|Year : 2015 | Volume
| Issue : 2 | Page : 101-103
D-dimer: A useful marker in neonatal sepsis
Pancham Kumar1, Anjula Chauhan2, Parveen Bhardwaj1, Lokesh Chauhan1, Mohit Karol1
1 Department of Pediatrics, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
2 Department of Mathematics, Rajkiya Kanya Maha Vidyalaya, Shimla, Himachal Pradesh, India
|Date of Web Publication||6-Apr-2015|
Dr. Pancham Kumar
Department of Pediatrics, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Objectives: To measure D-dimer levels in neonatal sepsis and compare D-dimer as a marker of sepsis with the gold standard that is, blood culture and other established marker of sepsis like C-reactive protein, micro-erythrocyte sedimentation rate and total leucocyte count (TLC) in predicting sepsis. Study Design: Prospective observational hospital based study. Setting: Tertiary care hospital. Subjects: From November 2010 to October 2011, 936 neonates were admitted to the neonatal unit of Indira Gandhi Medical College, Shimla, Himachal Pradesh. Out of these, 355 neonates were admitted with suspected sepsis. Out of these, only 101 term neonates were without asphyxia and blood culture positive and were enrolled as cases, and 96 term neonates without the asphyxia admitted for neonatal jaundice without sepsis were enrolled as controls. Methods: All neonates, cases and control were investigated as per the protocol at admission and simultaneously the D-dimer levels were measured. D-dimer levels were evaluated in predicting neonatal sepsis and were compared with other established markers of sepsis in predicting sepsis. Results: In the study group, age ranged from 0 to 22 days with an average of 5.58 days. In the control group, age ranged from 0 to 23 days with an average of 5.62 days. Sex distribution was almost equal in both groups. The mean value of D-dimer in the cases and control group were 1.832 mg% and 1.365 mg% respectively. The study group had significantly higher values of D-dimer (P - 0.04). Sensitivity and negative predictive value of D-dimer in predicting sepsis were 90.0% and 84.4% respectively, the highest amongst all the markers studied in sepsis. Positive predictive value and specificity of TLC in sepsis was highest in all the marker studied. Negative predictive value of various markers was comparable in sepsis. Conclusion: D-dimer is a sensitive predictor of sepsis in neonates with a high sensitivity and negative predictive value. Hence, it should be included in the septic screening of newborns.
Keywords: D-dimer, sepsis, screen
|How to cite this article:|
Kumar P, Chauhan A, Bhardwaj P, Chauhan L, Karol M. D-dimer: A useful marker in neonatal sepsis. J Clin Neonatol 2015;4:101-3
| Introduction|| |
Sepsis is one of the most common problems encountered in neonatology. , Early diagnosis of neonatal sepsis continues to pose a problem to the doctors caring for newborns. It is proposed that coagulation dysfunction, one of the many complications of neonatal sepsis is present in around 10% of sick newborn.  It may be evident or subclinical disseminated intravascular coagulation. D-dimer one of fibrinogen degradation product is increased in disseminated intravascular coagulation. Hence, in this observational prospective study, the role of D-dimer as a predictor of sepsis in newborns has been studied and also compared with previously studied and established markers of sepsis.
| Methods|| |
From November 2010 to October 2011, 936 neonates were admitted to the neonatal unit of Indira Gandhi Medical College, Shimla, Himachal Pradesh. Out of these, 355 neonates were admitted with suspected sepsis. Out of these, only 101 term neonates with blood culture positive sepsis were enrolled as cases and 96 term neonates admitted for neonatal jaundice without sepsis were enrolled as controls.
All neonates, cases as well as controls were investigated as per the protocol at admission and simultaneously the D-dimer levels were measured. D-dimer levels were evaluated for predicting neonatal sepsis and were compared with other established markers of sepsis. D-dimer was measured using NycoCard kit. Test principle for measuring was based upon an immunometric flow through principle measuring range was taken to be 0.1-20.0 mg. Measuring interval was taken to be be 0.1 mg, and values<0.3 were considered to be normal. Neonates with congenital anomalies, birth asphyxia and prematurity were not included in the study, being confounding variables. The neonates with probable sepsis were also excluded from the study. Only culture positive neonates were taken as cases. The following case definition was used:
Neonates admitted with clinical picture suggestive of septicemia (lethargy, refusal or decreased feeding, diarrhea, vomiting, abdominal distention hypothermia, hyperthermia, poor weight gain, weight loss, tachypnea, grunt, apnea, poor respiratory effort, chest retractions, shock, excessive cry, irritability, neck retractions, seizures, bulging anterior fontanel) with isolation of pathogen in blood culture. 
| Results|| |
In the study group, age ranged from 0 to 22 days with an average of 5.58 days. In the control group age ranged from 0 to 23 days with an average of 5.62 days. Sex distribution was almost equal in both groups [Table 1].
The incidence of confirmed sepsis in the suspected group was 44.82%. The mean value of D-dimer in the cases and control group were 1.832 mg% and 1.365 mg% respectively. The study group had significantly higher values of D-dimer (P - 0.04) as shown in [Table 2].
Mean values along with range of D- dimer, TLC, microESR and CRP are shown in [Table 3]. Sensitivity and negative predictive value of D-dimer was highest in confirmed sepsis amongst all the markers studied. Positive predictive value and specificity of total leucocyte count (TLC) in confirmed sepsis was highest amongst all markers studied. Negative predictive value of various markers was comparable in suspected, confirmed and probable sepsis [Table 4].
|Table 4: Comparison of various markers of sepsis with D-dimer in predicting sepsis|
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| Discussion|| |
D-dimer values were significantly higher in the study group as compared to the control group [Table 2]. D-dimer had the highest sensitivity of 90.0% among all markers in the sepsis group [Table 4]. As in the study by Mautone et al.  it was found that D-dimer is increased in septic neonates as compared to newborns with mild infection. Armengou et al. in his study in foals found that normal D-dimer concentration is better at eliminating the diagnosis of sepsis than an increased D-dimer concentration at predicting sepsis.
In the other markers of sepsis studied positive predictive value and specificity of TLC in neonatal sepsis was highest (82.8% and 90.7% respectively). Micro-erythrocyte sedimentation rate (MicroESR) in the study was found to have highest negative predictive value in sepsis. C-reactive protein (CRP) was reasonably fair marker of sepsis on various parameters like positive and negative predictivity, sensitivity and specificity [Table 4].
Total leucocyte count, CRP and microESR in study had various parameters like positive and negative predictivity, sensitivity and specificity values, which were comparable to the studies carried in past by Fowli and Schmidt et al., Garland and Bowman, Misra et al., Ahmed et al. ,,,
Comparison of D-dimer with total leucocyte count, C-reactive protein and micro-erythrocyte sedimentation rate in predicting neonatal sepsis
It can be concluded that D-dimer is a sensitive marker in predicting sepsis as it had the highest sensitivity of 90% amongst D-dimer, TLC, CRP and microESR [Table 4].
D-dimer had the lowest specificity and positive predictive value of 58.3% and 69.4% respectively amongst the markers studied. Highest specificity and positive predictive value of 82.8% each, was seen for TLC [Table 4].
Negative predictive value of D-dimer was comparable to other markers of the sepsis studied. However, D-dimer and microESR had high negative predictive of value 84.4% and 90.4% respectively [Table 4].
| Conclusion|| |
D-dimer in the present study has been shown to be the most sensitive predictor of sepsis in neonates with a sensitivity and negative predictive value of 90% and 84.4% respectively. Considering high sensitivity and negative predictive value of D-dimer, it can be a very useful tool during dilemma of neonatal sepsis in addition to its established role in coagulation disturbances. However, keeping in view the small study group, further study on a larger group of newborns is suggested to further validate the role of D-dimer as a predictor of sepsis.
| References|| |
Singh M. Care of Newborn. 7 th
ed. Delhi: Satya Publications; 2010. p. 223.
Puopolo KM. Bacterial and fungal infections. In: Cloherty JP, Eichenward EC, Stark AR, editors. Manual of Neonatal Care. 6 th
ed. New Delhi: Wolters Kluwer (India) Pvt. Ltd.; 2008. p. 274-300.
Singh M. Care of Newborn. 7 th
ed. Delhi: Satya Publication; 2010. p. 358.
Tripathi S, Malik GK. Neonatal sepsis: Past, present and future. Internet J Med Update 2010;5:45-54.
Mautone A, Giordano P, Montagna O, Quercia M, Altomare M, De Mattia D. Coagulation and fibrinolytic systems in the ill preterm newborn. Acta Paediatr 1997;86:1100-4.
Armengou L, Monreal L, Tarancon I, Navarro M, Rios J, Segura D. Plasma D-dimer concentration in sick newborn foals. Journal of Veterinary Internal Medicine 2008:22; 411-7.
Fowlie PW, Schmidt B. Diagnostic tests for bacterial infection from birth to 90 days - A systematic review. Arch Dis Child Fetal Neonatal Ed 1998;78:F92-8.
Garland SM, Bowman ED. Reappraisal of C-reactive protein as a screening tool for neonatal sepsis. Pathology 2003;35:240-3.
Misra PK, Kumar R, Malik GK, Mehra P, Awasthi S. Simple hematological tests for diagnosis of neonatal sepsis. Indian Pediatr 1989;26:156-60.
Ahmed Z, Ghafoor T, Waqar T, Ali S, Aziz S, Mahmud S. Diagnostic value of C-reactive protein and haematological parameters in neonatal sepsis. J Coll Physicians Surg Pak 2005;15:152-6.
[Table 1], [Table 2], [Table 3], [Table 4]