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Objective: To develop definitions of bloodstream infections in sociated categories) used by neonatal clinicians and researchers
the newborn that would enable clinicians to identify infection have been either adapted/modified from definitions developed for
early, so patients can be enrolled in clinical trials. The definitions adults or generated by individuals to suit their local needs or the
should be useful for surveillance and epidemiologic purposes. needs of a particular study. It is clear that definitions generated
Method: Search of EMBASE, MEDLINE, and Cochrane Library for adults are not applicable to children or to newborn infants. In
using age and English language limited key words sepsis, septi- addition, developing and using unique definitions to suit individ-
cemia, and shock. Extensive study of textbook of neonatology and ual or local needs make comparisons of outcome data and result
discussions with experts in the field. of studies very difficult. This article proposes a set of definitions
Results: The search identified >2,000 references. The most that are based as much as possible on current evidence. These
appropriate were selected and reviewed. Definitions of blood- definitions may be applicable widely for daily management of an
stream infection were developed after consultation with an inter- infant with an infection and for research and epidemiologic stud-
national faculty. ies. (Pediatr Crit Care Med 2005; 6[Suppl.]:S45–S49)
Conclusion: Current definitions of neonatal infection (and as- KEY WORDS: definitions; neonatal infections; neonatal sepsis
I n September 2004, the Interna- in their application to meet the previ- large volumes of blood or multiple sam-
tional Sepsis Forum convened a ously mentioned objectives. Descriptions ples can be taken, this is not possible in
consensus conference to establish of specific definitions of pediatric infec- the newborn, where the average volume
a series of definitions for a large tions, systemic inflammatory response of blood placed in a blood culture bottle is
number of infections in children and in syndrome (SIRS), sepsis, severe sepsis, ⬍0.5 mL (1, 2), making this test mark-
the newborn. The goals of these defini- and septic shock produced by the Inter- edly less sensitive.
tions were as follows: national Consensus Conference in 2002 Decision making in clinical medicine
are in press; they do not include defini- requires quantitative reasoning based on
1. Identify infection early so that optimal
tions of BSI in the newborn. An attempt the probability of the disease being
therapy can be instituted.
is made to suggest definitions for neo- present. This in itself is based on the
2. Identify infections so that patients can
nates based on available evidence and to correct interpretation of clinical signs
be enrolled in clinical trials
provide an explanation and the rationale and symptoms and results from labora-
3. Be useful for surveillance and epide-
behind the variables used to support the tory investigations plus clinicians’ per-
miologic studies
suggested definitions. ceived ratio between harm and benefit of
This submission deals with blood- BSI reflects a highly complex process the treatment. However, at the end of the
stream infections (BSIs) in the newborn day the ultimate decision made by an
that is dependent on a series of interac-
including term and premature infants. It astute clinician must be based on
tions between a pathogen and the host.
briefly outlines the burden of the disease Chachmah or wisdom.
Our understanding of this process has
in both the developing and the developed
improved considerably in recent years
world, describes the search strategy used, Burden of Disease
and is still evolving. It is now accepted,
discusses the definitions currently in
for example, that the traditional concepts Throughout the world, 1.6 million
common use, and reviews the difficulties
of BSI do not adequately reflect events in neonates die every year from infection
vivo and may even be an oversimplifica- (3). Although most of these deaths are
tion of the processes involved. This im- in developing countries, where neona-
From the University of London and Epsom and St.
Helier University Hospitals, NHS Trust, Carshalton, UK. provement in our understanding has tal mortality from sepsis may be as high
This work was supported by the Mannion Family highlighted the fact that the definitions as 60% (4), the incidence of infection in
Fund—Center for the Critically Ill Child, Division of of sepsis used in adults or even in chil- the developed world is also high at 2.2–
Critical Care Medicine at Children’s Hospital Boston, dren cannot be extrapolated to neonates.
the PALISI Network, and the ISF. 8.6 per 1000 live births (5). In fact, 48%
Copyright © 2005 by the Society of Critical Care For example, in adults and even in older of all infections occur in children of ⬍1
Medicine and the World Federation of Pediatric Inten- children, great reliance is placed on a yr of age, and just over half (27%) occur
sive and Critical Care Societies positive blood culture for diagnosis of in the newborn period. Despite under-
DOI: 10.1097/01.PCC.0000161946.73305.0A BSI. Although this may be valid where reporting, which is common, between