Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis

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Missaoui" }, { "@type": "Person", "name": "Rania Ben Rabeh" }, { "@type": "Person", "name": "Azza Hedhili" }, { "@type": "Person", "name": "Salem Yahiaoui" }, { "@type": "Person", "name": "Sofien Atitallah" }, { "@type": "Person", "name": "Olfa Bouyahia" }, { "@type": "Person", "name": "Sonia Mazigh Mrad" }, { "@type": "Person", "name": "Samir Boukthir" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": " Background Pericardial effusion (PE) is a rare condition in neonates and usually due to central venous catheters. Infective pericarditis is an extremely rare condition in neonates. Methods We describe a case of a preterm neonate with Escherichia coli pericarditis. Results A preterm female neonate born at 34 weeks of gestation with a birth weight of 1600 grams was admitted because of respiratory distress. The patient was managed using a high-flow nasal cannula. She did not receive a central venous catheter or antibiotics. The outcome was good and the patient was discharged on day 14 of life. On day 18, she was readmitted because of fever and shortness of breath. Blood sample culture was positive for Escherichia coli. On day 21, the patient presented signs of heart failure. Chest radiography showed cardiomegaly. Cardiac ultrasound showed pre tamponade. Our patient was managed with pericardial drainage and cefotaxime administration. The outcome was good and further follow-up was unremarkable. Conclusions Even though rare, infective pericarditis with effusion should be suspected in neonates who show deterioration in respiratory and hemodynamic status even if they do not have central venous catheter. 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F1000Research 2025, 14 :770 ( https://doi.org/10.12688/f1000research.167697.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] N. Missaoui https://orcid.org/0000-0003-4317-5479 1 , Rania Ben Rabeh 1 , Azza Hedhili 1 , [...] Salem Yahiaoui 1 , Sofien Atitallah https://orcid.org/0000-0002-5200-1844 1 , Olfa Bouyahia 1 , Sonia Mazigh Mrad 1 , Samir Boukthir 1 N. Missaoui https://orcid.org/0000-0003-4317-5479 1 , Rania Ben Rabeh 1 , [...] Azza Hedhili 1 , Salem Yahiaoui 1 , Sofien Atitallah https://orcid.org/0000-0002-5200-1844 1 , Olfa Bouyahia 1 , Sonia Mazigh Mrad 1 , Samir Boukthir 1 PUBLISHED 09 Sep 2025 Author details Author details 1 University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, Tunis, 1007, Tunisia N. Missaoui Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Rania Ben Rabeh Roles: Validation, Writing – Review & Editing Azza Hedhili Roles: Writing – Original Draft Preparation Salem Yahiaoui Roles: Supervision Sofien Atitallah Roles: Writing – Review & Editing Olfa Bouyahia Roles: Supervision Sonia Mazigh Mrad Roles: Supervision Samir Boukthir Roles: Supervision OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Pericardial effusion (PE) is a rare condition in neonates and usually due to central venous catheters. Infective pericarditis is an extremely rare condition in neonates. Methods We describe a case of a preterm neonate with Escherichia coli pericarditis. Results A preterm female neonate born at 34 weeks of gestation with a birth weight of 1600 grams was admitted because of respiratory distress. The patient was managed using a high-flow nasal cannula. She did not receive a central venous catheter or antibiotics. The outcome was good and the patient was discharged on day 14 of life. On day 18, she was readmitted because of fever and shortness of breath. Blood sample culture was positive for Escherichia coli . On day 21, the patient presented signs of heart failure. Chest radiography showed cardiomegaly. Cardiac ultrasound showed pre tamponade. Our patient was managed with pericardial drainage and cefotaxime administration. The outcome was good and further follow-up was unremarkable. Conclusions Even though rare, infective pericarditis with effusion should be suspected in neonates who show deterioration in respiratory and hemodynamic status even if they do not have central venous catheter. READ ALL READ LESS Keywords pericardial effusion, neonate, E coli, drainage Corresponding Author(s) N. Missaoui ( [email protected] ) Close Corresponding author: N. Missaoui Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Missaoui N et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Missaoui N, Ben Rabeh R, Hedhili A et al. Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.12688/f1000research.167697.2 ) First published: 06 Aug 2025, 14 :770 ( https://doi.org/10.12688/f1000research.167697.1 ) Latest published: 09 Sep 2025, 14 :770 ( https://doi.org/10.12688/f1000research.167697.2 ) Revised Amendments from Version 1 We have made changes to our first draft of the manuscript for more clarity and accuracy. Grammar and expression errors have been corrected in all sections. In the introduction, we added a reference explaining the pathogenesis of pericardial effusion caused by central venous catheters. In the case report, we provided additional data about: - The mother's serology - The patient's and her sister's anthropometrics - The patient's physical examination during her first hospitalization - The COVID-19 test result - The discussion and exclusion of the diagnosis of early onset neonatal infection, justifying the non-prescription of antibiotics - Details of the cardiac ultrasound - Data from the physical examination at discharge - Details of follow-up In the Discussion section, we have: - Added a reference describing the incidence of PE in neonates with central venous catheters (recommended by reviewer) - Detailed the rarity of isolation of the pathogen in pericardial fluid according to the literature - Added a reference (recommended by reviewer) on the rarity of PE in neonatal E. coli septicaemia - Added a paragraph (recommended by reviewer) on the value of our case report in the context of rational antibiotic prescription to prevent bacterial resistance - Added a paragraph on the impact on practice, limitations, and recommendations Figures: we have: - Modified the titles (recommended by reviewer) to emphasize findings before and after pericardial drainage - Added arrows on the radiograph showing cardiomegaly We have made changes to our first draft of the manuscript for more clarity and accuracy. Grammar and expression errors have been corrected in all sections. In the introduction, we added a reference explaining the pathogenesis of pericardial effusion caused by central venous catheters. In the case report, we provided additional data about: - The mother's serology - The patient's and her sister's anthropometrics - The patient's physical examination during her first hospitalization - The COVID-19 test result - The discussion and exclusion of the diagnosis of early onset neonatal infection, justifying the non-prescription of antibiotics - Details of the cardiac ultrasound - Data from the physical examination at discharge - Details of follow-up In the Discussion section, we have: - Added a reference describing the incidence of PE in neonates with central venous catheters (recommended by reviewer) - Detailed the rarity of isolation of the pathogen in pericardial fluid according to the literature - Added a reference (recommended by reviewer) on the rarity of PE in neonatal E. coli septicaemia - Added a paragraph (recommended by reviewer) on the value of our case report in the context of rational antibiotic prescription to prevent bacterial resistance - Added a paragraph on the impact on practice, limitations, and recommendations Figures: we have: - Modified the titles (recommended by reviewer) to emphasize findings before and after pericardial drainage - Added arrows on the radiograph showing cardiomegaly See the authors' detailed response to the review by Khadijat Isezuo and Asma'u Adamu See the authors' detailed response to the review by Lamin Makalo READ REVIEWER RESPONSES Introduction Pericardial effusion (PE) is a rare condition in neonates. Symptoms include difficulty breathing and fever. Without appropriate treatment, it can quickly progress to hemodynamic collapse, tamponade, and ultimately, death. The most common cause of pericardial effusion in neonates are central venous catheters. It is due to the mechanical and osmotic injury of the thin and immature myocardium in neonates and especially preterm. 1 Case report A preterm female infant and her twin sister were born at 34 weeks of gestation via an emergency caesarean section due to covid 19 infection in the mother. Maternal serologies (toxoplasmosis, rubella, hepatitis B and syphilis) and prenatal ultrasound findings were unremarkable. The first twin was small for gestational age and had severe respiratory distress. She was referred to the PICU. She was discharged on day 10 of hospitalization. No further symptoms were noted. Our patient weighted 1600 g (small for gestational age), and Apgar score was 8 at 1 min and 9 at 10 min. She was referred to out neonatal unit in the pediatric ward for respiratory distress. At presentation, respiratory rate was 62 per minute, heart rate was 138 per minute and oxygen saturation was 97%. Chest radiography was normal. Covid 19 polymerase chain reaction test was negative. She was placed on oxygen therapy via high-flow nasal cannula for three days. The patient received fluids through a peripheral venous catheter. The diagnosis of early onset neonatal infection was discussed but excluded based on: rapid improvement of respiratory status, normal CRP levels and negative blood culture. The patient did not receive any antibiotics. Final diagnosis was transient tachypnea of the newborn. As her respiration improved, she was placed on room air on day 3 of life, fluid infusion was discontinued on day 4 of life, and she was gradually fed with milk formula (breast milk was not available as her family lived from our facility). She was fed initially via gastric tube and gradually via bottle. The patient was discharged on day 14 of life. On day 18 of life, she presented to the emergency room with fever and dyspnea. Respiratory rate was 65/minute with intercostal recession. Oxygen saturation was 97% in room air. The patient was placed on oxygen via a nasal cannula. Chest radiography was normal. Laboratory tests showed a leukocyte count of 26000/mm 3 and an elevated reactive protein C level of 220 mg/l. Initially, a nosocomial infection was suspected, and the patient was received imipenem and amikacin. There was no improvement in her respiratory status. On day 21 of life, two blood cultures obtained on the day of readmission were positive for multidrug-sensitive Escherichia coli ( E. coli ). The patient was then switched to cefotaxime. On day 23 of life, our patient developed signs of heart failure with tachycardia, hepatomegaly, tachypnea, and a capillary refill of 4 seconds. Chest radiography revealed cardiomegaly (cardiothoracic ratio 0.67) with a globular heart shape ( Figure 1 ). Electrocardiogram was normal. Cardiac ultrasound was not available in our hospital so it was performed by cardiologists in another facility. It revealed echogenic, circumferential pericardial effusion (11 mm) and pre tamponade (protodiastolic right ventricle collapse). It also showed a small patent ductus arteriosus. There were no signs of endocarditis. Figure 1. Pre-pericardiocentesis chest radiography demonstrating marked cardiomegaly with globular cardiac silhouette. A pericardial drain was inserted surgically, and 8 ml of purulent fluid mixed with blood was aspirated. Cytological analysis showed 3 leukocytes per ml. Biochemical analysis was not performed. No bacteria were isolated in pericardial fluid. After pericardial drainage, the respiratory status improved, and the shape of the heart was normal on chest radiography ( Figure 2 ). The pericardial catheter was removed 10 days later. Cefotaxime was continued for a total duration of 14 days. A second cardiac ultrasound was performed at the age of 32 days. It showed no pericardial effusion. The patient was discharged on day 35 of hospitalization. At discharge, her weight was 2550 g and her physical examination showed normal body temperature, respiratory rate 34 per minute and heart rate 124 per minute. She had regular follow-up until the age of 6 months. At that age, her weight was 6700 g and her physical examination was normal. She was lost of follow-up since. Figure 2. Post-pericardiocentesis chest radiography showing resolution of cardiomegaly with normalization of cardiac silhouette. Discussion Pericardial effusion (PE) is rare in neonates. Its clinical presentation depends on the speed and amount of fluid accumulation. 2 This can lead to tamponade and even death. The most common cause is iatrogenic because of central venous catheters. 3 In a meta-analysis of 21 studies and 99 cases, pooled incidence of PE in neonates who had central venous catheters was 3.8‰. Mortality rate was 2.7%. 1 In a national American study of all cases of pericardial effusion, the lowest incidence was observed in neonates (0.04%). 4 In a literature review, 34 patients were enrolled. The most common causes were central venous catheters (n = 21), Down syndrome (n = 3), and infections (n = 3). The pathogen agent was isolated in pericardial fluid in only one cas (candida albicans). The second case was caused by Escherichia coli isolated in blood culture. In the third case, PE was secondary to parainfluenza virus 3 which was isolated in nasopharyngeal swab. 3 Pericardial effusion due to an E. coli infection is rare. To date, only case reports have been published. In 1979, Wynn described purulent pericarditis in a 64 hours aged neonate. Autopsy confirmed the diagnosis of pericardial effusion, and E coli was isolated from the blood culture. 5 In 2006, Benjamin described pericarditis in a 10 days old boy. E. coli was isolated from blood samples obtained in the emergency room before referral. He was managed with pericardectomy, pericardial drainage, cefotaxime, and indomethacin. The intraoperative samples were negative. 6 Even in E. coli sepsis, pericardial effusion remains rare. Lai described the epidemiology of invasive E. coli infection in 94 Chinese neonates, including early and late onset disease. No case of pericardial effusion was described. 7 In our case, initial suspicion of a nosocomial infection was raised given the patient’s recent hospitalization. The isolation of E. coli with multidrug sensitivity underscores the potential for multidrug-resistant strains in neonatal units, especially in settings where broaded-spectrum antibiotics such as carbapenems and aminoglycosides are frequently used empirically. This highlights the importance of strict infection prevention measures, rational antibiotic stewardship and early targeted therapy guided by culture results. The management of PE is variable, from surveillance in small asymptomatic effusions to pericardiocentesis, pericardectomy, and pericardial drainage. 3 , 8 In an American retrospective cohort, pericardial drainage was performed in 8.5% of neonates. 4 Follow-up and outcomes Outcomes in case reports of infective pericarditis in neonates were good, except in the case of postmortem diagnosis. 5 In an American study, the overall mortality was 6.8%, and mortality was the highest among neonates (12.4%). 4 Although neonatal pericardial effusion is rare, it should be considered in neonates with cardiac failure, especially in the context of infection. This diagnosis should be considered in neonates who develop signs of deterioration even if they have no central venous catheters. Infective pericarditis in neonates is a rare condition. Management depends on tolerance of the effusion. Mortality was higher in neonates than in the other age groups. Implication for practice This case underscores the need for clinicians to maintain high index of suspicion for pericardial effusion in neonates presenting with sepsis and cardiorespiratory deterioration. The absence of central venous catheters cannot reduce the probability. Incorporating point-of-care echocardiography in deteriorating neonates could facilitate earlier detection and intervention. Furthermore, routine review of empirical antibiotic regimens in neonatal sepsis is critical to balance adequate coverage with antimicrobial stewardship. Limitations This report has limitations inherent to single case studies. The follow-up period was relatively short. Ultrasound images were not available in this report. Conclusion Neonatal pericardial effusion due to Escherichia coli is an exceedingly rare but potentially life-threatening condition. Early recognition and timely pericardicentesis can be lifesaving. Recommendations: • Clinicians should suspect pericardial involvement in neonates with unexplained cardiorespiratory compromise during sepsis, even without central catheters. • Echocardiography should be integrated in the evaluation of deteriorating neonates with sepsis. • Infection prevention and control practices should be strengthened in neonatal units to minimize the risk of nosocomial multi-drug resistant infections. • Empiric antibiotic therapy in neonatal sepsis should be carefully tailored, with early de-escalation based on culture results, to preserve antimicrobial effectiveness. • Collaborative multicenter registries and pooled case reports are needed to clarify the epidemiology, management and outcomes of neonatal infective pericarditis. Use of AI tools: The authors did not use AI technology in the writing process. Ethics and consent Approval of the local ethics committee of Bechir Hamza Hospital was obtained (n°13/2022). Written informed consent was obtained from the patient’s guardian for the publication of clinical details. Data availability All data underlying the results are available as part of the article. Reporting guidelines Figshare: CARE checklist for “Pericardial effusion in late onset neonatal Esherichia coli sepsis”. https://doi.org/10.6084/m9.figshare.29611250.v2 9 All Data are available under the terms of Creative Common Zero (CC0) . References 1. Wang J, Wang Q, Liu Y, et al. : The incidence and mortality rate of catheter-related neonatal pericardial effusion: A meta-analysis. Medicine (Baltimore). 2022; 101 : e32050. Publisher Full Text 2. Park M-J, Ahn J-H, Lee HJ, et al. : Rapidly Progressive Pericardial Effusion and Cardiac Tamponade in a Term Infant with an Umbilical Venous Catheter: A Case Report. Neonatal. Med. 2022; 29 : 135–140. Publisher Full Text 3. Ferraz Liz C, Domingues S, Pinho L, et al. : Neonatal pericardial effusion: case report and review of the literature. J. Pediatr. Neonatal. Individ. Med. 2020; 9 : 90111. Publisher Full Text 4. Sasaki J, Sendi P, Hey MT, et al. : The Epidemiology and Outcome of Pericardial Effusion in Hospitalized Children: A National Database Analysis. J. Pediatr. 2022; 249 : 29–34. PubMed Abstract | Publisher Full Text 5. Wynn RJ, Neonatal E: coli pericarditis. J. Perinat. Med. 1979; 7 : 23–26. Publisher Full Text 6. Benjamin BK, Ebenroth ES: Purulent pericarditis in a neonate. Pediatr Cardiol. 2006; 27 : 351–353. Publisher Full Text 7. Lai J, Zhu Y, Tang L, et al. : Epidemiology and antimicrobial susceptibility of invasive Escherichia coli infection in neonates from 2012 to 2019 in Xiamen, China. BMC Infect. Dis. 2021; 21 : 295. Publisher Full Text 8. Aranda Cazón C, Arruza Gómez L, Herranz Carrillo G, et al. : Parainfluenza 3 Respiratory Infection Associated with Pericardial Effusion in a Very Low Birthweight Infant. Case Rep. Infect Dis. 2017; 2017 : 1–4. PubMed Abstract | Publisher Full Text | Free Full Text 9. Missaoui N: CARE checklist for “Pericardial effusion in late onset neonatal Esherichia coli sepsis”.pdf.2025. Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 06 Aug 2025 ADD YOUR COMMENT Comment Author details Author details 1 University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, Tunis, 1007, Tunisia N. Missaoui Roles: Conceptualization, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Rania Ben Rabeh Roles: Validation, Writing – Review & Editing Azza Hedhili Roles: Writing – Original Draft Preparation Salem Yahiaoui Roles: Supervision Sofien Atitallah Roles: Writing – Review & Editing Olfa Bouyahia Roles: Supervision Sonia Mazigh Mrad Roles: Supervision Samir Boukthir Roles: Supervision Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 09 Sep 2025, 14:770 https://doi.org/10.12688/f1000research.167697.2 version 1 Published: 06 Aug 2025, 14:770 https://doi.org/10.12688/f1000research.167697.1 Copyright © 2025 Missaoui N et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Missaoui N, Ben Rabeh R, Hedhili A et al. Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.12688/f1000research.167697.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 09 Sep 2025 Revised Views 0 Cite How to cite this report: Isezuo K and Adamu A. Reviewer Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.187677.r412608 ) The direct URL for this report is: https://f1000research.com/articles/14-770/v2#referee-response-412608 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 16 Sep 2025 Khadijat Isezuo , Paediatric Cardiology Unit, Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria Asma'u Adamu , Neonatal Unit, Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria Approved VIEWS 0 https://doi.org/10.5256/f1000research.187677.r412608 Thanks for the opportunity to review this paper after the initial corrections. The authors have adhered to the comments and this has made the report significantly improved. However, there are a few typographical errors and two pending issues pertaining oxygen ... Continue reading READ ALL Thanks for the opportunity to review this paper after the initial corrections. The authors have adhered to the comments and this has made the report significantly improved. However, there are a few typographical errors and two pending issues pertaining oxygen use with normal saturation and an abnormal Chest X-ray interpretation. They are highlighted in the comments below. 1.our She was referred to out neonatal unit in the pediatric ward for respiratory distress. 2. nasogastric She was fed initially via gastric tube 3. this was not addressed and no reason given Oxygen saturation was 97% i n room air. The patient was placed on oxygen via a nasal cannula. 4. delete "was" Initially, a nosocomial infection was suspected, and the patient was received imipenem 5. lost to She was lost of follow-up since. 6. Figure 2 caption Figure 2. Post-pericardiocentesis chest radiography showing resolution of cardiomegaly with normalization of cardiac silhouette. It only shows reduction in cardiomegaly and not a resolution. The cardiac silhouette is still not completely normal. So caption as a reduction. Moreover, the cardiothoracic ratio was not measured to compare both. 7. case The pathogen agent was isolated in pericardial fluid in only one cas (candida.... 8. pericardiectomy He was managed with pericardectomy, 9. broad-spectrum The isolation of E. coli with multidrug sensitivity underscores the potential for multidrug-resistant strains in neonatal units, especially in settings where broaded-spectrum antibiotics such as carbapenems and aminoglycosides are frequently used empirically. 10. Cardiac ultrasound Ultrasound images were not available in this report. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Paediatric cardiology, Neonatology, Infectious disease, Nutrition We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Isezuo K and Adamu A. Reviewer Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.187677.r412608 ) The direct URL for this report is: https://f1000research.com/articles/14-770/v2#referee-response-412608 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Makalo L. Reviewer Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.187677.r412607 ) The direct URL for this report is: https://f1000research.com/articles/14-770/v2#referee-response-412607 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 16 Sep 2025 Lamin Makalo , University of the Gambia, Serrekunda, Banjul, The Gambia Approved VIEWS 0 https://doi.org/10.5256/f1000research.187677.r412607 Good enough to be indexed, ... Continue reading READ ALL Good enough to be indexed, Dr Lamin Makalo University of The Gambia. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Paediatric Hematology, Pulmonology, Cardiology, Nutrition and Gastroenterology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Makalo L. Reviewer Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.187677.r412607 ) The direct URL for this report is: https://f1000research.com/articles/14-770/v2#referee-response-412607 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 06 Aug 2025 Views 0 Cite How to cite this report: Isezuo K and Adamu A. Reviewer Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.184830.r406263 ) The direct URL for this report is: https://f1000research.com/articles/14-770/v1#referee-response-406263 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 01 Sep 2025 Khadijat Isezuo , Paediatric Cardiology Unit, Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria Asma'u Adamu , Neonatal Unit, Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.184830.r406263 Dr Khadijat O. Isezuo (Reviewer A) General comments: This is an interesting case report which clearly depicts the evolution of symptomatology in a preterm neonate eventually leading to a diagnosis of pericardial ... Continue reading READ ALL Dr Khadijat O. Isezuo (Reviewer A) General comments: This is an interesting case report which clearly depicts the evolution of symptomatology in a preterm neonate eventually leading to a diagnosis of pericardial effusion. A positive blood culture yielded E.coli and was attributed to be the cause of pericarditis though the pericardial fluid was sterile despite being purulent. It brings to bear that the relatively immunodeficient neonate can manifest deep seated foci of sepsis and unstable cardiorespiratory symptomatology should be thoroughly investigated. However, the possibility of infective endocarditis was not mentioned as a possible differential and excluded with the Dukes criteria.[1] The overall status and outcome of the other twin could also be mentioned. The COVID status of the babies should be excluded too Title It is ok except the possibility of early onset sepsis in the child due to timing of initial symptoms and lack of antibiotics Abstract: Introduction _line 1: Adjust to “Usually due to complication of Central Venous Catheter” ‘Remove infective’ from methods Conclusion: infective pericarditis with effusion Introduction it is too short and has no references explain briefly how Central venous catheter causes pericardial effusion one can mention other causes of neonatal pericardial effusion ie frequent causes here to expatiate on how common or rare infective causes are. Case Report The serological findings--- Do they refer to the mother or babies? Which test specifically were done? Any possibility of covid infection contributing to respiratory distress in them? This can be explored in the discussion if word count allows for it. [2,3,4] What was the 1 st twin diagnosis and anthropometry and were they AGA or SGA or LGA? Where was this patient managed if the twin was in PICU? What were her own investigations if related? The 3 rd paragraph of the case report is too choked up. It contains the events at birth, those during the 1 st admission till discharge, those on readmission. It makes it a bit difficult to follow. It is better to separate them, possibly sub-headers if guidelines allow. During the 1 st admission, diagnosis was TTN, this seems odd for that level of prematurity. Was sepsis considered then? Specifically, early onset sepsis? Was there any other risk in the mother? Any sepsis screen then? Despite the length of stay, why no antibiotics? At what day was the infusion discontinued? A table showing the summary of investigation results and reference changes would be useful rather than being subsumed within the text She had 4 chest x-rays in how many days? Safety? Present the normal x-rays images chronologically side by side before the abnormal one. In the text, mention as follows—repeat chest x-ray on day*** of life so as to give more context. Chest x-ray with pericardial effusion also has minimal pleural effusion on the right side. What were the cardiothoracic ratios? Is there any ECG result? Why echo not done earlier and no echo image is provided at diagnosis and at resolution? The echo dimensions of the free space occupied by fluid can also be mentioned. There is no specific mention if intra-cardiac defect was excluded eg a PDA at this age in a preterm. Likewise as mentioned in the general comment, infective endocarditis (gram negative) was not fully explored and excluded with the criteria. [1] What were the parameters at discharge eg weight, respiratory rate, heart rate, temperature? Discussion As acute pericarditis is a major clinical manifestation of long COVID-19 syndrome, was there any link to their mother’s status? [5] Discussion did not on dwell on neonatal causes of pericardial effusion. In the 3rd paragraph, no reference number for Benjamin’s findings. Find out if this very recent study includes neonatal cases and reference it --------[6] Richard, B., Preka, E., Grapin, M. Et al. Pericardial effusion in pediatric Shiga toxin-producing E. Coli hemolytic uremic syndrome: a French multicentre study. Pediatr Nephrol (2025). https://doi.org/10.1007/s00467-025-06877-0 The references are too few. This can be used to support or disprove the rarity. Kindly check it.----[7] Lai, J., Zhu, Y., Tang, L. et al. Epidemiology and antimicrobial susceptibility of invasive Escherichia coli infection in neonates from 2012 to 2019 in Xiamen, China. BMC Infect Dis 21, 295 (2021). https://doi.org/10.1186/s12879-021-05981-4 Others What of confidentiality in ethics statement? And other ethical issues. Final recommendation: To accept after the above revisions are fairly addressed. Prof Asma’u Adamu (Reviewer B) Title The title can be modified to “Purulent pericardial effusion in a preterm neonate with late onset Escherichia coli septicaemia” Abstract That was divided into two subsections. It is not necessary - to remove background, methods and result and allow the sentences to flow Keywords Delete drainage Case Report The first twin that had severe respiratory distress, what was the diagnosis, birth, PCV and APGAR? Correct to transient Tachypnoea of the new born not transient tachypnoea in the newborn. Delete moderate respiratory distress – leave as respiratory distress She was placed in a high-flow nasal cannula oxygen therapy – add oxygen therapy ; do so also in the abstract The patient receive fluid through a peripheral venous catheter – correct to the patient received fluid via a peripheral venous line Add the oxygen saturation of the patient in a room air at presentation before commencement of oxygen and heart rate Why feeding with milk formula not breast milk; add reason for not giving breastmilk. Four days later (on day 18) add (on day 18 of life) Add the specific chest retractions observed in this patient like intercostal recession, subcostal recession and so on. Delete that she had retraction The patient was placed on oxygen with a normal oxygen saturation of 97%. Delete the patient was placed on oxygen And the patient was received Imipenem and Amikacin – correct to the patient received Imipenem and Amikacin On day 21, the two blood cultures that were obtained, add their antibiotic sensitivity pattern The cefotaxime that was switched to, is it based on the antibiotic sensitivity? Add (23 days of life) The hepatomegaly, is it tender? If tender add Chest radiography revealed significant cardiomegaly – delete significant No bacteria was detected- replace detected with isolated Discussion To date only case reports Are they the only case reports on similar case? If yes add to date the only case reports You have compared your findings with other reports, what made your case different, if any add to the discussion Highlight diagnostic delay, patient developed tamponade on day 23 despite antibiotic could an earlier, ECHO have helped Also discuss lessons for clinician. In neonate with sepsis and cardiac signs, early ECHO is crucial in the absence of central lines Add also in the discussion the reason for negative culture of the pericardial fluid such as prior use of antibiotics, inflammation and so on. Could a pericardial biopsy and PCR have helped? [8] References Some of the references were too old, use recent references Final recommendation: To accept after revisions Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly References 1. McLennan D, Morgan G: Infective Endocarditis, a Rare Complication of Late Neonatal Group B Strep Sepsis. Frontiers in Pediatrics . 2018; 6 . Publisher Full Text 2. Shabil M, Gaidhane S, Ballal S, Kumar S, et al.: Maternal COVID-19 infection and risk of respiratory distress syndrome among newborns: a systematic review and meta-analysis. BMC Infectious Diseases . 2024; 24 (1). Publisher Full Text 3. Lim J: Impacts of maternal COVID-19 during pregnancy on neonatal health and epidemiology. Clinical and Experimental Pediatrics . 2024; 67 (3): 149-151 Publisher Full Text 4. Lee S, Jin J, Yoo J, Yoon S: Association between maternal coronavirus disease 2019 and transient tachypnea of the newborn: a single-center study. Clinical and Experimental Pediatrics . 2023; 66 (11): 493-500 Publisher Full Text 5. Chacko A, Rodrigues S: 109: CARDIAC TAMPONADE: A DELAYED COMPLICATION OF COVID-19. Critical Care Medicine . 2022; 50 (1). Publisher Full Text 6. Richard B, Preka E, Grapin M, Nobili F, et al.: Pericardial effusion in pediatric Shiga toxin-producing E. coli hemolytic uremic syndrome: a French multicentre study. Pediatric Nephrology . 2025. Publisher Full Text 7. Lai J, Zhu Y, Tang L, Lin X: Epidemiology and antimicrobial susceptibility of invasive Escherichia coli infection in neonates from 2012 to 2019 in Xiamen, China. BMC Infectious Diseases . 2021; 21 (1). Publisher Full Text 8. Tsushima T, Ishii N, Matsuzaka S, Armitage K, et al.: Culture‐negative group B streptococcal pericarditis: A case report and literature review of the diagnostic use of polymerase chain reaction. Clinical Case Reports . 2019; 7 (3): 509-514 Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Paediatric cardiology, Neonatology, Infectious disease, Nutrition We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Isezuo K and Adamu A. Reviewer Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.184830.r406263 ) The direct URL for this report is: https://f1000research.com/articles/14-770/v1#referee-response-406263 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 12 Sep 2025 Nada Missaoui , University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, 1007, Tunisia 12 Sep 2025 Author Response Dear Dr Isezuo, We sincerely thank your for evaluating our manuscript. Response to comment 1 (Introduction): More details were added as well as the role of central venous ... Continue reading Dear Dr Isezuo, We sincerely thank your for evaluating our manuscript. Response to comment 1 (Introduction): More details were added as well as the role of central venous catheters. Response to comment on Main body: more information about maternal serologies, twin anthropometry were added. The diagnosis of early onset neonatal infection (during the first hospitalization) was discussed and excluded. Infusion was discontinued on day 4. Details have been added to the manuscript. Our patient had 4 X rays during her two hospitalizations (45 days). We believe that her safety was not compromised. ECG was normal (already mentioned in the original version). Cardiac ultrasound is not available in our facility. All the findings of cardiac ultrasound were added to the manuscript (this detail as well as was added to the manuscript). Physical examination parameters were mentioned in the revised version of the manuscript. We appreciate your suggestions regarding discussion and recent articles. They enhanced the quality of our article. Dear Dr Isezuo, We sincerely thank your for evaluating our manuscript. Response to comment 1 (Introduction): More details were added as well as the role of central venous catheters. Response to comment on Main body: more information about maternal serologies, twin anthropometry were added. The diagnosis of early onset neonatal infection (during the first hospitalization) was discussed and excluded. Infusion was discontinued on day 4. Details have been added to the manuscript. Our patient had 4 X rays during her two hospitalizations (45 days). We believe that her safety was not compromised. ECG was normal (already mentioned in the original version). Cardiac ultrasound is not available in our facility. All the findings of cardiac ultrasound were added to the manuscript (this detail as well as was added to the manuscript). Physical examination parameters were mentioned in the revised version of the manuscript. We appreciate your suggestions regarding discussion and recent articles. They enhanced the quality of our article. Competing Interests: No competing interests to disclose Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 12 Sep 2025 Nada Missaoui , University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, 1007, Tunisia 12 Sep 2025 Author Response Dear Dr Isezuo, We sincerely thank your for evaluating our manuscript. Response to comment 1 (Introduction): More details were added as well as the role of central venous ... Continue reading Dear Dr Isezuo, We sincerely thank your for evaluating our manuscript. Response to comment 1 (Introduction): More details were added as well as the role of central venous catheters. Response to comment on Main body: more information about maternal serologies, twin anthropometry were added. The diagnosis of early onset neonatal infection (during the first hospitalization) was discussed and excluded. Infusion was discontinued on day 4. Details have been added to the manuscript. Our patient had 4 X rays during her two hospitalizations (45 days). We believe that her safety was not compromised. ECG was normal (already mentioned in the original version). Cardiac ultrasound is not available in our facility. All the findings of cardiac ultrasound were added to the manuscript (this detail as well as was added to the manuscript). Physical examination parameters were mentioned in the revised version of the manuscript. We appreciate your suggestions regarding discussion and recent articles. They enhanced the quality of our article. Dear Dr Isezuo, We sincerely thank your for evaluating our manuscript. Response to comment 1 (Introduction): More details were added as well as the role of central venous catheters. Response to comment on Main body: more information about maternal serologies, twin anthropometry were added. The diagnosis of early onset neonatal infection (during the first hospitalization) was discussed and excluded. Infusion was discontinued on day 4. Details have been added to the manuscript. Our patient had 4 X rays during her two hospitalizations (45 days). We believe that her safety was not compromised. ECG was normal (already mentioned in the original version). Cardiac ultrasound is not available in our facility. All the findings of cardiac ultrasound were added to the manuscript (this detail as well as was added to the manuscript). Physical examination parameters were mentioned in the revised version of the manuscript. We appreciate your suggestions regarding discussion and recent articles. They enhanced the quality of our article. Competing Interests: No competing interests to disclose Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Makalo L. Reviewer Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.184830.r406267 ) The direct URL for this report is: https://f1000research.com/articles/14-770/v1#referee-response-406267 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 21 Aug 2025 Lamin Makalo , University of the Gambia, Serrekunda, Banjul, The Gambia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.184830.r406267 I’ve reviewed the case report titled “Pericardial effusion in late onset neonatal Escherichia coli sepsis” (F1000Research, 2025) . Here’s my assessment of its fitness for publication: Strengths Relevance and Novelty ... Continue reading READ ALL I’ve reviewed the case report titled “Pericardial effusion in late onset neonatal Escherichia coli sepsis” (F1000Research, 2025) . Here’s my assessment of its fitness for publication: Strengths Relevance and Novelty Infective pericarditis due to E. coli in neonates is very rare; documenting such a case adds value to neonatal infectious disease literature. The case highlights the importance of suspecting pericardial effusion even without a central venous catheter. Structure and Clarity Follows the expected case report format : Abstract, Introduction, Case description, Discussion, Conclusion, Ethics, and Data availability. Clinical timeline is clear: initial presentation, discharge, readmission, infection, diagnosis of pericardial effusion, management, and outcome. Ethical approval and informed consent are explicitly stated. Use of Literature References are relevant and include both classic and recent reports. Situates the case in the context of previously reported neonatal pericardial effusions. Compliance CARE guidelines checklist has been attached (per Fig share reference). Transparency regarding AI use (declared none). No conflicts of interest or funding bias. Weaknesses / Areas for Improvement Language and Grammar Several sentences are grammatically awkward or lack fluency (e.g., “difficulty to breath” should be “difficulty breathing”). Some inconsistencies in spacing and punctuation. Case Details Pericardial fluid analysis : It was stated no bacteria were detected, but biochemical/cytological analysis details (protein, glucose, cell count) are missing. These would strengthen diagnostic certainty. Antibiotic regimen : The switch from imipenem/amikacin to cefotaxime is described, but no rationale is given for narrowing therapy despite E. coli being multidrug-sensitive. Twin context : The first twin’s outcome is described but seems peripheral—clarify its relevance. Follow-up duration : States “further follow-up was unremarkable” but doesn’t indicate for how long (weeks/months). This limits assessment of long-term prognosis. Figures Only X-rays (before and after drainage) are provided. Cardiac ultrasound images would have added diagnostic weight. Discussion Could be expanded to discuss: Pathophysiology of E. coli spread to the pericardium. Why neonates may be more vulnerable. Broader implications for neonatal sepsis management in resource-limited settings. Minor Issues Typo in title and reporting guideline reference: “Esherichia coli” instead of Escherichia coli . Some references (e.g., Ferraz Liz et al.) could benefit from more context when cited. Conclusions Even though rare, infective pericarditis should be suspected in neonates who show deterioration in respiratory and hemodynamic status even if they do not have a central venous catheter. This case also highlights concerns for multidrug resistance in neonatal sepsis and the importance of antibiotic stewardship. I recommend the following for the figures Figure 1. Pre-pericardiocentesis chest radiograph demonstrating marked cardiomegaly with a globular cardiac silhouette (arrows indicate the enlarged cardiac borders). Figure 2. Post-pericardiocentesis chest radiograph showing resolution of cardiomegaly with normalization of cardiac silhouette (arrows indicate normalized heart borders). Discussion (MDR concern & implications) I suggest adding after the paragraph describing E. coli reports: “In our case, initial suspicion of a nosocomial infection was raised given the patient’s recent hospitalization. The isolation of E. coli with multidrug sensitivity underscores the potential for multidrug-resistant (MDR) strains in neonatal units, especially in settings where broad-spectrum antibiotics such as carbapenems and aminoglycosides are frequently used empirically. Although our isolate was susceptible, vigilance is warranted as MDR E. coli pericarditis could severely limit therapeutic options. This highlights the importance of strict infection prevention measures, rational antibiotic stewardship, and early targeted therapy guided by culture results.” Implications for practice I suggest inserting in the Discussion/Conclusion transition: “This case underscores the need for clinicians to maintain a high index of suspicion for pericardial effusion in neonates presenting with sepsis and cardiorespiratory deterioration, even in the absence of central venous catheters. The overlap between neonatal sepsis and cardiac failure may delay recognition of pericardial involvement. Incorporating point-of-care echocardiography in deteriorating neonates could facilitate earlier detection and intervention. Furthermore, routine review of empirical antibiotic regimens in neonatal sepsis is critical to balance adequate coverage with antimicrobial stewardship.” Limitations I suggest adding this before conclusion: “This report has limitations inherent to single case studies. Pericardial fluid biochemical and cytological analyses were not performed, limiting full characterization of the effusion. The follow-up period was relatively short, and longer-term outcomes could not be assessed. Ultrasound images were not archived for inclusion in this report, which would have provided stronger diagnostic demonstration.” Conclusion and Recommendations The following is suggested to strengthen the conclusion and therefore give recommendations to strengthen the report Conclusion Neonatal pericardial effusion due to Escherichia coli is an exceedingly rare but potentially life-threatening condition. Early recognition and timely pericardiocentesis can be lifesaving. Recommendations Clinicians should suspect pericardial involvement in neonates with unexplained cardiorespiratory compromise during sepsis, even without central catheters. Echocardiography should be integrated into the evaluation of deteriorating neonates with sepsis. Infection prevention and control practices should be strengthened in neonatal intensive care settings to minimize the risk of nosocomial MDR infections. Empiric antibiotic therapy in neonatal sepsis should be carefully tailored, with early de-escalation based on culture results, to preserve antimicrobial effectiveness. Collaborative multicenter registries and pooled case reports are needed to clarify the epidemiology, management, and outcomes of neonatal infective pericarditis. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Paediatric Hematology, Pulmonology, Cardiology, Nutrition and Gastroenterology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Makalo L. Reviewer Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.184830.r406267 ) The direct URL for this report is: https://f1000research.com/articles/14-770/v1#referee-response-406267 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 12 Sep 2025 Nada Missaoui , University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, 1007, Tunisia 12 Sep 2025 Author Response Dear Dr Makalo, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Response to comment 1: We ... Continue reading Dear Dr Makalo, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Response to comment 1: We have made corrections to grammar and punctuations mistakes. Response to comment 2: Details of pericardial fluid analysis, the rational of antibiotic switch and follow-up have been added to the manuscript. Response to comment 3: Cardiac ultrasound was not performed in our facility (this detail was added to the manuscript). Unfortunately, no images were provided from cardiologists. Response to comments on discussion: we appreciate your suggestions. We have included them in the manuscript. Dear Dr Makalo, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Response to comment 1: We have made corrections to grammar and punctuations mistakes. Response to comment 2: Details of pericardial fluid analysis, the rational of antibiotic switch and follow-up have been added to the manuscript. Response to comment 3: Cardiac ultrasound was not performed in our facility (this detail was added to the manuscript). Unfortunately, no images were provided from cardiologists. Response to comments on discussion: we appreciate your suggestions. We have included them in the manuscript. Competing Interests: No competing interests disclosed Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 12 Sep 2025 Nada Missaoui , University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, 1007, Tunisia 12 Sep 2025 Author Response Dear Dr Makalo, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Response to comment 1: We ... Continue reading Dear Dr Makalo, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Response to comment 1: We have made corrections to grammar and punctuations mistakes. Response to comment 2: Details of pericardial fluid analysis, the rational of antibiotic switch and follow-up have been added to the manuscript. Response to comment 3: Cardiac ultrasound was not performed in our facility (this detail was added to the manuscript). Unfortunately, no images were provided from cardiologists. Response to comments on discussion: we appreciate your suggestions. We have included them in the manuscript. Dear Dr Makalo, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Response to comment 1: We have made corrections to grammar and punctuations mistakes. Response to comment 2: Details of pericardial fluid analysis, the rational of antibiotic switch and follow-up have been added to the manuscript. Response to comment 3: Cardiac ultrasound was not performed in our facility (this detail was added to the manuscript). Unfortunately, no images were provided from cardiologists. Response to comments on discussion: we appreciate your suggestions. We have included them in the manuscript. Competing Interests: No competing interests disclosed Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 06 Aug 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 09 Sep 25 read read Version 1 06 Aug 25 read read Lamin Makalo , University of the Gambia, Serrekunda, The Gambia Khadijat Isezuo , Usmanu Danfodiyo University, Sokoto, Nigeria Asma'u Adamu , Usmanu Danfodiyo University, Sokoto, Nigeria Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Isezuo K et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Sep 2025 | for Version 2 Khadijat Isezuo , Paediatric Cardiology Unit, Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria Asma'u Adamu , Neonatal Unit, Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria 0 Views copyright © 2025 Isezuo K et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thanks for the opportunity to review this paper after the initial corrections. The authors have adhered to the comments and this has made the report significantly improved. However, there are a few typographical errors and two pending issues pertaining oxygen use with normal saturation and an abnormal Chest X-ray interpretation. They are highlighted in the comments below. 1.our She was referred to out neonatal unit in the pediatric ward for respiratory distress. 2. nasogastric She was fed initially via gastric tube 3. this was not addressed and no reason given Oxygen saturation was 97% i n room air. The patient was placed on oxygen via a nasal cannula. 4. delete "was" Initially, a nosocomial infection was suspected, and the patient was received imipenem 5. lost to She was lost of follow-up since. 6. Figure 2 caption Figure 2. Post-pericardiocentesis chest radiography showing resolution of cardiomegaly with normalization of cardiac silhouette. It only shows reduction in cardiomegaly and not a resolution. The cardiac silhouette is still not completely normal. So caption as a reduction. Moreover, the cardiothoracic ratio was not measured to compare both. 7. case The pathogen agent was isolated in pericardial fluid in only one cas (candida.... 8. pericardiectomy He was managed with pericardectomy, 9. broad-spectrum The isolation of E. coli with multidrug sensitivity underscores the potential for multidrug-resistant strains in neonatal units, especially in settings where broaded-spectrum antibiotics such as carbapenems and aminoglycosides are frequently used empirically. 10. Cardiac ultrasound Ultrasound images were not available in this report. Competing Interests No competing interests were disclosed. Reviewer Expertise Paediatric cardiology, Neonatology, Infectious disease, Nutrition We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Isezuo K and Adamu A. Peer Review Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.187677.r412608) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-770/v2#referee-response-412608 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Makalo L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Sep 2025 | for Version 2 Lamin Makalo , University of the Gambia, Serrekunda, Banjul, The Gambia 0 Views copyright © 2025 Makalo L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Good enough to be indexed, Dr Lamin Makalo University of The Gambia. Competing Interests No competing interests were disclosed. Reviewer Expertise Paediatric Hematology, Pulmonology, Cardiology, Nutrition and Gastroenterology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Makalo L. Peer Review Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.187677.r412607) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-770/v2#referee-response-412607 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Isezuo K et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 01 Sep 2025 | for Version 1 Khadijat Isezuo , Paediatric Cardiology Unit, Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria Asma'u Adamu , Neonatal Unit, Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria 0 Views copyright © 2025 Isezuo K et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dr Khadijat O. Isezuo (Reviewer A) General comments: This is an interesting case report which clearly depicts the evolution of symptomatology in a preterm neonate eventually leading to a diagnosis of pericardial effusion. A positive blood culture yielded E.coli and was attributed to be the cause of pericarditis though the pericardial fluid was sterile despite being purulent. It brings to bear that the relatively immunodeficient neonate can manifest deep seated foci of sepsis and unstable cardiorespiratory symptomatology should be thoroughly investigated. However, the possibility of infective endocarditis was not mentioned as a possible differential and excluded with the Dukes criteria.[1] The overall status and outcome of the other twin could also be mentioned. The COVID status of the babies should be excluded too Title It is ok except the possibility of early onset sepsis in the child due to timing of initial symptoms and lack of antibiotics Abstract: Introduction _line 1: Adjust to “Usually due to complication of Central Venous Catheter” ‘Remove infective’ from methods Conclusion: infective pericarditis with effusion Introduction it is too short and has no references explain briefly how Central venous catheter causes pericardial effusion one can mention other causes of neonatal pericardial effusion ie frequent causes here to expatiate on how common or rare infective causes are. Case Report The serological findings--- Do they refer to the mother or babies? Which test specifically were done? Any possibility of covid infection contributing to respiratory distress in them? This can be explored in the discussion if word count allows for it. [2,3,4] What was the 1 st twin diagnosis and anthropometry and were they AGA or SGA or LGA? Where was this patient managed if the twin was in PICU? What were her own investigations if related? The 3 rd paragraph of the case report is too choked up. It contains the events at birth, those during the 1 st admission till discharge, those on readmission. It makes it a bit difficult to follow. It is better to separate them, possibly sub-headers if guidelines allow. During the 1 st admission, diagnosis was TTN, this seems odd for that level of prematurity. Was sepsis considered then? Specifically, early onset sepsis? Was there any other risk in the mother? Any sepsis screen then? Despite the length of stay, why no antibiotics? At what day was the infusion discontinued? A table showing the summary of investigation results and reference changes would be useful rather than being subsumed within the text She had 4 chest x-rays in how many days? Safety? Present the normal x-rays images chronologically side by side before the abnormal one. In the text, mention as follows—repeat chest x-ray on day*** of life so as to give more context. Chest x-ray with pericardial effusion also has minimal pleural effusion on the right side. What were the cardiothoracic ratios? Is there any ECG result? Why echo not done earlier and no echo image is provided at diagnosis and at resolution? The echo dimensions of the free space occupied by fluid can also be mentioned. There is no specific mention if intra-cardiac defect was excluded eg a PDA at this age in a preterm. Likewise as mentioned in the general comment, infective endocarditis (gram negative) was not fully explored and excluded with the criteria. [1] What were the parameters at discharge eg weight, respiratory rate, heart rate, temperature? Discussion As acute pericarditis is a major clinical manifestation of long COVID-19 syndrome, was there any link to their mother’s status? [5] Discussion did not on dwell on neonatal causes of pericardial effusion. In the 3rd paragraph, no reference number for Benjamin’s findings. Find out if this very recent study includes neonatal cases and reference it --------[6] Richard, B., Preka, E., Grapin, M. Et al. Pericardial effusion in pediatric Shiga toxin-producing E. Coli hemolytic uremic syndrome: a French multicentre study. Pediatr Nephrol (2025). https://doi.org/10.1007/s00467-025-06877-0 The references are too few. This can be used to support or disprove the rarity. Kindly check it.----[7] Lai, J., Zhu, Y., Tang, L. et al. Epidemiology and antimicrobial susceptibility of invasive Escherichia coli infection in neonates from 2012 to 2019 in Xiamen, China. BMC Infect Dis 21, 295 (2021). https://doi.org/10.1186/s12879-021-05981-4 Others What of confidentiality in ethics statement? And other ethical issues. Final recommendation: To accept after the above revisions are fairly addressed. Prof Asma’u Adamu (Reviewer B) Title The title can be modified to “Purulent pericardial effusion in a preterm neonate with late onset Escherichia coli septicaemia” Abstract That was divided into two subsections. It is not necessary - to remove background, methods and result and allow the sentences to flow Keywords Delete drainage Case Report The first twin that had severe respiratory distress, what was the diagnosis, birth, PCV and APGAR? Correct to transient Tachypnoea of the new born not transient tachypnoea in the newborn. Delete moderate respiratory distress – leave as respiratory distress She was placed in a high-flow nasal cannula oxygen therapy – add oxygen therapy ; do so also in the abstract The patient receive fluid through a peripheral venous catheter – correct to the patient received fluid via a peripheral venous line Add the oxygen saturation of the patient in a room air at presentation before commencement of oxygen and heart rate Why feeding with milk formula not breast milk; add reason for not giving breastmilk. Four days later (on day 18) add (on day 18 of life) Add the specific chest retractions observed in this patient like intercostal recession, subcostal recession and so on. Delete that she had retraction The patient was placed on oxygen with a normal oxygen saturation of 97%. Delete the patient was placed on oxygen And the patient was received Imipenem and Amikacin – correct to the patient received Imipenem and Amikacin On day 21, the two blood cultures that were obtained, add their antibiotic sensitivity pattern The cefotaxime that was switched to, is it based on the antibiotic sensitivity? Add (23 days of life) The hepatomegaly, is it tender? If tender add Chest radiography revealed significant cardiomegaly – delete significant No bacteria was detected- replace detected with isolated Discussion To date only case reports Are they the only case reports on similar case? If yes add to date the only case reports You have compared your findings with other reports, what made your case different, if any add to the discussion Highlight diagnostic delay, patient developed tamponade on day 23 despite antibiotic could an earlier, ECHO have helped Also discuss lessons for clinician. In neonate with sepsis and cardiac signs, early ECHO is crucial in the absence of central lines Add also in the discussion the reason for negative culture of the pericardial fluid such as prior use of antibiotics, inflammation and so on. Could a pericardial biopsy and PCR have helped? [8] References Some of the references were too old, use recent references Final recommendation: To accept after revisions Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly References 1. McLennan D, Morgan G: Infective Endocarditis, a Rare Complication of Late Neonatal Group B Strep Sepsis. Frontiers in Pediatrics . 2018; 6 . Publisher Full Text 2. Shabil M, Gaidhane S, Ballal S, Kumar S, et al.: Maternal COVID-19 infection and risk of respiratory distress syndrome among newborns: a systematic review and meta-analysis. BMC Infectious Diseases . 2024; 24 (1). Publisher Full Text 3. Lim J: Impacts of maternal COVID-19 during pregnancy on neonatal health and epidemiology. Clinical and Experimental Pediatrics . 2024; 67 (3): 149-151 Publisher Full Text 4. Lee S, Jin J, Yoo J, Yoon S: Association between maternal coronavirus disease 2019 and transient tachypnea of the newborn: a single-center study. Clinical and Experimental Pediatrics . 2023; 66 (11): 493-500 Publisher Full Text 5. Chacko A, Rodrigues S: 109: CARDIAC TAMPONADE: A DELAYED COMPLICATION OF COVID-19. Critical Care Medicine . 2022; 50 (1). Publisher Full Text 6. Richard B, Preka E, Grapin M, Nobili F, et al.: Pericardial effusion in pediatric Shiga toxin-producing E. coli hemolytic uremic syndrome: a French multicentre study. Pediatric Nephrology . 2025. Publisher Full Text 7. Lai J, Zhu Y, Tang L, Lin X: Epidemiology and antimicrobial susceptibility of invasive Escherichia coli infection in neonates from 2012 to 2019 in Xiamen, China. BMC Infectious Diseases . 2021; 21 (1). Publisher Full Text 8. Tsushima T, Ishii N, Matsuzaka S, Armitage K, et al.: Culture‐negative group B streptococcal pericarditis: A case report and literature review of the diagnostic use of polymerase chain reaction. Clinical Case Reports . 2019; 7 (3): 509-514 Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Paediatric cardiology, Neonatology, Infectious disease, Nutrition We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 12 Sep 2025 Nada Missaoui, University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, 1007, Tunisia Dear Dr Isezuo, We sincerely thank your for evaluating our manuscript. Response to comment 1 (Introduction): More details were added as well as the role of central venous catheters. Response to comment on Main body: more information about maternal serologies, twin anthropometry were added. The diagnosis of early onset neonatal infection (during the first hospitalization) was discussed and excluded. Infusion was discontinued on day 4. Details have been added to the manuscript. Our patient had 4 X rays during her two hospitalizations (45 days). We believe that her safety was not compromised. ECG was normal (already mentioned in the original version). Cardiac ultrasound is not available in our facility. All the findings of cardiac ultrasound were added to the manuscript (this detail as well as was added to the manuscript). Physical examination parameters were mentioned in the revised version of the manuscript. We appreciate your suggestions regarding discussion and recent articles. They enhanced the quality of our article. View more View less Competing Interests No competing interests to disclose reply Respond Report a concern Isezuo K and Adamu A. Peer Review Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.184830.r406263) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-770/v1#referee-response-406263 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Makalo L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 21 Aug 2025 | for Version 1 Lamin Makalo , University of the Gambia, Serrekunda, Banjul, The Gambia 0 Views copyright © 2025 Makalo L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I’ve reviewed the case report titled “Pericardial effusion in late onset neonatal Escherichia coli sepsis” (F1000Research, 2025) . Here’s my assessment of its fitness for publication: Strengths Relevance and Novelty Infective pericarditis due to E. coli in neonates is very rare; documenting such a case adds value to neonatal infectious disease literature. The case highlights the importance of suspecting pericardial effusion even without a central venous catheter. Structure and Clarity Follows the expected case report format : Abstract, Introduction, Case description, Discussion, Conclusion, Ethics, and Data availability. Clinical timeline is clear: initial presentation, discharge, readmission, infection, diagnosis of pericardial effusion, management, and outcome. Ethical approval and informed consent are explicitly stated. Use of Literature References are relevant and include both classic and recent reports. Situates the case in the context of previously reported neonatal pericardial effusions. Compliance CARE guidelines checklist has been attached (per Fig share reference). Transparency regarding AI use (declared none). No conflicts of interest or funding bias. Weaknesses / Areas for Improvement Language and Grammar Several sentences are grammatically awkward or lack fluency (e.g., “difficulty to breath” should be “difficulty breathing”). Some inconsistencies in spacing and punctuation. Case Details Pericardial fluid analysis : It was stated no bacteria were detected, but biochemical/cytological analysis details (protein, glucose, cell count) are missing. These would strengthen diagnostic certainty. Antibiotic regimen : The switch from imipenem/amikacin to cefotaxime is described, but no rationale is given for narrowing therapy despite E. coli being multidrug-sensitive. Twin context : The first twin’s outcome is described but seems peripheral—clarify its relevance. Follow-up duration : States “further follow-up was unremarkable” but doesn’t indicate for how long (weeks/months). This limits assessment of long-term prognosis. Figures Only X-rays (before and after drainage) are provided. Cardiac ultrasound images would have added diagnostic weight. Discussion Could be expanded to discuss: Pathophysiology of E. coli spread to the pericardium. Why neonates may be more vulnerable. Broader implications for neonatal sepsis management in resource-limited settings. Minor Issues Typo in title and reporting guideline reference: “Esherichia coli” instead of Escherichia coli . Some references (e.g., Ferraz Liz et al.) could benefit from more context when cited. Conclusions Even though rare, infective pericarditis should be suspected in neonates who show deterioration in respiratory and hemodynamic status even if they do not have a central venous catheter. This case also highlights concerns for multidrug resistance in neonatal sepsis and the importance of antibiotic stewardship. I recommend the following for the figures Figure 1. Pre-pericardiocentesis chest radiograph demonstrating marked cardiomegaly with a globular cardiac silhouette (arrows indicate the enlarged cardiac borders). Figure 2. Post-pericardiocentesis chest radiograph showing resolution of cardiomegaly with normalization of cardiac silhouette (arrows indicate normalized heart borders). Discussion (MDR concern & implications) I suggest adding after the paragraph describing E. coli reports: “In our case, initial suspicion of a nosocomial infection was raised given the patient’s recent hospitalization. The isolation of E. coli with multidrug sensitivity underscores the potential for multidrug-resistant (MDR) strains in neonatal units, especially in settings where broad-spectrum antibiotics such as carbapenems and aminoglycosides are frequently used empirically. Although our isolate was susceptible, vigilance is warranted as MDR E. coli pericarditis could severely limit therapeutic options. This highlights the importance of strict infection prevention measures, rational antibiotic stewardship, and early targeted therapy guided by culture results.” Implications for practice I suggest inserting in the Discussion/Conclusion transition: “This case underscores the need for clinicians to maintain a high index of suspicion for pericardial effusion in neonates presenting with sepsis and cardiorespiratory deterioration, even in the absence of central venous catheters. The overlap between neonatal sepsis and cardiac failure may delay recognition of pericardial involvement. Incorporating point-of-care echocardiography in deteriorating neonates could facilitate earlier detection and intervention. Furthermore, routine review of empirical antibiotic regimens in neonatal sepsis is critical to balance adequate coverage with antimicrobial stewardship.” Limitations I suggest adding this before conclusion: “This report has limitations inherent to single case studies. Pericardial fluid biochemical and cytological analyses were not performed, limiting full characterization of the effusion. The follow-up period was relatively short, and longer-term outcomes could not be assessed. Ultrasound images were not archived for inclusion in this report, which would have provided stronger diagnostic demonstration.” Conclusion and Recommendations The following is suggested to strengthen the conclusion and therefore give recommendations to strengthen the report Conclusion Neonatal pericardial effusion due to Escherichia coli is an exceedingly rare but potentially life-threatening condition. Early recognition and timely pericardiocentesis can be lifesaving. Recommendations Clinicians should suspect pericardial involvement in neonates with unexplained cardiorespiratory compromise during sepsis, even without central catheters. Echocardiography should be integrated into the evaluation of deteriorating neonates with sepsis. Infection prevention and control practices should be strengthened in neonatal intensive care settings to minimize the risk of nosocomial MDR infections. Empiric antibiotic therapy in neonatal sepsis should be carefully tailored, with early de-escalation based on culture results, to preserve antimicrobial effectiveness. Collaborative multicenter registries and pooled case reports are needed to clarify the epidemiology, management, and outcomes of neonatal infective pericarditis. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Paediatric Hematology, Pulmonology, Cardiology, Nutrition and Gastroenterology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 12 Sep 2025 Nada Missaoui, University of Tunis El Manar Faculty of Medicine of Tunis, Tunis, 1007, Tunisia Dear Dr Makalo, We sincerely appreciate your constructive feedback. Your insightful comments have helped us refine and enhance the quality of our manuscript. Response to comment 1: We have made corrections to grammar and punctuations mistakes. Response to comment 2: Details of pericardial fluid analysis, the rational of antibiotic switch and follow-up have been added to the manuscript. Response to comment 3: Cardiac ultrasound was not performed in our facility (this detail was added to the manuscript). Unfortunately, no images were provided from cardiologists. Response to comments on discussion: we appreciate your suggestions. We have included them in the manuscript. View more View less Competing Interests No competing interests disclosed reply Respond Report a concern Makalo L. Peer Review Report For: Case Report: Pericardial effusion in late onset neonatal Escherichia coli sepsis [version 2; peer review: 2 approved] . F1000Research 2025, 14 :770 ( https://doi.org/10.5256/f1000research.184830.r406267) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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