 infants were sent home before confirmation of the diagnosis. Both of these infants were rehospitalized and treated with systemic antibiotics.
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Deaths and Postdischarge Outcomes
There were a total of 8 deaths in the cohort, including 4 with infections mentioned above. We were unable to track 10 infants to 1 week postdischarge. These 10 infants were healthy at discharge, and 2 had received antibiotic therapy.
The rehospitalization rate in the first week after discharge was 2.4% (67/2785). Infants were rehospitalized for the following reasons: jaundice and/or feeding difficulties, 52; confirmed infections (included in Table 1), 4; rule out sepsis with negative cultures, 4; and miscellaneous diagnoses, 7.
Other Cases of Vertically Transmitted Sepsis or Meningitis
We scanned the electronic records of the 15 391 infants who did not have a sepsis evaluation and of the 123 infants who had a CBC obtained for other reasons. Searches in KPMCP clinical, administrative, and research databases showed that none of these infants had sepsis or meningitis during the week after discharge from the birth hospitalization.
Descriptions of deaths, infants with infections, and infants lost to follow-up are provided in the "Appendix."
Neonatal Evaluation and Treatment
The majority of infants (75.8%) were first noted to be at risk for sepsis before or at the moment of birth and 91.2% were identified by 12 hours of age. The same occurred with the 205 infants who experienced assisted ventilation. Among these infants, 89.8% had such therapy initiated by 12 hours of age. All 62 of the infants with infections were identified by 10 hours of age.
A total of 1510 infants had clinical signs consistent with infection. Among the remaining 1275 infants who were initially asymptomatic, evaluations were performed because of risk factors for sepsis. These included maternal chorioamnionitis (425 infants or 33.3% of the asymptomatic infants); rupture of membranes (ROM) >18 hours (432; 33.9%); fever >100.4°F (315; 24.7%); GBS carriage (60; 4.7%); 188 prematurity; and foul smelling amniotic fluid (37; 2.9%)
Maternal Treatment
There were 1217 infants whose 1206 mothers were treated with intrapartum antibiotics. Among these 1206 mothers, 435 had chorioamnionitis documented by a physician's note; 589 had ROM >18 hours; 487 had other clinical signs consistent with infection (eg, temperature >100.9°F, ROM before delivery, and foul smelling amniotic fluid); 279 delivered at <37 weeks' gestation; and 81 were GBS carriers. The reason for intrapartum antibiotic therapy could not be determined in 125 women. There were 1568 infants whose 1541 mothers did not receive intrapartum antibiotics. Among these 1541 mothers, 121 had chorioamnionitis documented by a physician's note; 148 had ROM >18 hours; 154 had other clinical signs consistent with infection (eg, temperature >100.9°F, ROM before delivery, and foul smelling amniotic fluid); 194 delivered at <37 weeks' gestation; and 48 were GBS carriers.
Infection Rates in Specific Subgroups
Infection rates among specific infant subgroups are shown in Table
3 (stratified by maternal
characteristics) and in Table 4
(stratified by neonatal characteristics). Among treated infants, the
highest infection rates observed were in those who were critically ill
(where the rate was 9.7%) and those whose mothers' highest antepartum
temperature was 102°F (6.1%). The infection rate was lowest among
asymptomatic infants (.9%). Among untreated infants, the highest
infection rates were among those whose mothers' highest antepartum
temperature was 101.5°F (12.0%) and those who were critically ill
(10.3%). The infection rate was lowest among asymptomatic infants
(1.0%). Likelihood of infection increased with increasing temperature,
more rigorous documentation of chorioamnionitis, and increased clinical
signs. More detailed data are provided in the "Appendix."
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Among the 853 infants who received antibiotic therapy during the birth hospitalization, the first CBC was obtained before antibiotics were given in 669 cases (78%), within 2 hours after treatment in 173 (20%), and >2 hours in 11 (2%). The median difference between the time of the first CBC and the initiation of antibiotic therapy was 4 hours. All but 5 of these infants had a blood culture obtained.
Among the 1932 infants who were not treated with antibiotics during the
birth hospitalization, 1492 (77.2%) had the first CBC obtained between
0 and 11.9 hours of age, 242 (12.5%) between 12.0 and 23.9 hours of
age, and 194 (10.0%) at 24 hours of age. Only 61.2% of these
infants had a blood culture obtained. There were 4 infants who only had
a blood culture result recorded, because CBC results were lost.
A total of 68 asymptomatic infants experienced at least 1 lumbar puncture. None had meningitis. There were 10 cases of meningitis among the 153 symptomatic infants who experienced lumbar puncture.
Among the 1275 initially asymptomatic infants, where the infection rate was 1.0%, the treatment rate was 10.9%. If an infant had clinical signs but was not initially critically ill, where the infection rate was 2.3%, the treatment rate was 38.2%. Among the 182 infants who were critically ill, the infection rate was 10.9%. Only 144 of these 182 infants (79.1%) were treated with antibiotics. All 38 infants who were initially critically ill and who did not receive systemic antibiotics during the birth hospitalization were discharged from the hospital in good condition. We could not determine why physicians elected not to treat these infants.
Overall Effect of Maternal Antibiotic Treatment
Compared with infants who did not receive intrapartum antibiotics, infants whose mothers were so treated were more likely to be asymptomatic (694/1217 vs 781/1568; P = .001) and were less likely to be critically ill (65/1217 vs 718/1568; P = .021). They were also less likely to be infected (20/1217 vs 72/1568; P = .066).
Infections Among Infants of Confirmed GBS Carriers
The neonatal infection rate among confirmed GBS carriers was
11.5% (15/131). Among these women, 59/131 received antibiotic prophylaxis 4 hours before delivery. There were 5 infants with infections in this group, but only 1 with a positive blood culture. All
5 infants showed clinical signs of infection by 8 hours of age. There
were 10 infections (6 with positive cultures) among the infants of the
72/131 GBS carriers who did not receive antibiotic prophylaxis 4
hours before delivery. All 10 infants showed clinical signs of
infection by 12 hours of age.
Neutrophil Kinetics
The 62 infants with infections had significantly lower ANCs than those without infections, even after controlling for age of the infant at the time the test was obtained, whether the mother received intrapartum antibiotics, cesarean section status, prematurity, and presence of preeclampsia. The adjusted mean ± standard deviation (SD) for the ANC in infected infants was 6290 ± 710, whereas that for noninfected infants was 9610 ± 230. Having a high ANC was not associated with the presence of infection in multivariate analyses.
Figure 1 shows the ANCs of the 62 infants with infections superimposed on the 90th and 10th percentile bands. Figure 2 shows the ANCs of the 62 infants with infections superimposed on the 90th and 10th percentile bands according to Manroe et al.21 Nearly one half of the infants with infections would not have been considered to have a low ANC using these commonly used criteria. Table 5 compares the sensitivity, specifity, positive predictive value, and negative predictive value for the ANC, I:T ratio, and clinical examination. The area under the receiver operator characteristic curve for the I:T ratio was .74 ± .03.
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Multivariate Analyses (Table 6)
Evaluation of predictors for infection was performed separately
for infants who did and who did not receive intrapartum antibiotics. The dependent variable was the presence of any infection
(n = 42 for the untreated group; n = 20 for the treated group). Logistic models included the following
potential predictors: race (white, black, Hispanic, and all other),
maternal age (
20, 21-30, and 31 years); presence of maternal
chorioamnionitis; ROM length (11, 12-17, and 18 hours); infant
asymptomatic status; use of epidural anesthesia; history of diabetes;
history of illegal drug use in this pregnancy; preeclampsia; whether
the ANC was in the lowest 10th percentile for age (both criteria);
gestation (<37 vs 37 weeks); birth weight (<2500 g vs 2500 g);
and parity (primigravidas vs all others). We added the following
predictors to models for the treated group: whether antibiotic
therapy occurred 4 hours before delivery; meconium-stained amniotic
fluid; and placental problems (oligohydramnios or polyhydramnios). In
light of the results of bivariate analyses (provided in the
"Appendix"), we added the following predictors to models for the
untreated group: obstetric catastrophe (placenta previa, placental
abruption, uterine rupture, and/or prolapsed umbilical cord); cesarean
section; and oligohydramnios.
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Stepwise models showed that the following variables were significantly associated with an increased risk of infection: ANC in lowest 10th percentile for chronological age and presence of meconium in the amniotic fluid. Initial asymptomatic status was protective. Maternal chorioamnionitis was significantly associated with neonatal infection in the untreated group but not in the treated group.
We tested 2 additional models, substituting 2 objective variables for
chorioamnionitis: ROM length and highest maternal antepartum temperature. The first model included highest antepartum temperature 101.5°F; ROM 12 hours; ANC in lowest 10th percentile for
chronological age; asymptomatic status; and presence of meconium in the
amniotic fluid. Among infants of untreated mothers, all of these
predictors remained significant. Among infants of treated mothers, only
fever and low ANC remained significant, although asymptomatic status approached significance (adjusted odds ratio [AOR]: .42; 95%
confidence interval [CI]: .16-1.11). The second model used ROM 18
hours; this predictor was not significant in either group.
We also forced race (white vs non-white), maternal age (20, 21-30,
and 31 years), and parity (primigravidas vs all others) into the
models shown on Table 4. The same variables remained predictive without
major changes in odds ratios (ORs). To assess possible treatment bias
in our infection definition, we tested the above models using modified
criteria (infants who received systemic antibiotics and experienced
assisted ventilation or received pressors were considered to have an
infection). Chorioamnionitis, initial asymptomatic status, and low ANC
for age remained predictive.
We did not find significant associations between time of maternal treatment and infection in bivariate or multivariate analyses.
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
References
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Rule out sepsis is one of the most common discharge diagnoses in neonatology. We are not aware of other population-based studies that provide maternal and neonatal data on all infants ever evaluated or of any similar studies with postdischarge follow-up.
We must stress certain limitations. Our study population is one of relatively low risk. However, less controversy exists about treating high-risk infants, so this limitation is not significant, and our findings can be generalized to other insured populations. A second limitation inherent in our study design is that we cannot fully assess the effect of certain risk factors (eg, prematurity) because women with such risk factors receive special treatment (eg, intrapartum antibiotics) in the KPMCP. Our retrospective methodology may underestimate the true frequency of infection attributable to false-negative culture results and prompt resolution of clinical signs in some infants. Because only 221/2785 newborns had one, our study can only have a limited role in addressing another controversial issue, whether all infants suspected of sepsis should have a lumbar puncture.5,9,10,12 Finally, we did not use a test recommended by some authors, C-reactive protein (CRP).36-38 Use of CRP is not widespread in the KPMCP because the existing literature does not permit full assessment of its utility (eg, no data are available comparing the predictive ability of CRP with that of the clinical examination).
The risk of sepsis among asymptomatic infants is very low.9,11,12 In our cohort, asymptomatic infants had an infection rate of 1.0%. This low rate is still 10 times as high as the population rate (~1/1000 live births in this birth weight range).1,2 This finding supports the notion that screening, treatment, and observation protocols cannot be based on asymptomatic status alone.
We found that outcomes among infants whose mothers received intrapartum antibiotics are better than among those whose mothers did not. Infants whose mothers were treated were less likely to be symptomatic, need assisted ventilation, or have bacterial infection. The rationale for intrapartum treatment is based on randomized clinical trials.39,40 However, adoption of this strategy by obstetricians is not uniform, and many pediatricians remain unconvinced that maternal treatment obviates the need for neonatal treatment.39-43 One key concern is that such treatment may partly suppress bacterial growth leading to false-negative culture results.39,40,42
We did not find differences in outcome associated with the timing of maternal treatment. This should be interpreted carefully. Strong biologic reasons for supporting early maternal antibiotic treatment exist.44-46 Similar caution should be exercised with respect to conditions (eg, diabetes) associated with perinatal morbidity, which, although predictive, failed to reach statistical significance in our analyses because of limited numbers.
Our findings with respect to the CBC suggest that use of this test needs reassessment. Current recommendations are vague and are based on small studies. They emphasize using CBC results obtained at 12 to 24 hours of age and the use of the I:T ratio, an extremely subjective and statistically unreliable47 test which Schelonka et al22,23 have shown to classify large numbers of normal newborns as being at risk for sepsis. A better way to use the CBC as a screening tool would be to define likelihood ratios for ANC percentile ranges based on an infant's chronological age.48 Our finding that the sensitivity of the physical examination is greater than that of the I:T ratio or ANC supports this approach.
Our finding that only 144/182 of initially critically ill infants received systemic antibiotics suggests that more variation exists in this area than has been previously suspected. Our data provide a hint as to what may account for some of this variation. First, some infants may be misclassified by existing approaches used to interpret CBC results. Second, given limited data, clinicians are both overestimating and underestimating infants' risk for infection. Other reasons may have played a role, but determining these is outside the scope of this article. A recent study suggests that what we are describing may not be so uncommon. Baker et al49 developed and implemented an evidence-based protocol and recently reported that 28/422 febrile infants were not managed according to a defined standard of care, including 21/321 high-risk infants who did not receive antibiotics.50 Clearly, more research is needed in the areas of clinician compliance as well as clinician perception of risk.
We were also surprised that many women with clear indications for systemic antibiotics (eg, presence of chorioamnionitis) did not receive them. These findings point out how clinician behavior deviates from what is considered appropriate in the literature, and that nominal adherence to a given strategy (such as the risk factor-based strategy proposed by the Centers for Disease Control and Prevention39) may be insufficient to change clinician behavior. Screening for GBS is not universal in the KPMCP. The fact that only 15% of women who were screened tested positive suggests that current KPMCP strategies may not be that effective. This phenomenon has been documented in other settings.39-41,43
A detailed assessment of how findings from this study could help define strategies for evaluating newborns at risk for sepsis is outside the scope of this article. Such strategies should be based on combinations of predictors, 4 of which are critical: chorioamnionitis; elevated maternal temperature; initial neonatal examination; and whether the mother received intrapartum treatment. Coupled with judicious, empirically defined time frames, it should be possible to define rational recommendations for appropriate neonatal antibiotic treatment and/or observation. Such recommendations would undoubtedly lead to increased treatment in some infants (eg, those experiencing respiratory failure) and less treatment in a larger group of infants (those with few or no clinical signs).
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ACKNOWLEDGMENTS |
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This study was supported by the Kaiser Foundation Health Plan, Inc and the Permanente Medical Group, Inc (Innovation Program Grant 115-6030); by the Sidney Garfield Memorial Fund (Grant 115-9025); and by Grant MCJ-060803 from the Maternal and Child Health Program (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services.
Neonatal Infection Study Group includes the following members: Dr Randy Bergen, KPMC Walnut Creek; Dr Lawrence Dong, KPMC Santa Clara; Dr Allen Fischer, KPMC Sacramento; Dr Michael Jennis, KPMC Oakland; Dr James Kantor, KPMC San Francisco; Dr Alma Martinez, San Francisco General Hospital; Dr Stephen McMurtry, KPMC Vallejo; Dr Brian Saunders, KPMC San Diego; Dr Cindy Wikler, KPMC Hayward; and Dr Ted Zukin, KPMC Walnut Creek.
We extend special thanks to Drs Marc Usatin, Albert Kahane, W. Harry Caulfield, Steve Black, Henry Shinefield, William Likosky, and Francis J. Crosson, whose enthusiastic administrative support made completion of this study possible.
We also thank Randy Watson, Wesley Hawkins, Ana Macedo, Vernal Mason, Marlena Jacobs, and Jodi Cupp for their assistance during the course of the study, and Dr Janet Mohle-Boetani for her help in the review of group B streptococcal data.
We also thank Drs Joseph V. Selby, Tracy A. Lieu, Thomas B. Newman, and Douglas K. Richardson for reviewing the manuscript.
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FOOTNOTES |
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Received for publication Apr 12, 1999; accepted Oct 5, 1999.
Reprint requests to (G.J.E.) Kaiser Permanente Medical Care Program, Division of Research, Perinatal Research Unit, 3505 Broadway, Room 718, Oakland, CA 94611. E-mail: gabriel.escobar{at}ncal.kaiperm.org
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ABBREVIATIONS |
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KPMCP, Kaiser Permanente Medical Care Program; CBC, complete blood count; GBS, group B streptococcus(al); CSF, cerebrospinal fluid; I:T ratio, ratio of immature to total neutrophils; ANC, absolute neutrophil count; ROM, rupture of membranes; SD, standard deviation; AOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio; CRP, C-reactive protein.
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REFERENCES |
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Abstract
Methods
Results
Discussion
References
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1996.
Pediatrics
1997;
100:905-918 This article has been cited by other articles:
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 D. Gazzolo, D. Grutzfeld, F. Michetti, A. Toesca, M. Lituania, M. Bruschettini, A. Dobrzanska, and P. Bruschettini Increased S100B in Cerebrospinal Fluid of Infants with Bacterial Meningitis: Relationship to Brain Damage and Routine Cerebrospinal Fluid Findings Clin. Chem., May 1, 2004; 50(5): 941 - 944. [Full Text] [PDF]
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G. L. Jackson, W. D. Engle, D. M. Sendelbach, D. A. Vedro, S. Josey, J. Vinson, C. Bryant, G. Hahn, and C. R. Rosenfeld Are Complete Blood Cell Counts Useful in the Evaluation of Asymptomatic Neonates Exposed to Suspected Chorioamnionitis? Pediatrics, May 1, 2004; 113(5): 1173 - 1180. [Abstract] [Full Text] [PDF]
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G. J. Escobar Effect of the Systemic Inflammatory Response on Biochemical Markers of Neonatal Bacterial Infection: A Fresh Look at Old Confounders Clin. Chem., January 1, 2003; 49(1): 21 - 22. [Full Text] [PDF]
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G. J. Escobar, P. A. Braveman, L. Ackerson, R. Odouli, K. Coleman-Phox, A. M. Capra, C. Wong, and T. A. Lieu A Randomized Comparison of Home Visits and Hospital-Based Group Follow-Up Visits After Early Postpartum Discharge Pediatrics, September 1, 2001; 108(3): 719 - 727. [Abstract] [Full Text] [PDF]
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