ORIGINAL ARTICLE Pediatr Infect Vaccine Vol.24, pissn No.1, eissn Pediatr Infect Vaccine 2017;24:1-6 DOI:
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1 ORIGINAL ARTICLE Pediatr Infect Vaccine Vol.24, pissn No.1, eissn Pediatr Infect Vaccine 2017;24:1-6 DOI: 신생아균혈증에서 Delta Neutrophil Index 의진단적의의 고일두 ᆞ 전인수 ᆞ 김황민 연세대학교원주의과대학소아과학교실 Diagnostic Significance of the Delta Neutrophil Index and Other Conventional Parameters in Neonatal Bacteremia Il Doo Koh, Ihn Soo Jeon, Hwang Min Kim Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, the Republic of Korea Purpose: We investigated the effectiveness of the delta neutrophil index (DNI) for the prediction of neonatal bacteremia and compared it to other indices. Methods: A total of 146 pediatric patients, aged less than 31 days, admitted to the neonatal intensive care unit of Wonju Severance Christian Hospital with fever before or during hospitalization were enrolled in this study. We divided the patients into two groups based on the existence of neonatal bacteremia and performed blood culture tests on both groups. We examined white blood cell count, absolute neutrophil count, DNI, platelet count, and C-reactive protein (CRP) test. We used a receiver operating characteristic (ROC) curve to evaluate their diagnostic significance. Results: Seventy-seven patients were diagnosed with neonatal bacteremia. The mean gestational age was weeks and the mean birth weight was 3.20 kg. The mean gestational age of the control group was weeks and the mean birth weight was 2.20 kg. Causative organisms of bacteremia included Staphylococcus aureus (n=22), Staphylococcus epidermidis (n=18), and Streptococcus agalactiae (n=8). Both DNI and CRP were significantly associated with neonatal bacteremia after adjusting for gestational age and birth weight. The area under the ROC curve (AUC) for DNI (0.70) was higher than that for CRP (0.68). Conclusions: The DNI can be used to effectively predict neonatal bacteremia. The prediction will be more accurate if DNI is used in conjunction with other indices. In future, it will be useful to compare DNI with other indices and investigate its relationship with prognosis. Key Words: Delta neutrophil index; Neonatal bacteremia 서론 접수 : 2016 년 6 월 16 일수정 : 2016 년 8 월 22 일승인 : 2016 년 10 월 15 일 책임저자 : 김황민연세대학교원주의과대학소아과학교실 Tel: 033) , Fax: 033) khm9120@yonsei.ac.kr 신생아균혈증은신생아사망및이환의중요한원인질환이다. 신속한진단과적합한항생제치료가신생아균혈증의예후에큰영향을미치게된다 1). 신생아균혈증을진단하는표준은혈액배양검사이다. 그러나이방법은 48시간에서 72시간이상이소요되기때문에균혈증이확진되기전균혈증을예측할수있는인자들에대해예전부터 1
2 고일두외 2 인 : 신생아균혈증에서 Delta Neutrophil Index 의진단적의의 많은연구가이루어져왔다 2,3). 신생아균혈증의급성기에 서 procalcitonin 이균혈증의진단이나예후를예측하는인 자로각광받고있으나항상일관된예측을하지는못했다 4,5). 또한 C- 반응단백 (C-reactive pro tein [CRP]) 과같은 급성기염증반응물질, interleukin 6 (IL-6) 이나 IL-8 과 같은사이토카인이패혈증의예측인자로서연구되어왔으 나쉽게이루어지기어려운검사이거나, 감염에의하지않 은염증질환에서도비특이적으로상승하여실제로적용 하기에많은어려움이있었다 4,6). Delta neutrophil index (DNI) 는말초혈액의미성숙과 립구의수를반영하는지표로염증반응에따른좌측편향 이일어나는것을원리로하여최근에파종혈관내응고나 균혈증의진단, 그리고이로인한사망률과의연관성에대 해최근에활발하게연구가이루어지고있다 7). 본연구에 서는 DNI 가신생아균혈증을예측하는지표로서의효용 성을다른여러가지지표들과비교하여알아보고자하였 다. 방법 1. 대상및정의 2012 년 1 월부터 2014 년 12 월까지원주세브란스기독 병원신생아중환자실에 38.0 이상의발열을주소로입 원하였거나, 신생아중환자실에입원중에발열이있었던 생후 31 일미만의환아들을대상으로연구를진행하였다. 본연구에서환아들을두군으로분류하였다. 첫번째군 은발열을주소로내원하여균혈증을진단받은환아들, 두 번째군은발열은있었으나혈액배양검사가음성이보고 된군으로나누어두집단을비교하였다. 신생아균혈증의 진단은서로다른부위에서시행한혈액배양검사두가지 에서모두같은세균이동정되었을때로정의하였다. 발 열을주소로입원한환아의경우에는입원당시에혈액배 양검사를시행하였으며, 입원중인환아가발열이있을경 우발열이있는즉시혈액배양검사를시행하였다. 혈액배 양검사와동시에총백혈구수절대호중구수, DNI, 혈소 판수, CRP 를시행하였다. 참여한환아들의나이, 성별, 재 태주수, 출생체중, 그리고분만형태를조사하였다. 2. 통계 통계분석은 SAS software version 9.2 (SAS Inc., Cary, NC, USA) 를이용하였다. 변수별로집단간의차이가있 는지를보기위하여 two-sample t-test, chi-square test 와각그룹간의재태주수와출생체중을보정하기위한 logistic regression 을이용하였다. 또한변수별로얼마 나진단에유용하지를비교하기위해 receiver operating characteristic (ROC) curve 상의 area under the ROC curve 를계산하여비교하였다. 각변수와재원기간과의 연관성을알아보기위하여 Pearson 상관계수를구하였다. 통계적유의수준은 P 값이 0.05 미만인경우로정의하였다. 3. 연구윤리심의 본연구는원주세브란스기독병원연구윤리위원회 (Institutional Review Board; CR ) 의승인을 받았다. 결과 1. 인구학적특징 본연구에포함된환아는총 146 명이었으며이중균혈 증으로진단받은환아는총 77 명 (52.7%) 이었다. 인구학 적특성상참여한환아들의재태주수는평균 주였으 며출생체중의평균은 2.67 kg 이었고이는균혈증인그 룹과그렇지않은그룹에서통계적으로차이를보였다. 참 여한환아들의나이는생후 일이었으며남녀비율은 1.05:1 이었다 (Table 1). 환아들의출생력으로는총 45 명 의환아가조산아였으며그중재태주수 28 주미만의환 아가 21 명, 28 주이상 32 주미만의환아가 11 명, 32 주이 상 37 주미만의환아는 13 명이었다. 출생체중으로는 1 kg 미만의초극소저체중아가 21 명, 1 kg 이상 1.5 kg 미 만의극소저체중아가 5 명, 2.5 kg 미만의저체중아환아 는 12 명이었다. 동반질환으로서는신생아호흡곤란증후 군이있어폐표면활성제를투여받아야했던환아가 24 명 Table 1. Clinical Characteristics of Study Population Characteristic Total (n=146) Control (n=69) Bacteremia (n=77) P-value Age (day) 13.16± ± ± GA (wk) 35.89± ± ±6.89 <0.001 Birth weight (kg) 2.67± ± ±1.14 <0.001 Delivery type (C-sec/SVD) 64/82 30/39 34/ Sex (male/female) 75/71 38/31 37/ Deaths <0.001 Values are presented as mean±standard deviation. Abbreviations: GA, gestational age; C-sec, cesarean section; SVD, spontaneous vaginal delivery. 2
3 Pediatr Infect Vaccine Vol.24, No.1, 2017 이있었으며, 동맥관개존증이있어정맥이부프로펜을사용한환아가 26명있었다. 그외의동반기형이나선천기형을동반한환아는없었다. 균혈증의원인균으로는 22명 (28.5%) 의환아에서 Staphylococcus aureus, 18명 (23.3%) 의환아에서 Staphylococcus epidermidis, 8명 (10.3%) 의환아에서 Streptococcus agalactiae, 4명 (5.1%) 의환아에서 Klebsiella pneumoniae, 3명 (3.8%) 의환아에서 Escherichia coli가동정되었다. 그외에도 22명의환아에서서로다른균주들이동정되었다. 를통해진단적연관성을평가한결과 DNI가 0.70 (95% confidence interval [CI], ), CRP는 0.68 (95% CI, ) 이었다 (Fig. 1). 고찰 신생아균혈증은이환율과사망률이높은질병이기때문에빠르게균혈증의가능성을평가하여경험적항생제나수액요법과같은적절한치료를시행해야한다 8). 본연 2. 균혈증에대한진단적연관성 균혈증을진단받은환아들의평균값은각각총백혈구수 15,273/μL, 절대호중구수 9,196/μL, 혈소판수 / μl, DNI 11.22%, CRP 5.48 mg/dl 였다. 균혈증을진단받지않은환아들의평균값은각각총백혈구수 12,065/μL, ANC 6,668/μL, 혈소판수 /μl, DNI 2.49%, CRP 1.29 mg/dl 였다 (Table 2). 총백혈구수, ANC, 그리고혈소판수는단변량로지스 틱회귀분석에서는균혈증과연관성을보이지만재태주수 와출생체중을보정하였을경우유의한연관성을보이지 않았다. 재태주수와출생체중을보정한다변량로지스틱 회귀분석을시행한결과 DNI 는 1% 증가할때마다균혈증 의유병률 8% 증가, 그리고 CRP 1 mg/dl 의증가는 18% 의 균혈증유병률의증가와연관되었다 (Table 3). 각각의 cutoff 치는총백혈구수 14,650/μL ( 민감도 41.6%, 특이도 78.3%), 절대호중구수는 8,135/μL ( 민감도 40.3%, 특이 도 76.8%), 혈소판수 /μl ( 민감도 5.2%, 특이 도 95.7%), DNI 3.15% ( 민감도 54.5%, 특이도 81.2%), CRP 3.54 mg/dl ( 민감도 45.5%, 특이도 91.3%) 였다 (Table 4). 재태주수와출생체중을보정한뒤에도통계적 으로유의한연관성을보인 CRP, DNI 에대하여 ROC curve Table 3. Multivariate Logistic Regression of Delta Neutrophil Index and Other Parameters between Bacteremia and Nonbacteremia Group Parameter Odds ratio 95% CI P-value WBC Model 1* Model ANC Model 1* Model PLT Model 1* <0.001 Model DNI Model 1* Model CRP Model 1* <0.001 Model *Crude odds ratio of each laboratory marker for bacteremia. Odds ratio adjusted by gestational age and birth weight. Abbreviations: CI, confidence interval; WBC, white blood cell count; ANC, absolute neutrophil count; PLT, platelet count; DNI, delta neutrophil index; CRP, C-reactive protein. Table 2. Comparison of Delta Neutrophil Index and Other Parameters between Bacteremia and Non-bacteremia Group Parameter Control (n=69) Bacteremia (n=77) P-value WBC (/μl) 12,065±5,023 15,273±10, ANC (/μl) 6,668±4,557 9,196±9, PLT ( 10 3 /μl) 372± ±184 <0.001 DNI (%) 2.49± ±15.75 <0.001 CRP (mg/dl) 1.29± ±7.17 <0.001 Values are presented as mean±standard deviation. Abbreviations: WBC, white blood cell count; ANC, absolute neutrophil count; PLT, platelet count; DNI, delta neutrophil index; CRP, C-reactive protein. Table 4. Diagnostic Performance of Delta Neutrophil Index and Other Conventional Parameters Parameter Cut-off Sensitivity (%) Specificity (%) PPV (%) NPV (%) WBC (/μl) 14, ANC (/μl) 8, PLT ( 10 3 /μl) DNI (%) CRP (mg/dl) Abbreviations: PPV, positive predictive value; NPV, negative predictive value; WBC, white blood cell count; ANC, absolute neutrophil count; PLT, platelet count; DNI, delta neutrophil index; CRP, C-reactive protein. 3
4 고일두외 2 인 : 신생아균혈증에서 Delta Neutrophil Index 의진단적의의 Fig. 1. Receiver operating characteristic (ROC) curves of delta neutrophil index and other conventional parameters predicting neonatal bacteremia. The irregular form of the curve is due to the smaller sample size in the validation dataset. Abbreviations: DNI, delta neutrophil index; CRP, C-reactive protein. 구에서는신생아균혈증의예측인자로서 DNI 의효용성을 다른인자들과비교해보고자하였다. 혈소판수와신생아균혈증과의상관성을다룬여러가 지논문들이이미있으며, 또한균혈증예측의혈액학적 점수체계에도혈소판수가중요하게사용되고있다. 균혈 증이진행되면혈소판의파괴가증가하며, 내독소에의한 거대핵세포의감소로혈소판생성이줄어들기때문에그 수가감소하게된다. 그러므로혈소판감소는균혈증과의 관련성이높으며좋지않은예후를시사한다 9). 하지만본 연구에서는혈소판수는통계적인연관성을보이지는않 았다. CRP 는감염에노출이되었을경우감염이나조직의손 상을통하여 6 8 시간이내에생성이되며 19 시간의반 감기를가지는단백질이다. CRP 는신생아감염에있어서 1,000 배까지도상승할정도로특이도가높지만상대적 으로다른지표에비하여상승하는속도가느리기때문에 균혈증의치료에대한반응을평가하는데유용한지표로 알려져있다 4,10,11). Procalcitonin 은세균의내독소에노출이된후단핵구 와간세포에서생성하는물질이다. Procalcitonin 은약 4 시 간뒤부터상승하여 6 8시간에최고치에다다르며 24시간이상상승을유지한다. 많은연구들에서 procalcitonin 이균혈증이나괴사성장염에서상승하며다른급성기염증반응인자에비하여민감도나특이도가높고치료의평가나예후의예측에도효과적인것으로밝혀졌다 12). 또한, 신생아균혈증의예측인자로서백혈구세포표면인자나사이토카인들이그동안연구되어왔다. Ng 등 13) 에의하면, 백혈구세포표면인자로최근에많이연구된 CD11b나 CD64 의경우조발형신생아균혈증의초반부터높은민감도와특이도를보이며, CRP나 procalcitonin과비교평가하였을때민감도와음성예측도는거의 100% 에달한다고보고되기도하였다. 신생아에서성인에비하여 IL-6, IL-8 양성을보이는세포들이많아 IL-6, IL-8 등의사이토카인에대한연구가중점적으로이루어져왔다 14). 태아제대혈의 IL-6를통한조발형균혈증의민감도는 87% 100%, 음성예측도는 93% 100% 에이른다고한다 15). 그외에도전염증사이토카인으로서 IL-1이나종양괴사인자에대한연구에대한연구도최근시도되고있다. 그러나이러한연구와진단적가능성에도불구하고대부분일반적인균혈증감별검사로진행하기에검사장비나비용, 시간적인문제로실제임상에이용하기에현재까지는무리가있다 16,17). 본연구에서는 procalcitonin 이나다른세포표면인자, 사이토카인검사를시행한환아의수가적어조사에포함시킬수없었다. DNI는말초혈액의미성숙과립구의수를반영하는지표이다 7). 감염으로염증반응이일어나게되면미성숙한중성구들이말초혈액순환에서관찰되는좌측편향이일어난다 18). 따라서미성숙과립구들을감별계산하여신생아균혈증의지표로사용하려는연구도있어왔다 19,20). 띠중성구보다도미성숙과립구는감염을예측하는데높은민감도를보이는것으로알려져있으나측정이쉽지않으며진단적인참고범위도명확하지않다 21). DNI는백혈구를세포화학적골수세포형과산화효소채널 (cytochemical myeloperoxidase channel) 로감별계산한것과 nuclear nodularity channel을통해감별계산한것의차이를비교하여순환중인미성숙과립구의비율을알아내는방법이다 22). DNI는추가적인장비나투자없이도적은양의혈액으로시행할수있어부담이적다. 이전의연구들에서 DNI가파종혈관내응고나균혈증과연관성이있다는것이밝혀졌다 7). 그밖에도 DNI의진단적인효용성외에예후와의연관성도연구되고있다. Kim 등 23) 에따르면균혈증이발생한지 72시간이내에시행한 DNI 수치는총백혈구수나 CRP 4
5 Pediatr Infect Vaccine Vol.24, No.1, 2017 에비하여더사망률을유의하게예측했다. 또 Hwang 등 24) 은 DNI 와혈청알부민의비율을통해성인균혈증환 자들의사망률을예측할수있다는연구결과를발표한바 도있다. Procalcitonin 이나 CRP 가출생전후시기에서감 염외에도여러질병에있어서합병증이나위험인자에대 해예측을하는데유용하다는연구결과는있으나 25), DNI 가신생아균혈증에대하여사망률이나예후를예측하는 지여부에대한연구는아직까지부족한상태이다. 본연구의한계점으로는연구에참여할환아를선별하 는데있어입원중이던환아와발열을주소로입원한환 아를모두포함하였으며, 혈액배양에서균이증명된경우 만을포함하여선택바이어스가있을수있다는점이다. 혈액배양과정에서검체의부족으로인한위음성이결과 에영향을미쳤을수있다. 그리고부적절한검체채취로 인하여오염에의한오류가결과에영향을미칠수있었 다. 또다른한계점으로는 DNI 의측정과균혈증의발병시 간과의관계에대한기록이명확하지않았다는점이있다. 입원중이었던환아의경우발열즉시검체를채취하였으 나, 발열을주소로내원한환아들은발열과검체채취의 시간간격이서로달라정확한비교가이루어질수없었 다. 향후균혈증으로입원한환아들의 DNI 의변화양상을 추적관찰하면언제시행한 DNI 가가장균혈증을잘예측 할수있고예후와관련이높게나타나는지를더자세하 게확인할수있을것으로사료된다. DNI 가 CRP 보다도신생아균혈증을잘예측해내었다. 이런자료를바탕으로 DNI 와다른지표를함께고려한다 면신생아균혈증을예측하는데유용할것으로생각된다. 더하여 DNI 는다른여러지표들에비해추가적인장비나 투자없이도적은양의혈액으로도쉽게분석할수있기때 문에많은의료기관에서더쉽게이용할수있을것으로생 각된다. 향후 DNI 의다른균혈증예측인자나점수체계들 과의비교를통한추가적인연구와, 균혈증의예후와의연 관성에대한연구도필요할것으로사료된다. References 1. Jiang JH, Chiu NC, Huang FY, Kao HA, Hsu CH, Hung HY, et al. Neonatal sepsis in the neonatal intensive care unit: characteristics of early versus late onset. J Microbiol Immunol Infect 2004;37: Garcia-Prats JA, Cooper TR, Schneider VF, Stager CE, Hansen TN. Rapid detection of microorganisms in blood cultures of newborn infants utilizing an automated blood culture system. Pediatrics 2000;105(3 Pt 1): Kumar Y, Qunibi M, Neal TJ, Yoxall CW. Time to positivity of neonatal blood cultures. Arch Dis Child Fetal Neonatal Ed 2001;85:F Benitz WE. Adjunct laboratory tests in the diagnosis of earlyonset neonatal sepsis. Clin Perinatol 2010;37: Muller B, Christ-Crain M, Nylen ES, Snider R, Becker KL. Limits to the use of the procalcitonin level as a diagnostic marker. Clin Infect Dis 2004;39: Arnon S, Litmanovitz I. Diagnostic tests in neonatal sepsis. Curr Opin Infect Dis 2008;21: Nahm CH, Choi JW, Lee J. Delta neutrophil index in automated immature granulocyte counts for assessing disease severity of patients with sepsis. Ann Clin Lab Sci 2008;38: Centers for Disease Control and Prevention. Prevention of perinatal group B streptococcal disease: a public health perspective. MMWR Recomm Rep 1996;45(RR-7): Rodwell RL, Leslie AL, Tudehope DI. Early diagnosis of neonatal sepsis using a hematologic scoring system. J Pediatr 1988;112: Benitz WE, Han MY, Madan A, Ramachandra P. Serial serum C-reactive protein levels in the diagnosis of neonatal infection. Pediatrics 1998;102:E Ng PC, Cheng SH, Chui KM, Fok TF, Wong MY, Wong W, et al. Diagnosis of late onset neonatal sepsis with cytokines, adhesion molecule, and C-reactive protein in preterm very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 1997;77:F Guibourdenche J, Bedu A, Petzold L, Marchand M, Mariani- Kurdjian P, Hurtaud-Roux MF, et al. Biochemical markers of neonatal sepsis: value of procalcitonin in the emergency setting. Ann Clin Biochem 2002;39(Pt 2): Ng PC, Li G, Chui KM, Chu WC, Li K, Wong RP, et al. Neutrophil CD64 is a sensitive diagnostic marker for earlyonset neonatal infection. Pediatr Res 2004;56: Schultz C, Rott C, Temming P, Schlenke P, Moller JC, Bucsky P. Enhanced interleukin-6 and interleukin-8 synthesis in term and preterm infants. Pediatr Res 2002;51: Mehr S, Doyle LW. Cytokines as markers of bacterial sepsis in newborn infants: a review. Pediatr Infect Dis J 2000;19: 5
6 고일두외 2 인 : 신생아균혈증에서 Delta Neutrophil Index 의진단적의의 Mishra UK, Jacobs SE, Doyle LW, Garland SM. Newer approaches to the diagnosis of early onset neonatal sepsis. Arch Dis Child Fetal Neonatal Ed 2006;91:F Ng PC, Lam HS. Biomarkers for late-onset neonatal sepsis: cytokines and beyond. Clin Perinatol 2010;37: Cornbleet PJ. Clinical utility of the band count. Clin Lab Med 2002;22: Ansari-Lari MA, Kickler TS, Borowitz MJ. Immature granulocyte measurement using the Sysmex XE Relationship to infection and sepsis. Am J Clin Pathol 2003;120: Nigro KG, O'Riordan M, Molloy EJ, Walsh MC, Sandhaus LM. Performance of an automated immature granulocyte count as a predictor of neonatal sepsis. Am J Clin Pathol 2005;123: Ardron MJ, Westengard JC, Dutcher TF. Band neutrophil counts are unnecessary for the diagnosis of infection in patients with normal total leukocyte counts. Am J Clin Pathol 1994;102: Harris N, Jou JM, Devoto G, Lotz J, Pappas J, Wranovics D, et al. Performance evaluation of the ADVIA 2120 hematology analyzer: an international multicenter clinical trial. Lab Hematol 2005;11: Kim HW, Yoon JH, Jin SJ, Kim SB, Ku NS, Jeong SJ, et al. Delta neutrophil index as a prognostic marker of early mortality in gram negative bacteremia. Infect Chemother 2014;46: Hwang YJ, Chung SP, Park YS, Chung HS, Lee HS, Park JW, et al. Newly designed delta neutrophil index-to-serum albumin ratio prognosis of early mortality in severe sepsis. Am J Emerg Med 2015;33: Chiesa C, Pellegrini G, Panero A, Osborn JF, Signore F, Assumma M, et al. C-reactive protein, interleukin-6, and procalcitonin in the immediate postnatal period: influence of illness severity, risk status, antenatal and perinatal complications, and infection. Clin Chem 2003;49:60-8. 요약 목적 : 본연구에서는 delta neutrophil index (DNI) 가신생아균혈증을예측하는지표로서의효용성을다른지표들과의비교를통해알아보고자하였다. 방법 : 원주세브란스기독병원신생아중환자실에발열을주소로입원한환아들과입원중발열이있었던생후 31일미만환아 146명을대상으로혈액배양검사와동시에시행한총백혈구수, 절대호중구수, DNI, 혈소판수, C-반응단백 (C-reactive protein, CRP) 에대하여분석하였다. 결과 : 균혈증이있었던환아 77명의평균재태주수는 38.74주, 출생체중은 3.20 kg였다. 대조군의평균재태주수는 33.34주, 출생체중은 2.20 kg였다. 균혈증의원인은 Staphylococcus aureus (22명), Staphylococcus epidermidis (18명), Streptococcus agalactiae (8명) 등이었다. DNI와 CRP만이재태주수와출생체중보정후균혈증과연관성을보여 area under the ROC curve를조사하였고 DNI 0.70, CRP 0.68이었다. 결론 : DNI는신생아균혈증을예측하는데효과적인지표이다. 다른인자들과함께고려한다면균혈증을예측하는데더도움이될것이다. 6
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