Paediatrica Indonesiana

Volume 55

May 2015

Number 3

Original Article

Immature-to-total neutrophil ratio as an early

diagnostic tool of bacterial neonatal sepsis
Darnifayanti, Guslihan Dasa Tjipta, Rusdidjas, Bugis Mardina Lubis

Abstract

Background Bacterial sepsis is the main cause of morbidity and

mortality in neonates. Early diagnosis and appropriate treatment

for the condition can reduce mortality rates. Blood cultures are
the gold standard to diagnose bacterial sepsis, but they require
3-5 days for results, whilst the disease may progress rapidly in
neonates. Examination of immature-to-total neutrophil ratio (I/T
ratio) in peripheral blood smears is a quicker and less expensive
method to diagnose bacterial sepsis in neonates. Some studies
found the sensitivity of I/T ratio to be 88%-90% in predicting
bacterial spesis.
Objective To assess the usefulness of the I/T ratio as an early
diagnostic tool for neonatal bacterial sepsis.
Methods This cross-sectional study was conducted from February
to March 2011. Subjects were collected by consecutive sampling.
Fifty-three neonates suspected to have bacterial sepsis in the
Perinatology Unit at H. Adam Malik Hospital were included.
Subjects underwent routine blood examinations, C-reactive
protein level measurements, blood cultures, and peripheral blood
smears. All statistical analyses were conducted with SPSS (version
16.0 for Windows).
Results Of the 53 subjects, 26 had bacterial sepsis based on blood
cultures. The I/T ratio had a sensitivity of 88.46%, specificity
81.84%, positive predictive value 82.14%, and negative predictive
value 88%. The receiver operating characteristic curve showed a
cut-off point of 83.3 (95%CI 71.3 to 95.3)%.
Conclusion The I/T ratio may be a good alternative to blood
cultures as an early indicator of bacterial neonatal sepsis, as it
is faster, less expensive and has good sensitivity and specificity.
[Paediatr Indones. 2015;55:153-7.].
Keywords: bacterial sepsis, IT ratio, blood culture,
neonate, diagnostic

eonatal sepsis is an inflammatory response

to bacteremia occuring during the first
month of life. Infection remains a major
problem in developing countries, including
Indonesia. Infection rates in small infants and newborns
are quite high in Indonesia and often develop into
septicemia.1 Septicemia in newborns is a systemic
inflammatory reaction to local infection that may lead
to the development of more grave conditions.2 Blood
cultures have been known as the gold standard for
diagnosing neonatal sepsis and should be performed
prior to antibiotic administration. Blood cultures
require 48-72 hours for results, whilst the disease may
progress rapidly, increasing mortality rates in these
neonates.3
Neutrophils are the cellular components of
the basic body defense mechanism. The number of
neutrophils varies in the first week of life. Infection
causes the release of neutrophils into the bloodstream,
leading to increased true white blood cell count.4

This study was presented at the Kongres Nasional Ilmu Kesehatan Anak/
KONIKA XV (The 15th Child Health National Congress) Manado, July
11-14, 2011.
From the Department of Child Health, University of Sumatera Utara
Medical School /H. Adam Malik Hospital, Medan, Indonesia.
Reprint requests to: Dr. Darnifayanti, Department of Child Health,
University of Sumatera Utara Medical School/H. Adam Malik Hospital,
Jl. Bunga Lau No.17, Medan 20136. Tel. +62618361721 8365663. Fax.
+62618361721. E-mail: [email protected].

Paediatr Indones, Vol. 55, No. 3, May 2015 153

Darnifayanti et al: Immature-to-total neutrophil ratio as an early diagnostic tool of sepsis

Immature neutrophils are at a younger stage than

neutrophil bands (metamyelocytes, myelocytes,
promyelocytes and myeloblasts). These young
granulocytes are usually found during infection and
septicemia.3,4 The ratio of immature neutrophils to
total neutrophils (I/T ratio) increases when the white
blood cell count differential shows a left shift. An I/T
ratio > 0.2 has been considered to be a marker for
septicemia in newborns.3,5 We aimed to assess the
usefulness of the I/T ratio as an early diagnostic tool
for neonatal bacterial sepsis.

Methods
This cross-sectional study was conducted to determine
the sensitivity and specificity of the I/T ratio method as

an early diagnostic tool for neonatal bacterial sepsis in

the Perinatology Unit of Haji Adam Malik Hospital from
February to March 2011. The subjects were suspected
of having neonatal bacterial sepsis based on clinical
symptoms and risk factors. Subjects were collected by
consecutive sampling. Blood specimens were taken from
subjects 48 hours prior to antibiotic administration. We
excluded neonates with multiple congenital anomalies,
anemia, and icterus within the first 24 hours of life.
Blood specimens were obtained from 53 newborn
babies ( 27 females and 26 males) with suspected
septicemia. Blood smear specimens were taken from
venous blood and blood cultures were performed to
confirm diagnoses. Differential counts were perfomed
manually using a binocular microscope.
All statistical analyses were conducted with SPSS
(version 16.0 for Windows). Sensitivity, specificity,

Table 1. Demographic data of subjects

Characteristics
Gestational age, n
26 28 weeks
28 30 weeks
30 32 weeks
32 34 weeks
34 36 weeks
36 38 weeks
38 40 weeks
40 42 weeks
Gender, n
Male
Female
Mean birth weight, grams (SD)
Diagnosis, n
TTN
Asphyxia
Anal atresia
ELBW
LBW
VLBW
Down syndrome
Gastroschisis
Umbilical hernia
Macrosomia
Hirschsprungs disease
Hypoxic encephalopathy
Meningocele
Omphalitis
Cephalohematoma
Omphalocele
Suspected sepsis
Respiratory distress

Positive
(n = 26)
3
6
0
1
11
2
1
2
14
12
2,329.2 (982.01)
1
0
2
1
1
2
1
2
0
0
3
1
0
1
3
0
1
7

Blood cultures results

Negative
(n = 27)
0
3
5
0
14
3
2
0
14 (51.9)
13 (48.1)
2,509.2 (878.66)
0
1
0
0
1
1
0
1
1
1
1
3
1
0
0
1
1
14

TTN=transient tachypnea of newborn; ELBW=extremely low birth weight; LBW=low birth weight; VLBW=very low birth weight

154 Paediatr Indones, Vol. 55, No. 3, May 2015

Darnifayanti et al: Immature-to-total neutrophil ratio as an early diagnostic tool of sepsis

Results
During the study period, fifty-three neonates
suspected of having neonatal sepsis in the Perinatology
Unit underwent routine blood examinations, blood
cultures, and peripheral blood smears to examine I/T
ratios.
Table 1 shows the subjects characteristics
including gestational age, gender, birth weight, and
diagnosis. We found 26 infants with sepsis diagnosed
by positive blood cultures. The incidence of sepsis in
this study was 45.6%. Subjects mean gestational age
was 34-36 weeks. More males had sepsis than females,
and respiratory distress was the most common diagnosis accompanying neonatal sepsis in our subjects.
Table 2 shows the microorganisms found in
blood cultures of the septic newborns. Most of the
bacteria were gram-positive. Staphylococcus epidermidis
was the most commonly found species.

Table 2. Microorganisms identified in blood cultures of

septic newborns (N=26)
Microorganisms
Enterobacter aerogenes
Enterobacter agglomerans
Klebsiella oxytoca
Pseudomonas sp
Staphylococcus aureus
Staphylococcus epidermidis
Staphylococcus saprophyticus
Streptococcus faecalis
Streptococcus viridans

n
1
1
1
6
1
9
4
1
2

Table 3. Sensitivity and specificity of the I/T ratio method

compared to blood cultures
Positive
I/T Ratio
>0.2
0.2
Total

23
3
26

Blood culture
Negative
5
22
27

Total
28
25
53

The sensitivity of I/T ratio was 88.46%; specificity

was 81.48%; positive predictive value was 82.14%; and
negative predictive value was 88%. The positive likelihood ratio was 4.776 and negative likelihood ratio was
0.142. The area under the curve in this study was 83.3%
(95%CI 71.3 to 95.3; P< 0.05) (Figure 1). This result
was indicative of good accuracy of the diagnostic test.

ROC Curve
1.0

0.8

Sensitivity

positive predictive value, and negative predictive

value of the I/T ratio method were determined using a
two-by-two table with 95% confidence intervals. The
cut-off point for diagnosis was determined by receiver
operating characteristic (ROC) curve.

0.5

0.3

0.0
0.0

0.3

0.5

0.8

1.0

1 - Specificity
Diagonal Segments are produced by ties.

Figure 1. ROC curve of sensitivity and specificity of

the I/T ratio

Discussion
Of the 53 subjects, we found 49% had bacterial
sepsis based on positive blood cultures. Subjects
were of various gestational ages, but those of 34-36
week gestational age had the most bacterial sepsis
(42.3%). This finding is consistent with theory that
a risk factor for bacterial sepsis is prematurity due to
underdeveloped organs.6 Premature infants may be
predisposed to respiratory distress, limited calorie
intake, increased risk of bleeding and infection. They
are, therefore, at higher risk for neonatal sepsis than
full term infants.7
Neonatal sepsis remains a major problem in
developing countries including Indonesia and is the
major cause of mortality in neonates.3 As the signs and
symptoms are non-specific, it is important to diagnose
sepsis early, so that appropriate treatment may be
administered.8 In addition to clinical manifestations,
various hematological changes are associated with
sepsis including total white blood cell count, total
neutrophil count, platelet count and increased
C-reactive protein level.9

Paediatr Indones, Vol. 55, No. 3, May 2015 155

Darnifayanti et al: Immature-to-total neutrophil ratio as an early diagnostic tool of sepsis

Other risk factors for sepsis in neonates

are low birth weight, respiratory distress syndrome,
and a history of aggressive resuscitation. Severe
asphyxia causes infection due to cellular hypoxia and
inflammation.6 We found that neonates of low birth
weight were more likely to have sepsis than those
of normal birth weight. More males (53.8%) than
females had neonatal sepsis, this difference was not
significant.10 The most common working diagnosis in
this study was respiratory distress (26.95%), similar
to an American study that found the most common
causes of sepsis in neonates to be respiratory tract
infection (38%), gastrointestinal infection (18%),
post-operative infection (5%), and unidentified
causes (24%).11 Staphylococcus epidermidis was the
most commonly cultured species (17%) found in
our subjects, similar to other studies which reported
that many hospitalized infants have Staphylococcus
epidermidis growth on the skin.12,13
We found the I/T ratio to have sensitivity
88.46%, specificity 81.48%, positive predictive value
82.14%, and negative predictive value 88%. A New
York study found that an I/T ratio of > 0.2 had sensitivity of 90% and specificity of 78%.8 Another study
in Australia found that the I/T ratio had sensitivity
96% and specificity 71%.10 Furthermore, a study in
northern California using an I/T ratio >0.15 found
sensitivity to be 89% and specificity 94%.14 A Netherlands study using an I/T ratio >0.2 found it had
sensitivity of 89% and specificity 82%.15 Lastly, an
Indian study using an I/T ratio > 0.2 had sensitivity
93.75% and specificity 85.48%.4
The I/T ratio test was sufficiently accurate to
diagnose sepsis in potentially infected neonates. As such,
the I/T ratio can be used as an early diagnostic tool for
neonatal bacterial sepsis because of its high sensitivity
and specificity. It is also quicker and less expensive than
blood cultures, so this test may help reduce the mortality
and morbidity due to neonatal sepsis.
To generalize these findings, studies with a large
number of neonates are needed. Clinical sepsis and
I/T ratio are sufficiently accurate as diagnostic tests
for sepsis in neonates. Parallel test increase sensitivity,
the negative result revealed that it is not sepsis. Serial
test will increase specificity. There is high probability
of having sepsis, if the result was positive.
In conclusion, I/T ratio can be used as an early
diagnostic tool for neonatal sepsis because of its high

156 Paediatr Indones, Vol. 55, No. 3, May 2015

sensitivity and specificity. It may be a good alternative

to blood cultures, as it is less expensive and takes less
time to perform.

Conflict of interest
None declared.

References
1. Amirullah A. Sepsis pada bayi baru lahir. In: Kasim SM,
Yunanto A, Dewi R, Sarosa IG, Usman A, editors. Buku ajar
neonatologi. Jakarta: Ikatan Dokter Anak Indonesia; 2008.
p. 170-87.
2. Gomella TL. Infectious disease. In: Gomella TL, Cuningham
MD, Eyal FG, Zenk KE, editors. Neonatology: management,
procedures, on-call problems, disease and drugs. New York:
Lange, McGraw-Hill; 2004. p. 434-40.
3. Aulia D, Sanjaya AI, Timan IS. The use of immatane to total
neutrophil (IT) ratio to detect bacteriemia in neonatal sepsis.
J Lab Med Quality Assurance. 2003;25:237-42.
4. Jackson GL, Engle WD, Sendelbach DM, Vedro DA, Josey
S, Vinson J, et al. Are complete blood cell count useful in the
evaluation of asymptomatic neonates exposed to suspected
chorioamnitis? Pediatrics. 2004;113:1173-80.
5. 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:F208-12.
6. Klinger G, Levy I, Sirota L, Boyko V, Lerner-Geva L,
Reichman B, et al. Outcome of early-onset sepsis in
national cohort of very low birth weight infants. Pediatrics.
2010;125:e736-40.
7. Osrin D, Vergnano S, Costello A. Serious bacterial infections
in newborn infants in developing countries. Curr Opin Infect
Dis. 2004;17:217-24.
8. Phillip AG, Hewitt JR. Early diagnosis of neonatal sepsis.
Pediatrics. 1980;65:1036-41.
9. Rodwell RL, Leslie AL, Tudehope DI. Early diagnosis of
neonatal sepsis using a hematologic scoring system. J Pediatr.
1988;112:761-7.
10. Stoll BJ, Hansen N, Fanaroff A, Wright LL, Carlo WA,
Ehrenkranz RA, et al. Changes in pathogens causing earlyonset sepsis in very-low-birth-weight infants. N Engl J Med.
2002;347:240-7.
11. Saez-Llorens X, Vargas S, Guerra F, Coronado L. Application
of new sepsis definitions for evaluate outcome of pediatric

Darnifayanti et al: Immature-to-total neutrophil ratio as an early diagnostic tool of sepsis

patients with severe systemic infections. Pediatr Infect Dis
J. 1995:14;557-60.
12. Baltimore RS, Huie SM, Meek JI, Schuchat A, OBrien KL.
Early-onset neonatal sepsis in the era of group B streptococcal
prevention. Pediatrics. 2001;108:1094-8.
13. Stoll BJ. Infections of the neonatal. In: Behrman RE, Kiegman
RM, Jenson HB, Stanton BF, editors. Nelson textbook of
pediatrics. 18th ed. Philadelphia: Saunders Company; 2007.
p. 794-811.

14. Manroe BL, Rosenfeld CD, Weinberg AG, Browne R. The

differential leukocyte count in the assessment and outcome of
early-onset neonatal group B streptococcal disease. J Pediatr.
1977;91:632-7.
15. Franz AR, Kron M, Pohlandt F, Steinbach G. Comparison
of procalcitonin with interleukin 8, C-reactive protein and
differential white blood cell count for the early diagnosis of
bacterial infections in newborn infants. Pediatr Infect Dis J.
1999;18:666-71.

Paediatr Indones, Vol. 55, No. 3, May 2015 157