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but these manifestations may be subtle and nonspecific and are also found in non-infectious diseases&#46; Laboratory parameters can help identify it&#44; but they also offer a low specificity and can be altered in other conditions&#44; such as foetal distress or hypoxia-ischaemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Blood culture&#44; despite being the gold standard for diagnosis&#44; can have a decreased sensitivity in newborns due to a variety of factors&#44; such as bacteraemia with low bacterial loads&#44; the use of intrapartum antibiotic prophylaxis or difficulty drawing the necessary volume of blood&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#8211;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Universal maternal screening for colonization by <span class="elsevierStyleItalic">S&#46; agalactiae</span>&#44; the improved identification of risk factors for infection and the standardization of intrapartum antibiotic prophylaxis in risk pregnancies have achieved a drastic reduction in the incidence of EONS in the past few decades&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This has led various scientific societies to consider a change in detection strategies&#44; and the most recent management guidelines published by the American Academy of Pediatrics and several publications suggest that clinical observation of newborns could suffice for screening of vertically transmitted infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">On the other hand&#44; other tools have also been proposed in recent years&#44; such as the neonatal sepsis risk calculator &#40;available at <a href="https://neonatalsepsiscalculator.kaiserpermanente.org">https&#58;&#47;&#47;neonatalsepsiscalculator&#46;kaiserpermanente&#46;org</a>&#41;&#44; use of which could reduce the rate of hospitalization&#44; the use of diagnostic tests and the prescription of unnecessary empirical antibiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;12</span></a> However&#44; given the lack of clinical trials of large scope&#44; that it does not take into account the presence or absence of chorioamnionitis and that data on its safety are still scarce&#44; its utility is still under debate&#44; and some authors recommend against its use due to the risk of missing cases of sepsis or bacteraemia or of delayed initiation of antibiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;13&#44;14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Delays in the detection and treatment of EONS can cause significant sequelae and even the death of the patient&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but&#44; on the other hand&#44; the unnecessary use of antibiotics also has deleterious effects&#44; such as altering the normal flora of the newborn&#44; the development of antimicrobial resistance&#44; the increased risk of other infections and even an increase in overall mortality&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition&#44; the hospitalization of newborns increases health care costs&#44; results in the performance of more painful procedures and in some instances requires the separation of the newborn from the parents&#44; which can interfere with bonding and initiation of breastfeeding&#44; with the consequent risk to the infant&#8217;s neurodevelopment&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Thus&#44; it is important to find the balance between correctly identifying newborns with EONS and correctly use of diagnostic tests and rational use of antibiotics&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As it seems reasonable to assume that decreases in the incidence of EONS reflect a change in the management of these infants&#44; protocols are increasingly focusing on reducing the use of diagnostic tests and unnecessary antibiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> The aim of our study was to analyse the efficiency and yield of 3 different screening strategies in the detection of EONS&#44; with the purpose of identify the strategy that offers the best risk-benefit ratio for the newborn&#44; and to assess the safety of the new protocol in our hospital&#44; which promotes a less-invasive approach&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">We conducted a retrospective observational study including neonates born between January 1 and October 31&#44; 2020 at or after 34 weeks of gestation &#40;WG&#41;&#44; admitted to the maternity ward or the department of neonatal care who had perinatal risk factors for the development of EONS &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and&#47;or were admitted due to symptoms compatible with infection&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Our hospital manages approximately 2700 deliveries a year and has a level IIIC neonatal care unit with 25 intensive care beds and 32 intermediate care beds&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In addition&#44; there are 4 beds for rooming-in with the mother in the maternity ward for late preterm newborns delivered after 34 WG with birth weights greater than 1800 g in stable condition and for newborns with diseases requiring admission but not intensive care&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We excluded patients for whom we could not obtain full perinatal records due to transfer from another hospital or birth out of hospital&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We defined microbiologically confirmed sepsis by the presence of clinical manifestations of infection with elevation of acute phase reactants and a positive blood or cerebrospinal fluid culture&#46; We defined clinical&#47;laboratory sepsis by the observation of signs or symptoms of infection that could not be explained by a different aetiology associated with elevation of acute phase reactants but with negative microbiological results&#46; We defined asymptomatic bacteraemia by a positive blood culture in the absence of clinical and laboratory features of infection&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We reviewed the electronic health records of each patient to collect data on obstetric variables&#44; risk factors for infection&#44; childbirth variables&#44; clinical features at birth&#44; blood and microbiological tests and neonatal hospitalization-related variables &#40;setting of admission&#44; reason for admission&#44; antibiotherapy &#91;type and duration&#93;&#44; length of stay&#44; diagnosis&#44; death&#44; complications&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">We collected all the information in a database generated with the software SPSS version 25&#46;0&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">When the patients in the sample were born&#44; the old protocol for EONS of the hospital was applied &#40;strategy 1&#41;&#46; Based on the clinical manifestations&#44; perinatal data and the risk factors of infection and assuming a probability of EONS of 1 case in 1000 live births based on the incidence in our hospital the previous year&#44; we analysed the hypothetical approach that would have been implemented with the use of the neonatal sepsis calculator &#40;strategy 2&#41; and with the newly proposed protocol of our hospital &#40;strategy 3&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> details the characteristics of the three strategies&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">We started by performing a descriptive analysis to obtain frequencies and measures of central tendency and dispersion&#46; In the inferential analysis&#44; we used different statistical tests depending on the nature of the variables&#58; Kolmogorov-Smirnov and Shapiro-Wilk tests&#44; &#967;<span class="elsevierStyleSup">2</span> test&#44; Mann-Whitney <span class="elsevierStyleItalic">U</span> and Kruskal-Wallis tests&#46; We then made a comparative analysis of screening strategies&#44; comparing the current protocol &#40;strategy 1&#41; with both the use of the neonatal sepsis calculator &#40;strategy 2&#41; and the newly proposed protocol &#40;strategy 3&#41; in terms of the following variables&#58; patients considered candidates for laboratory screening&#44; hospital admission&#44; antibiotherapy&#44; detected cases and undetected cases of sepsis&#46; We used the McNemar test for paired data&#46; We considered <span class="elsevierStyleItalic">P</span> values of less than 0&#46;05 statistically significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">In the 10-month period under study&#44; 2316 newborns were admitted to the maternity ward or the neonatal unit of our hospital&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">After excluding preterm newborns delivered before 34 SG&#44; asymptomatic patients with no risk factors for infection and newborns delivered outside our hospital&#44; the sample included a total of 754 patients&#46; Of this total&#44; 74&#37; were born vaginally and 53&#46;1&#37; were male&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents the frequency of risk factors for infection&#46; One hundred and nine patients &#40;14&#46;4&#37;&#41; had 2 or more risk factors&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Blood tests and blood culture were performed in 428 newborns &#40;56&#46;8&#37;&#41;&#44; in 368 as indicated by the protocol of the unit and in 60 due to the presence of symptoms &#40;out of which it would have also been indicated by the protocol in 31&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">One hundred and twenty patients &#40;15&#46;9&#37;&#41; required admission &#40;28 rooming-in with the mother&#44; 27 in intermediate care and 65 in intensive care&#41;&#46; The reasons for admission were&#58; manifestations compatible with vertically transmitted infection &#40;60 patients&#41;&#44; prematurity &#40;n &#61; 24&#41;&#44; elevation of C-reactive protein in asymptomatic patient &#40;n &#61; 16&#41;&#44; bacteraemia in asymptomatic patient &#40;n &#61; 1&#41; and other non-infectious diseases &#40;n &#61; 19&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Sixty-five newborns &#40;8&#46;6&#37;&#41; received antibiotherapy&#44; of who 12 &#40;1&#46;6&#37;&#41; completed a minimum of 5&#8211;7 days on account of clinical&#47;laboratory sepsis &#40;10&#59; 1&#46;34&#37;&#41;&#44; microbiologically confirmed sepsis &#40;1&#59; 0&#46;13&#37;&#41; or asymptomatic bacteraemia &#40;1&#59; 0&#46;13&#37;&#41;&#46; Three of the cases of sepsis occurred in preterm newborns &#40;2 microbiologically confirmed&#44; 1 clinical&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">One patient died at 12 h post birth in the context of septic shock caused by <span class="elsevierStyleItalic">E&#46; coli</span>&#46; The bacterium isolated in the 2 patients with a positive blood culture that survived was <span class="elsevierStyleItalic">Enterococcus faecalis &#40;E&#46; faecalis&#41;&#46;</span></p><p id="par0115" class="elsevierStylePara elsevierViewall">Seventy newborns exhibited symptoms compatible with infection&#58; 10 were not admitted because the symptoms were mild and self-limited to the first hours of life&#44; and 60 required admission&#44; of who 48 received antibiotherapy&#46; In the remaining 12 newborns&#44; a watchful waiting approach was implemented on account of their symptoms being self-limited and compatible with transient tachypnoea or respiratory distress syndrome and the absence of leucocytosis or significant elevation of C-reactive protein &#40;CRP&#41; in the tests conducted at admission&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">All of the patients admitted due to clinical manifestations &#40;most of them&#44; respiratory distress&#41;&#44; underwent testing of CRP levels&#46; We found statistically significant differences in the maximum CRP levels between the group with a presentation classified as non-infectious &#40;median CRP&#44; 1 mg&#47;dL&#59; range&#44; 0&#46;02&#8211;4&#46;63&#41; and the group classified as having sepsis &#40;median 3&#46;87 mg&#47;dL&#59; range&#44; 0&#46;09&#8211;10&#46;69&#41; &#40;<span class="elsevierStyleItalic">P</span> &#61; 0&#46;038&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">We also found statistically significant differences in the maximum CRP levels between the group of patients who did not receive antibiotherapy and the group that did &#40;no antibiotics&#44; 0&#46;1 mg&#47;dL &#91;0&#46;02&#8211;1&#46;38&#93; vs antibiotics&#44; 1&#46;13 mg&#47;dL &#91;0&#46;02&#8211;10&#46;69&#93;&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">All patients that received a diagnosis of sepsis or bacteraemia had suggestive symptoms of infection&#44; save for 1 patient with asymptomatic bacteraemia by <span class="elsevierStyleItalic">E&#46; faecalis</span> who underwent screening due to risk factors for infection and whose blood culture prior to initiation of antibiotherapy was negative&#44; a case in which the decision to complete the 7-day course of antibiotherapy was made on account of the characteristics of the pathogen&#46; None of the asymptomatic patients that were admitted to hospital and who started antibiotherapy based on isolated CRP elevation received a diagnosis of sepsis or bacteraemia&#46; Three patients with a diagnosis of sepsis &#40;23&#37; of the cases of sepsis&#47;bacteraemia&#41; had no risk factors for infection&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> presents the results for the 3 screening strategies&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">We found statistically significant differences in the comparison of the former protocol &#40;strategy 1&#41; and the sepsis calculator &#40;strategy 2&#41; in the indication to do laboratory tests &#40;56&#46;8&#37; vs 9&#46;95&#37; of patients with S1 vs S2&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41;&#44; admission due to suspected infection &#40;11&#37; vs 6&#46;9&#37; with S1 vs S2&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41; and administration of antibiotherapy &#40;8&#46;6&#37; vs 6&#46;7&#37; with S1 vs S2&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">When we compared strategy 1 with the newly proposed protocol &#40;strategy 3&#41;&#44; we also found significant differences in the indication to do laboratory tests &#40;56&#46;8&#37; vs 22&#46;4&#37; with S1 vs S3&#59; <span class="elsevierStyleItalic">P</span> &#60; 0 &#46;01&#41;&#44; admission due to suspected infection &#40;11&#37; vs 7&#46;9&#37; with S1 vs S3&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41; and administration of antibiotherapy &#40;8&#46;6&#37; vs 6&#46;4&#37; with S1 vs S3&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">Our study demonstrated that the change in the strategy for detection of early-onset neonatal sepsis toward a less invasive approach based on observation could reduce the use of diagnostic tests&#44; the need of hospital admission and unnecessary administration of antibiotics without an increase in the frequency of undetected sepsis&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">With the former protocol in our hospital&#44; diagnostic tests were used often&#44; as blood tests and culture were ordered in more than half of patients with a risk factor for infection&#46; In a population similar to the sample under study&#44; the implementation of the newly proposed protocol would result in an important decrease in the laboratory tests performed with the previous protocol&#44; a reduction that would be even larger if the neonatal sepsis calculator was used instead&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">With strategy 1&#44; blood culture was indicated in patients with the highest risk &#40;intrapartum maternal fever&#44; suspected chorioamnionitis&#44; prolonged rupture of membranes or preterm birth&#41;&#44; as it is the gold standard for diagnosis of EONS&#44; although its use is debatable in the absence of symptoms and elevation of markers of infection&#44; which has led to its elimination in the new protocol in the management of asymptomatic patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;17</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In our sample&#44; of the patients admitted for initiation of empirical antibiotherapy based solely on CRP elevation in the absence of symptoms&#44; none ended up receiving a diagnosis of sepsis&#46; All had been born to term&#44; and most had 2 or more risk factors for infection&#46; Given the low specificity of abnormal blood test findings and the possibility of acute phase reactant elevation due to non-infectious causes&#44; the more tests are done&#44; the higher the likelihood of admission and of unnecessary antibiotherapy&#44; with the deleterious impact that this may have on the infant and the family&#44; to be added to the health care costs it entails&#46; None of these patients would have been admitted or received antibiotherapy with the new protocol or the neonatal sepsis calculator&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Other earlier biomarkers&#44; such as interleukin-6 &#40;IL-6&#41;&#44; have also been studied in relation to EONS&#46; Measurement of this marker had yet to be established in the older protocol of our hospital&#44; so we did not analyse its use in this study&#44; but it has been included in the new protocol&#46; Its high negative predictive value may contribute to a reduction in the performance of additional blood tests and the administration of antibiotherapy if its value in the early stages &#40;in cord blood or within hours of birth&#41; is normal&#46; However&#44; its short half-life diminishes its usefulness as a marker of EONS in patients who are initially asymptomatic&#44; as after the initial hours of infection&#44; its levels could be low&#46; Furthermore&#44; this means that it cannot serve as the sole marker and that subsequent monitoring will have to depend on other markers with longer kinetics&#44; such as C-reactive protein&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;18&#8211;20</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In both the previous literature and our sample&#44; the factor most frequently associated with the final diagnosis of sepsis was the presence of symptoms&#44; despite their lack of specificity&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;12&#44;21</span></a> With the neonatal sepsis calculator&#44; the watchful waiting approach is not contemplated in patients with transient tachypnoea or respiratory distress requiring respiratory support or supplemental oxygen past 2 h post birth&#44; or patients with symptoms in general past this time&#44; and initiation of antibiotherapy is indicated&#46; For this reason&#44; when we compared the 3 strategies&#44; we found that the one in which antibiotherapy would be used the least is the newly proposed protocol of our hospital &#40;strategy 3&#41;&#44; which does contemplate close monitoring without initiation of antibiotherapy in these cases&#46; In our sample&#44; none of the symptomatic patients in whom antibiotherapy was not initiated and managed with watchful waiting received a diagnosis of sepsis or required antibiotherapy at a later time&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">However&#44; despite observing this decrease in the use of antibiotherapy and that it was statistically significant&#44; considering the clinical outcomes it did not seem so substantial&#44; probably because the use of antibiotics was already restricted with the old protocol&#46; We were unable to assess the reduction in the use of antibiotherapy that would be achieved by measuring IL-6 levels in patients admitted due to the presence of symptoms from the first hours of life because data on this variable were not available&#46; The introduction of IL-6 in the new protocol may contribute to reduce the frequency of unnecessary antibiotherapy further&#44; making the difference more relevant from a clinical perspective&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The older protocol could detect all cases of clinical&#47;laboratory and microbiologically confirmed sepsis diagnosed in the 10-month period under study&#46; Whereas the pathogens most frequently associated with EONS in Spain are <span class="elsevierStyleItalic">E&#46; coli</span> and <span class="elsevierStyleItalic">S&#46; agalactiae</span>&#44; <span class="elsevierStyleItalic">E&#46; faecalis</span> was the most common isolate in our sample&#44; although the proportion of blood cultures that yielded isolates was low&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Both the calculator and the new protocol would have missed the case of asymptomatic bacteraemia by <span class="elsevierStyleItalic">E&#46; faecalis</span>&#46; This case raised the question of whether the course of antibiotherapy had to be completed&#44; as the patient remained asymptomatic at all times&#44; without elevation of acute phase reactants&#44; and the blood culture of the sample obtained before initiation of antibiotherapy as a control was already negative&#46; Cases of asymptomatic bacteraemia in newborns have been described in the past&#44; but it is difficult to predict whether symptoms of sepsis could develop later if antibiotherapy is not administered&#44; and the literature on the subject is not conclusive&#44; so at that time&#44; the decision was made to complete treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;22&#44;23</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In our study&#44; in agreement with the literature&#44; the incidence of sepsis among newborns with risk factors for infection was greater in preterm compared to term infants&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;21</span></a> However&#44; although for the time being we believe it would be prudent to continue screening this population with blood tests&#44; all preterm newborns that received a diagnosis of sepsis in our sample exhibited symptoms&#44; and it may be worth considering whether the management of these patients with observation alone would be safe&#44; too&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The main limitation of our study is that we were unable to compare the 3 strategies in the real world&#44; but rather analysed the hypothetical course of action that would have been taken with strategies 2 and 3 in the same sample&#46; Other limitations are its retrospective design&#44; small sample size and low frequency of sepsis&#44; especially of microbiologically confirmed cases&#46; Furthermore&#44; the definition of clinical&#47;laboratory sepsis may have led to counting as sepsis some cases that actually had a non-infectious aetiology&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In conclusion&#44; the change in the management of patients with risk factors for vertically transmitted infection toward a less invasive approached based on clinical observation seems an effective and safe alternative that could reduce the frequency of hospitalization and unnecessary antibiotherapy&#44; although studies in larger sample and&#44; above all&#44; with a prospective design are required to analyse safety data in more depth&#44; especially in high-risk patients&#44; such as late preterm newborns&#46; Watchful waiting in patients with mild and self-limiting symptoms in the first hours of life was not associated with poorer outcomes or undetected sepsis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Early-onset neonatal sepsis &#40;EONS&#41; can cause significant morbidity and mortality&#44; especially if it is not detected early&#46; Given the decrease in its incidence in the past few decades&#44; it is important to find a balance between reducing the use of diagnostic tests and continuing to detect affected patients&#46; We compared 3 detection strategies in patients with risk factors &#40;RFs&#41; for infection&#58; laboratory screening &#40;S1&#41;&#44; the Neonatal Sepsis Risk Calculator &#40;S2&#41; and clinical observation &#40;S3&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational study in neonates born at 34 weeks of gestation or later and with RFs or symptoms compatible with EONS&#46; We analysed outcomes in our unit with the use of laboratory screening &#40;S1&#41; and compared them with the other two strategies &#40;S2 and S3&#41; to contemplate whether to modify our protocol&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The study included 754 patients&#44; and the most frequent RFs were prolonged rupture of membranes &#40;35&#46;5&#37;&#41; and maternal colonization by <span class="elsevierStyleItalic">Streptococcus agalactiae</span> &#40;38&#46;5&#37;&#41;&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Strategies S2 and S3 would decrease the performance of laboratory tests &#40;S1&#44; 56&#46;8&#37; of patients&#59; S2&#44; 9&#46;9&#37;&#59; S3&#44; 22&#46;4&#37;&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41;&#44; hospital admissions &#40;S1&#44; 11&#37;&#59; S2&#44; 6&#46;9&#37;&#59; S3&#44; 7&#46;9&#37;&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41; and the use of antibiotherapy &#40;S1&#44; 8&#46;6&#37;&#59; S2&#44; 6&#46;7&#37;&#59; S3&#44; 6&#46;4&#37;&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#46;01&#41;&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Sepsis was diagnosed in 13 patients&#44; and it would have been detected with S2 and S3 except in 1 patient who had asymptomatic bacteriemia by <span class="elsevierStyleItalic">Enterococcus faecalis</span>&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">No patient with mild and self-limited symptoms in whom antibiotherapy was not started received a diagnosis of sepsis later on&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Close clinical observation seems to be a safe option and could reduce the use of diagnostic tests&#44; hospital admission and unnecessary antibiotherapy&#46; The watchful waiting approach in patients with mild and self-limiting symptoms in the first hours post birth does not appear to be associated with failure to identify sepsis&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Patients and methods"
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          2 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La sepsis neonatal de inicio precoz &#40;SNIP&#41; puede causar morbi-mortalidad importante&#44; sobre todo si se retrasa su identificaci&#243;n&#46; La disminuci&#243;n de su incidencia en las &#250;ltimas d&#233;cadas motiva que sea importante encontrar un equilibrio entre reducir las pruebas complementarias y seguir detectando los pacientes afectos&#46; Comparamos 3 estrategias de detecci&#243;n en pacientes con factores de riesgo &#40;FR&#41;&#58; E1&#46; Cribado anal&#237;tico&#59; E2&#46; Calculadora de riesgo de sepsis neonatal&#59; E3&#46; Observaci&#243;n cl&#237;nica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pacientes y m&#233;todos</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo&#44; en reci&#233;n nacidos con edad gestacional &#8805;34 semanas y con FR o sintomatolog&#237;a compatible con SNIP&#46; Se analizaron los resultados de nuestra unidad con cribado anal&#237;tico &#40;E1&#41; y se compar&#243; con las otras 2 estrategias &#40;E2 y E3&#41; para valorar modificar nuestro protocolo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 754 pacientes cuyos FR m&#225;s frecuentes fueron la rotura prologada de membranas &#40;35&#44;5&#37;&#41; y la colonizaci&#243;n materna por <span class="elsevierStyleItalic">S&#46;agalactiae</span> &#40;38&#44;5&#37;&#41;&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Las E2 y E3 disminuir&#237;an la realizaci&#243;n de anal&#237;ticas &#40;E1 56&#44;8&#37; de los pacientes&#59; E2 9&#44;9&#37;&#59; E3 22&#44;4&#37;&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#44;01&#41;&#44; los ingresos hospitalarios &#40;E1 11&#37;&#59; E2 6&#44;9&#37;&#59; E3 7&#44;9&#37;&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#44;01&#41; y la administraci&#243;n de antibioterapia &#40;E1 8&#44;6&#37;&#59; E2 6&#44;7&#37;&#59; E3 6&#44;4&#37;&#59; <span class="elsevierStyleItalic">P</span> &#60; 0&#44;01&#41;&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">13 pacientes se diagnosticaron de sepsis&#44; las cuales se hubieran detectado con E2 y E3&#44; salvo un paciente con bacteriemia asintom&#225;tica por <span class="elsevierStyleItalic">E&#46; faecalis</span>&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Ning&#250;n paciente con cl&#237;nica leve y autolimitada en que no se inici&#243; antibioterapia&#44; se diagnostic&#243; posteriormente de sepsis&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">La observaci&#243;n cl&#237;nica estrecha parece una opci&#243;n segura y podr&#237;a disminuir la realizaci&#243;n de pruebas complementarias&#44; la tasa de hospitalizaci&#243;n y el uso de antibioterapia innecesaria&#46; Mantener una conducta expectante en pacientes con sintomatolog&#237;a leve y autolimitada en las primeras horas de vida parece no relacionarse con la no identificaci&#243;n de sepsis&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Introducci&#243;n"
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            "identificador" => "abst0035"
            "titulo" => "Pacientes y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Conclusiones"
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      ]
    ]
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Previous presentation&#58; this study was presented as an oral communication at the XXVIII Congress of Neonatology and Perinatal Medicine of the Sociedad Espa&#241;ola de Neonatolog&#237;a&#44; held online in October 2021&#46;</p>"
      ]
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                  \t\t\t\t">Preterm birth &#40;before 37 weeks&#8217; gestation&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Prolonged rupture of membranes &#40;&#8805;18 h&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Premature rupture of membranes &#40;before 37 weeks&#8217; gestation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Mother treated with antibiotherapy for confirmed or suspected invasive bacterial disease at any time during childbirth or in the 24 h preceding or following delivery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Invasive infection by <span class="elsevierStyleItalic">S&#46; agalactiae</span> in previous child&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maternal colonization&#44; bacteriuria or infection by <span class="elsevierStyleItalic">S&#46; agalactiae</span> during pregnancy &#40;diagnosis based on culture or intrapartum PCR&#41; or unknown culture status without or with incomplete intrapartum antibiotic prophylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Intrapartum maternal fever &#40;&#8805;38 &#176;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chorioamnionitis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Clinical symptoms&#40;Gibbs criteria&#41;&#58; maternal fever AND at least 2 of the following&#58; maternal leucocytosis &#40;&#62;15 000 cells&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; maternal tachycardia &#40;&#62;100 bpm&#41;&#44; foetal tachycardia &#40;&#62;160 bpm&#41;&#44; uterine tenderness&#44; malodorous amniotic fluid&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Subclinical features &#40;in absence of fever or other criteria&#41;&#58; glucose &#60;15 mg&#47;dL or leucocyte count &#62;30 cells&#47;mm<span class="elsevierStyleSup">3</span> in amniotic fluid&#44; presence of microorganisms in the Gram stain&#44; positive amniotic fluid culture&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Confirmed or suspected infection in twin in case of multiple pregnancy&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Risk factors for the development of early-onset neonatal sepsis with vertical transmission&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Preterm birth &#40;34<span class="elsevierStyleSup">&#43;0</span>&#8211;36<span class="elsevierStyleSup">&#43;6</span> weeks&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">132&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Prolonged rupture of membranes &#40;&#8805;18 h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">268&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Unknown maternal <span class="elsevierStyleItalic">S&#46; agalactiae</span> colonization status&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">159&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Maternal colonization by <span class="elsevierStyleItalic">S&#46; agalactiae</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">290&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">38&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intrapartum maternal fever &#40;&#8805;38 &#176;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Suspected chorioamnionitis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Intrapartum antibiotic administration&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Clinically significant symptoms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positive blood culture result in asymptomatic patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Administration of antibiotherapy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abnormal screening result in asymptomatic patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Clinically significant symptoms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">51 &#40;6&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Positive blood culture&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;0&#46;13&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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