# Intelligent Neonatal Sepsis Early Diagnosis System for Very Low Birth Weight Infants
## 5 Discussion  
The results of this study confirm what has already been highlighted in the literature about the prediction of the HeRO score with respect to the onset of sepsis. However, in all sepsis events announced early by the HeRO score, clinicians waited for at least one clinical and/or laboratory sign to appear before starting antibiotic therapy. In the literature, it is described how the early administration of antibiotics, even just an hour before, is useful in order to reduce mortality from sepsis [5; 6]. In this study, concerning the positive clinical cases for sepsis, the positivity of the score alone, however correct and predicted, was not sufficient to activate the useful actions to intervene with the desired treatment. On the other hand, the finding of a negative HeRO score in patients with sepsis alerts about the presence of only one symptom and/or a slight positivity (CRP \(<\) 1 mg /dL; PCT \(<\) 1 mg/mL) of one of the two laboratory indices, after an attentive discussion of the single clinical case suggested to the clinicians to wait (it is worth noting that these events concerned newborns with birth weight and gestational age values at the upper limits), but with the activation of serious clinical and laboratory tests and accepting the risk of accentuating the physiological anaemia of prematurity. Figure 5: HeRO score for two patients correctly classified also from the LN.E.S. system. (**Left**) A patient with sepsis; (**Right**) a patient without sepsis. Figure 6: HeRO score for two patients correctly classified only from the LN.E.S. system. (Both) Two patients without sepsis, but positive for HeRO. In 12 out of 20 events overall, the HeRO score was positive, but the patient did not develop sepsis. In addition to the positive score, in 10 events, patients presented only one symptom and/or a mild positivity of one of the two laboratory indices, activating surveillance as in the previous cases. The company that produces HeRO and the most recent literature on the topic report a list of clinical situations and/or pharmacological therapies that might influence the increase in the HeRO score. In fact, the clinical situations involving an increased release of cytokines and/or a stimulus of the vagus nerve can cause an increase in the HeRO score. This explains why apneas, intraventricular and/or parenchymal haemorrhage, periventricular leukomalacia, a sudden deterioration of respiratory conditions, but also necrotising enterocolitis (NEC), some drugs administered in the post-surgical course (anaesthetics, anticholinergics) and anti-inflammatory drugs may affect the HeRO score. It should also be borne in mind that sepsis often has an association with several of these pathologies: neonates with severe sepsis may have intra-ventricular haemorrhages (IVH) during sepsis, but also NEC, a sudden deterioration of respiratory conditions and other complications. All these conditions must be kept in mind and carefully evaluated when considering the HeRO score. One should also keep in mind what are the multiplicative risk factors of sepsis and that is a very low gestational age and birth weight (most are low factors), staying in the NICU (the longer the hospitalization, the greater the risk of sepsis) and the placement of central catheters (the more days from the positioning, the greater the risk of sepsis) [6]. This suggests that all the team involved in caring for the neonate must be educated and trained on the functioning of the HeRO device and on all situations that can influence the HeRO score, thus highlighting a limitation of the HeRO score. In fact, it can be observed how, in case of doubt, the clinician activates a series of additional checks (clinical checks and a series of blood sampling) and how, in strongly suspicious cases, he, or she, tends to wait for other clinical or laboratory confirmation before changing or starting antibiotic therapy. It would therefore be necessary to have other instruments in relation to the score of HeRO.