Pre-emptive antibiotic treatment vs 'standard' treatment in patients with elevated serum procalcitonin levels after elective colorectal surgery: a prospective randomised pilot study

Validity of C-Reactive Protein as a Surrogate Marker for Infectious Complications After Surgery for Colorectal Cancer

Abstract Background: This study aimed to establish a threshold of C-reactive protein (CRP) level for early detection of post-operative infectious complications after surgery for colorectal cancer. Patients and Methods: In this single-center, retrospective analysis, we studied the data of 178 patients who underwent surgery for colorectal cancer between January 2018 and February 2022. Elective surgery with curative intent was performed, and serum CRP levels were measured on five consecutive days after surgery. Receiver operating characteristic curves were utilized to assess the cutoff point of the CRP level with maximum predictive value, Results: A total of 59 cases of early post-operative complications, including pneumonia, wound infection, intra-abdominal infection, and anastomotic leakage were evaluated. During the monitoring period, patients with complications had higher CRP level than those without complications. The cutoff points on the five post-operative days were estimated to be 6.50, 10.83, 11.44, 6.67, and 5.71 mg/dL, respectively, and they were correlated to the occurrence of infectious complications. Higher CRP levels were associated with greater blood loss during surgery (p = 0.003) and increased length of hospital stay (p < 0.001) than did lower CRP levels. Conclusions: C-reactive protein monitoring in the early post-operative period is a cost-effective test that can be easily performed to predict the occurrence of infectious complications. It may be helpful in improving surgical outcomes, shortening the length of hospital stay and appropriate antibiotic administration.

Use of Procalcitonin to Guide Discontinuation of Antimicrobial Therapy in Patients with Persistent Intra-Abdominal Collections: A Case Series

Objective

Limited evidence exists for the use of procalcitonin (PCT) to guide the duration of antimicrobial therapy in patients with intra-abdominal abscesses (IAA). In this case series, we describe clinical presentations and outcomes using PCT to guide cessation of antimicrobial therapy in patients with persistent IAA who exhibited clinical improvement.

Methods

A retrospective analysis of patients with IAA who had PCT levels available to review was performed in a tertiary academic teaching institution in the United States between 2017 and 2018. Demographics, clinical characteristics, and outcomes were obtained from the medical records. Patients were followed up for a minimum of 180 days after completion of antimicrobial therapy to determine if evidence of recurrence or mortality was present.

Results

We identified four patients with IAA. They underwent early drainage of the source of infection and received empiric antimicrobial therapy according to individual risk factors and clinical scenarios. Antimicrobials were discontinued after clinical and radiographic improvement and evidence of normal PCT levels, regardless of the persistence of fluid collections. No evidence of recurrence or mortality was observed during the follow-up period.

Conclusions

We found PCT to be a useful aid in the medical decision-making process to safely discontinue antimicrobial therapy in a series of patients with persistent intra-abdominal collections despite early drainage and appropriate course of antimicrobial therapy.

A meta-analysis to assess usefulness of procalcitonin-guided antibiotic usage for decision making

Background & objectives:

Development of antibacterial resistance and its association with antibiotic overuse makes it necessary to identify a specific and sensitive biomarker for the diagnosis of bacterial infection and guiding antibiotic therapy. Procalcitonin (PCT), as a sepsis biomarker, may play a role in guiding antibiotics treatment in hospital settings. The aim of the current meta-analysis was to analyze the utility of PCT on various outcomes of interest in inpatients.

Methods:

Different databases were searched for randomized controlled trials comparing PCT-guided therapy with standard therapy in admitted patients with bacterial infections. Twenty six articles were found suitable for full text search and of these, 16 studies were considered finally for data extraction.

Results:

There were no significant differences found in total mortality [pooled odds ratio (OR) 1.04, 95% confidence interval (CI) 0.89-1.22, P=0.63], 28-day mortality (pooled OR 0.97, 95% CI 0.80-1.19, P=0.79), need of Intensive Care Unit admission (OR=0.80, 95% CI 0.59-1.09, P=0.16) and duration of stay in hospital (pooled mean difference −0.01, 95% CI −0.50-0.49, P=0.98) between treatment and control groups. PCT-guided treatment significantly decreased the duration of antibiotic treatment (pooled mean difference −2.79, 95% CI −3.52-−2.06, P<0.00001).

Interpretation & conclusions:

PCT-guided therapy significantly decreased antibiotics exposure and thus treatment cost. However, the hard endpoints did not demonstrate any significant benefits, possibly due to low power to detect differences and/or the presence of comorbidities.

C-reactive protein as a predictor of anastomotic leak in the first week after anterior resection for rectal cancer

AIM

Anastomotic leak (AL) after anterior resection results in increased morbidity, mortality and local recurrence. The aim of this study was to assess the ability of C-reactive protein (CRP) to predict AL in the first week after anterior resection for rectal cancer.

METHOD

A retrospective review of a prospectively maintained database that included all patients undergoing anterior resection between January 2008 and December 2013 was performed. The ability of CRP to predict AL was assessed using area under the receiver-operating characteristics (AUC) curves. The severity of AL was defined using the International Study Group of Rectal Cancer (ISREC) grading system.

RESULTS

Two-hundred and eleven patients were included in the study. Statistically significant differences in mean CRP values were found between those with and without an AL on postoperative days 5, 6 and 7. A CRP value of 132 mg/l on postoperative day 5 had an AUC of 0.75, corresponding to a sensitivity of 70%, a specificity of 76.6%, a positive predictive value of 16.3% and a negative predictive value of 97.5%. Multivariable analysis found that a CRP of > 132 mg/l on postoperative day 5 was the only statistically significant patient factor that was linked to an increased risk of AL (HR = 8.023, 95% CI: 1.936-33.238, P = 0.004).

CONCLUSION

Early detection of AL may minimize postoperative complications. CRP is a useful negative predictive test for the development of AL following anterior resection.

Perioperative Increase in Neutrophil CD64 Expression is an Indicator for Intra-abdominal Infection after Colorectal Cancer Surgery

BACKGROUND

Colorectal surgery is associated with a high incidence of postoperative infections. Early clinical signs are difficult to distinguish from the systemic inflammatory response related to surgical trauma. Timely diagnosis may significantly improve the outcome. The objective of this study was to compare a new biomarker index CD64 for neutrophils (iCD64n) with standard biomarkers, white blood cell (WBC) count, neutrophil/lymphocyte ratio (NLR), C-reactive protein (CRP) and procalcitonin (PCT) for the early detection of postoperative infection.

METHODS

The prospective study included 200 consecutive patients with elective colorectal cancer surgery. Postoperative values of biomarkers from the postoperative day (POD) 1 to POD5 were analysed by the receiver operating characteristic (ROC) analysis to predict infection. The Cox regression model and the Kaplan-Meier method were used to assess prognostic factors and survival.

RESULTS

The increase of index CD64n (iCD64n) after surgery, expressed as the ratio iCD64n after/before surgery was a better predictor of infection than its absolute value. The best 30-day predictors of all infections were CRP on POD4 (AUC 0.72, 99% CI 0.61-0.83) and NLR on POD5 (AUC 0.69, 99% CI 0.57-0.80). The best 15-day predictors of organ/space surgical site infection (SSI) were the ratio iCD64n on POD1 (AUC 0.72, 99% CI 0.58-0.86), POD3 (AUC 0.73, 99% CI 0.59-0.87) and CRP on POD3 (AUC 0.72, 99% CI 0.57-0.86), POD4 (AUC 0.79, 99% CI 0.64-0.93). In a multivariate analysis independent risk factors for infections were duration of surgery and perioperative transfusion while the infection itself was identified as a risk factor for a worse long-term survival.

CONCLUSIONS

The ratio iCD64n on POD1 is the best early predictor of intra-abdominal infection after colorectal cancer surgery. CRP predicts the infection with the same predictive value on POD3.

Diagnostic Accuracy of Procalcitonin and C-reactive Protein for the Early Diagnosis of Intra-abdominal Infection After Elective Colorectal Surgery: A Meta-analysis

OBJECTIVE

Intra-abdominal infections (IAIs) after elective colorectal surgery impact significantly the short- and long-term outcomes. In the era of fast-track surgery, they often come to light after discharge from hospital. Early diagnosis is therefore essential. C-reactive protein levels have proved to be accurate in this setting. Procalcitonin has been evaluated in several studies with conflicting results. This meta-analysis aimed to compare the predictive abilities of C-reactive protein and procalcitonin in the occurrence of IAIs after elective colorectal surgery.

METHODS

This meta-analysis included studies analyzing C-reactive protein and/or procalcitonin levels at postoperative days 2, 3, 4, and/or 5 as markers of intra-abdominal infection after elective colorectal surgery. Methodological quality was assessed by the QUADAS2 tool. The area under the curve summary receiver-operating characteristic was calculated for each day and each biomarker, using a random-effects model in cases of heterogeneity.

RESULTS

The meta-analysis included 11 studies (2692 patients). An IAI occurred in 8.9% of the patients. On postoperative day 3, area under the curve was 0.80 (95% CI, 0.76-0.85) for C-reactive protein and 0.78 (95% CI, 0.68-0.87) for procalcitonin. On postoperative day 5, their predictive accuracies were 0.87 (95% CI, 0.80-0.93) and 0.90 (95% CI, 0.82-0.98), respectively. The accuracy of C-reactive protein and procalcitonin did not differ at any postoperative day.

CONCLUSIONS

Levels of inflammatory markers under the cutoff value between postoperative days 3 and 5 ensure safe early discharge after elective colorectal surgery. Procalcitonin seems not to have added value as compared to C-reactive protein in this setting.

Procalcitonin-Guided Antibiotics after Surgery for Peritonitis: A Randomized Controlled Study

Background

Serum procalcitonin (PCT) is a useful biomarker to tailor the duration of antibiotics in respiratory infections. The objective of this study was to determine whether PCT levels could tailor postoperative antibiotic therapy in patients operated for peritonitis.

Method

Patients with peritonitis were randomized postoperatively. The control group received antibiotics for a defined duration according to institutional guidelines. In the study group, antibiotics were stopped based on serum PCT levels. Patients were stratified into three categories: (1) gastrointestinal perforation, (2) perforated appendicitis, and (3) postoperative complication. Primary outcome was duration of antibiotics.

Results

We included 162 patients; 83 and 79 patients in the control group and study group, respectively. In the subgroup of patients with peritonitis due to gastrointestinal perforation, we found 7 days of antibiotics in the PCT group versus 10 days in the control group (p value 0.065). There was no difference in infectious complications, mortality, median length of hospital stay, and necessity to restart antibiotics.

Conclusion

No significant differences were found in duration of antibiotics when applying PCT guidance. However, in the subgroup of primary perforation of the gastrointestinal tract, there was a difference in duration of antibiotics in favor of the PCT group without obtaining significance, as the study was not powered for subgroup analysis. Further studies including only this subgroup should be performed.

Post-Operative Infection Is an Independent Risk Factor for Worse Long-Term Survival after Colorectal Cancer Surgery

BACKGROUND

Colorectal cancer surgery is associated with a high incidence of post-operative infections, the outcome of which may be improved if diagnosed and treated early enough. We compared white blood cell (WBC) count, C-reactive protein (CRP), and procalcitonin (PCT) as predictors of post-operative infections and analyzed their impact on long-term survival.

METHODS

This retrospective study included 186 patients undergoing colorectal surgery. Post-operative values of WBC, CRP, and PCT were analyzed by the receiver operating characteristic (ROC) analysis. We followed infections 30 d after the surgery. A five-year survival was analyzed by Kaplan-Meier method and prognostic factors by Cox regression model.

RESULTS

Fifty-five patients (29.5%) developed post-operative infection, the most frequent of which was surgical site infection (SSI). C-reactive protein on post-operative day three and PCT on post-operative day two demonstrated the highest diagnostic accuracy for infection (area under the curve [AUC] 0.739 and 0.735). C-reactive protein on post-operative day three was an independent predictor of infection. Five-year survival was higher in the non-infected group (70.8%), compared with the infected group (52.1%). The worst survival (40.9%) was identified in patients with organ/space SSI. Post-operative infection and tumor stage III-IV were independent predictors of a worse five-year survival.

CONCLUSIONS

C-reactive protein on post-operative day three and PCT on post-operative day two may be early predictors of infection after colorectal cancer surgery. Post-operative infections in particular organ/space SSI have a negative impact on long-term survival.

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

BACKGROUND

Determination of the presence or absence of bacterial infection is important to guide appropriate therapy and reduce antibiotic exposure. Procalcitonin (PCT) is an inflammatory marker that has been suggested as a marker for bacterial infection.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of adding PCT testing to the information used to guide antibiotic therapy in adults and children (1) with confirmed or highly suspected sepsis in intensive care and (2) presenting to the emergency department (ED) with suspected bacterial infection.

METHODS

Twelve databases were searched to June 2014. Randomised controlled trials were assessed for quality using the Cochrane Risk of Bias tool. Summary relative risks (RRs) and weighted mean differences (WMDs) were estimated using random-effects models. Heterogeneity was assessed visually using forest plots and statistically using the I (2) and Q statistics and investigated through subgroup analysis. The cost-effectiveness of PCT testing in addition to current clinical practice was compared with current clinical practice using a decision tree with a 6 months' time horizon.

RESULTS

Eighteen studies (36 reports) were included in the systematic review. PCT algorithms were associated with reduced antibiotic duration [WMD -3.19 days, 95% confidence interval (CI) -5.44 to -0.95 days, I (2) = 95.2%; four studies], hospital stay (WMD -3.85 days, 95% CI -6.78 to -0.92 days, I (2) = 75.2%; four studies) and a trend towards reduced intensive care unit (ICU) stay (WMD -2.03 days, 95% CI -4.19 to 0.13 days, I (2) = 81.0%; four studies). There were no differences for adverse clinical outcomes. PCT algorithms were associated with a reduction in the proportion of adults (RR 0.77, 95% CI 0.68 to 0.87; seven studies) and children (RR 0.86, 95% CI 0.80 to 0.93) receiving antibiotics, reduced antibiotic duration (two studies). There were no differences for adverse clinical outcomes. All but one of the studies in the ED were conducted in people presenting with respiratory symptoms. Cost-effectiveness: the base-case analyses indicated that PCT testing was cost-saving for (1) adults with confirmed or highly suspected sepsis in an ICU setting; (2) adults with suspected bacterial infection presenting to the ED; and (3) children with suspected bacterial infection presenting to the ED. Cost-savings ranged from £368 to £3268. Moreover, PCT-guided treatment resulted in a small quality-adjusted life-year (QALY) gain (ranging between < 0.001 and 0.005). Cost-effectiveness acceptability curves showed that PCT-guided treatment has a probability of ≥ 84% of being cost-effective for all settings and populations considered (at willingness-to-pay thresholds of £20,000 and £30,000 per QALY).

CONCLUSIONS

The limited available data suggest that PCT testing may be effective and cost-effective when used to guide discontinuation of antibiotics in adults being treated for suspected or confirmed sepsis in ICU settings and initiation of antibiotics in adults presenting to the ED with respiratory symptoms and suspected bacterial infection. However, it is not clear that observed costs and effects are directly attributable to PCT testing, are generalisable outside people presenting with respiratory symptoms (for the ED setting) and would be reproducible in the UK NHS. Further studies are needed to assess the effectiveness of adding PCT algorithms to the information used to guide antibiotic treatment in children with suspected or confirmed sepsis in ICU settings. Additional research is needed to examine whether the outcomes presented in this report are fully generalisable to the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014010822.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Clinical Significance of C-reactive Protein Level After Laparoscopic Gastrectomy: From a Viewpoint of Intra-Abdominal Complications

In this retrospective study, we investigated whether postoperative intra-abdominal infectious complications (IIC) after laparoscopic gastrectomy (LG) is predictable in an early postoperative period using C-reactive protein (CRP). Intra-abdominal infectious complication after gastrectomy is caused mainly by anastomotic leakage or pancreatic injury associated with peripancreatic lymph node (LN) dissection, which may sometimes result in serious outcomes. C-reactive protein is widely used to evaluate the inflammatory status. However, the relationship between the CRP level and postoperative IIC following LG remains unclear. White blood cell count (WBC), CRP counts, and clinical data were available for 229 consecutive patients undergoing LG with lymphadenectomy. We compared CRP and WBC between patients with (Group A) and without (Group B) IIC to check whether these could be used to predict IIC in an early postoperative period. Using the receiver-operating characteristic (ROC) curve, the diagnostic accuracy was evaluated. On postoperative day 1 (POD1), increased CRP levels were associated with IIC (Group A: 9.6 mg/dL, Group B: 6.0 mg/dL; P = 0.000048), while WBC did not differ significantly. On POD3, the difference in CRP between both groups increased (A: 20.2 mg/dL, B: 10.7 mg/dL; P = 1.6 × 10−8). The optimal cutoff value was 14.9 mg/dL on POD3 (sensitivity: 0.79, specificity: 0.78), and the area under the ROC curve was 0.86. Measurements of CRP on POD1 and 3 are helpful for detecting possible IIC after LG, compared with WBC. It is necessary to pay attention to CRP levels for earlier detection of IIC.

Meta-analysis of the predictive value of C-reactive protein for infectious complications in abdominal surgery

BACKGROUND

The aim of this analysis was to assess the predictive value of C-reactive protein (CRP) for the early detection of postoperative infectious complications after a variety of abdominal operations.

METHODS

A meta-analysis of seven cohort studies from a single institution was performed. Laparoscopic gastric bypass and colectomies, as well as open resections of cancer of the colon, rectum, pancreas, stomach and oesophagus, were included. The predictive value of CRP was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

Of 1986 patients, 577 (29·1 (95 per cent c.i. 27·1 to 31·3) per cent) had at least one postoperative infectious complication. Patients undergoing laparoscopic gastric bypass (383 patients) or colectomy (285), and those having open gastric (97) or colorectal (934) resections were combined in a meta-analysis. Patients who had resection for cancer of the oesophagus (41) or pancreas (246) were analysed separately owing to heterogeneity. CRP levels 4 days after surgery had the highest diagnostic accuracy (AUC 0·76, 95 per cent c.i. 0·73 to 0·78). Sensitivity and specificity were 68·5 (60·6 to 75·5) and 71·6 (66·6 to 76·0) per cent respectively. Positive and negative predictive values were 50·4 (46·0 to 54·8) and 84·3 (80·8 to 87·3) per cent. The threshold CRP varied according to the procedure performed.

CONCLUSION

The negative predictive value of serum CRP concentration on day 4 after surgery facilitates reliable exclusion of postoperative infectious complications.

Normal behavior of plasma procalcitonin in adolescents undergoing surgery for scoliosis

Background and Aims:

Surgical site infections are relatively common after spinal deformity surgery. Early detection of deep wound infections is important, since it may allow retention of spinal instrumentation. However, serum C-reactive protein and erythrocyte sedimentation rate may remain elevated for almost 6 weeks, making differential diagnosis of systemic inflammatory response and acute deep bacterial wound infection difficult. Plasma procalcitonin has been suggested to be a useful indicator for bacterial infection. However, there are no studies evaluating behavior of procalcitonin in patients undergoing major spine surgery with instrumentation.

Materials and Methods:

A total of 50 consecutive adolescents (37 idiopathic scoliosis and 13 neuromuscular scoliosis, mean age = 15 years at surgery and follow-up time = 21 months (range = 12–29 months)) undergoing scoliosis surgery participated in this prospective follow-up study. White blood cell count, serum C-reactive protein, and plasma procalcitonin levels were measured on the day before surgery, on the day of surgery, and daily thereafter for 1 week. None of the patients developed signs of acute or delayed wound infection during the follow-up period; however, two neuromuscular scoliosis patients developed severe postoperative pneumonia, and their inflammatory parameter data will be reported separately.

Results:

Plasma procalcitonin levels peaked on the first postoperative day (mean = 0.19 ng/mL, range = 0.04–1.29 ng/mL), and mean values were less than 0.5 ng/mL during the whole first postoperative week, while C-reactive protein remained elevated during the whole first postoperative week (highest mean value = 63.8 mg/L (range = 5–248 mg/L) on third postoperative day). Patients with idiopathic scoliosis had lower C-reactive protein levels (p < 0.05 from first to sixth postoperative day) and lower procalcitonin levels (p < 0.05 from third to seventh postoperative day) than neuromuscular scoliosis patients. Two patients with postoperative pneumonia showed elevated procalcitonin values over the whole postoperative week (22.34 ng/mL and 0.72 ng/mL highest values, respectively).

Conclusions:

Elevated plasma procalcitonin levels seem useful when excluding acute deep wound infection from systemic inflammatory response.

Procalcitonin-guided antibiotic therapy: a systematic review and meta-analysis

BACKGROUND

The utility of procalcitonin to manage patients with infections is unclear. A systematic review of comparative studies using procalcitonin-guided antibiotic therapy in patients with infections was performed.

METHODS

Randomized, controlled trials comparing procalcitonin-guided initiation, intensification, or discontinuation of antibiotic therapy to clinically guided therapy were included. Outcomes were antibiotic usage, morbidity, and mortality. MEDLINE, EMBASE, the Cochrane Database, National Institute for Clinical Excellence, the National Guideline Clearinghouse, and the Health Technology Assessment Programme were searched from January 1, 1990 to December 16, 2011.

RESULTS

Eighteen randomized, controlled trials were included. Data were pooled into clinically similar patient populations. In adult intensive care unit (ICU) patients, procalcitonin-guided discontinuation of antibiotics reduced antibiotic duration by 2.05 days (95% confidence interval [CI]: -2.59 to -1.52) without increasing morbidity or mortality. In contrast, procalcitonin-guided intensification of antibiotics in adult ICU patients increased antibiotic usage and morbidity. In adult patients with respiratory tract infections, procalcitonin guidance significantly reduced antibiotic duration by 2.35 days (95% CI: -4.38 to -0.33), antibiotic prescription rate by 22% (95% CI: -41% to -4%), and total antibiotic exposure without affecting morbidity or mortality. A single, good quality study of neonates with suspected sepsis demonstrated reduced antibiotic duration by 22.4 hours (P = 0.012) and reduced the proportion of neonates on antibiotics for ≥ 72 hours by 27% (P = 0.002) with procalcitonin guidance.

CONCLUSION

Procalcitonin guidance can safely reduce antibiotic usage when used to discontinue antibiotic therapy in adult ICU patients and when used to initiate or discontinue antibiotics in adult patients with respiratory tract infections.

Procalcitonin and C-reactive protein as early predictors of anastomotic leak in colorectal surgery: a prospective observational study

BACKGROUND

Although the early diagnosis of anastomotic leak is a key point in reducing its clinical consequences, in daily practice, anastomotic leak diagnosis is often late.

OBJECTIVE

The aim of this study was to determine whether procalcitonin and C-reactive protein are good predictors of anastomotic leak in colorectal surgery.

DESIGN

This is a prospective observational study.

SETTINGS

This study was conducted by a specialized colorectal multidisciplinary team of a tertiary teaching hospital.

PATIENTS

A series of 205 consecutive patients who underwent elective colorectal surgery in a specialized unit was prospectively analyzed. The following data were collected: demographic, surgical, ASA class, POSSUM, and morbidity. During the first 5 postoperative days, procalcitonin, C-reactive protein, leukocytes, platelets, and vital signs were evaluated daily.

INTERVENTIONS

Daily assessment of clinical variable and serological data were conducted in the first 5 postoperative days.

MAIN OUTCOME MEASURES

The primary outcome measure was the area under the curve at receiving operating characteristic curve analysis of the different variables in relation to the anastomotic leak.

RESULTS

Anastomotic leak was detected in 17 (8.3%) patients; 11(5.4%) of the patients had a major anastomotic leak (need for drainage or reoperation). None of the variables evaluated were shown to be reliable in the early detection of anastomotic leak, considering both minor and major (maximum area under the curve <0.80). In contrast, when considering only major anastomotic leaks, procalcitonin and C-reactive protein were reliable predictors on postoperative days 3 to 5 (p < 0.0001, area under the curve >0.80). The best combination was procalcitonin at postoperative day 5 (area under the curve = 0.86), with a cutoff of 0.31 ng/mL, resulting in a 100% sensitivity, 72% specificity, 100% negative predictive value, and 17% positive predictive value.

LIMITATIONS

Only symptomatic patients were investigated to rule out anastomotic leakage.

CONCLUSIONS

Procalcitonin and C-reactive protein are both reliable predictors of major anastomotic leak after colorectal resection, although procalcitonin is more accurate. Raised procalcitonin and C-reactive protein serum concentration on postoperative days 3 to 5 renders necessary a careful evaluation of the patient before discharge.

Diagnostic study and meta-analysis of C-reactive protein as a predictor of postoperative inflammatory complications after pancreatic surgery

PURPOSE

Although C-reactive protein (CRP) can be measured by a standard blood test, its diagnostic value for distinguishing patients with inflammatory complications after pancreatic surgery from patients with normal postoperative inflammatory responses has not been adequately investigated. This study aimed to assess the diagnostic accuracy of CRP levels for the occurrence of postoperative inflammatory complications after pancreatic surgery.

METHODS

Clinical data and CRP levels measured in 280 patients after pancreatic surgeries (performed between 1998 and 2010) until postoperative day 10 (POD 10) were retrospectively analyzed. Using the receiver operating characteristic method, diagnostic accuracy was evaluated by an area under the curve (AUC) analysis. Furthermore, the results of the present study were compared to previously published reports by applying diagnostic meta-analysis techniques.

RESULTS

The 30-day mortality rate was 3.9% (95% CI 2.1-7.0%). Inflammatory complications occurred in 153 of 280 patients (54.6%; 95% CI 48.8-60.4%). On POD 4, the AUC was 0.67 (95% CI 0.58-0.76). The highest diagnostic accuracy was observed on POD 7 (AUC 0.77; 95% CI 0.68-0.85). In a diagnostic meta-analysis that included two additional studies, the diagnostic sensitivity on POD 4 was 0.63 (95% CI 0.50-0.76), and the specificity was 0.79 (95% CI 0.71-0.88). The highest sensitivity occurred on POD 6 (0.75; 95% CI 0.68-0.82). Considerable statistical heterogeneity was observed in the analysis of PODs 3, 4 and 5.

CONCLUSION

According to this limited evidence, CRP levels had a low to moderate diagnostic accuracy. Large, blinded studies are warranted for a more precise estimation of CRP's diagnostic value.

C-reactive protein as a predictor of postoperative infective complications after curative resection in patients with colorectal cancer

BACKGROUND

Infective complications particularly in the form of surgical site infections including anastomotic leak represent a serious morbidity after colorectal cancer surgery. Systemic inflammation markers, including C-reactive protein (CRP) and white cell count, have been reported to provide early detection. However, their relative predictive value is unclear. The aim of the present study was to examine the diagnostic accuracy of serial postoperative WCC, albumin and CRP in detecting infective complications.

METHODS

White cell count, albumin and CRP were measured postoperatively for 7 days in 454 consecutive patients undergoing surgery for colorectal cancer. All postoperative complications were recorded. The diagnostic accuracy of the white cell count, albumin and CRP values were analyzed by receiver operating characteristics curve analysis with surgical site infective complications as outcome measures.

RESULTS

One hundred four patients (23 %) developed infective complications, and 26 of them developed an anastomotic leak. CRP was most sensitive to the development of an infective complication, surgical site or at a remote site. On postoperative day 3 CRP the area under the receiver operating characteristic curve was 0.80 (p < 0.001) and the optimal cutoff value was 170 mg/L. This threshold was also associated with an increase in the length of hospital stay (p < 0.001), 30 day mortality (p < 0.05) and 12 month mortality (p < 0.10).

CONCLUSIONS

Postoperative CRP measurement on day 3 postoperatively is clinically useful in predicting surgical site infective complications, including an anastomotic leak, in patients undergoing surgery for colorectal cancer.

Value of serum procalcitonin in evaluating the prognosis of sepsis in elderly patients with colorectal cancer undergoing emergency colorectal surgery

Serum procalcitonin (PCT) levels may have predictive value in the prognosis of postoperative sepsis in elderly patients who have undergone colorectal surgery for colorectal cancer in intensive care units (ICUs). A prospective study involving 90 critically ill patients who underwent colorectal surgery for colorectal cancer in ICUs was performed. Twenty-eight patients were diagnosed with sepsis, in accordance with the American College of Chest Physicians/Society of Critical Care Medicine consensus criteria, and these patients were included in the sepsis group. Sixty-two patients, who were without evidence of sepsis, were enrolled in the control group. We measured the serum PCT concentrations preoperatively (immediately before induction of anesthesia), upon arrival in the ICU (ICU day 0), on the morning of the first postoperative day (postoperative day 1), and on the morning of the third postoperative day (postoperative day 3). The C-reactive protein (CRP) index, acute physiology and chronic health evaluation II (APACHE II) score, mechanical duration of ventilation, mortality rate, incidence of multiple organ failure, and usage of continuous renal replacement therapy were evaluated. The area under the curve for the receiver operating characteristic curve (AUC-ROCC) was measured to explore the association between the serum PCT and the prognosis. In the sepsis group, 12/28 patients died (mortality rate 43 %). In the control group, 6/62 patients died (mortality rate 9.7 %). On the first postoperative day, the serum PCT level was dramatically higher in the sepsis group than in the control group (2.71 ± 1.13 vs. 1.37 ± 0.57, P ≤ 0.05). The PCT level on the first postoperative day was distinctly higher than that measured upon arrival in the ICU (2.71 ± 1.13 vs. 1.31 ± 0.58, P ≤ 0.05). In the two groups, the CRP concentrations were both markedly higher on the first postoperative day than upon arrival in the ICU (138.89 ± 45.12 vs. 70.43 ± 23.54 in the sepsis group, and 133.13 ± 44.91 vs. 69.65 ± 24.98 in the control group, P ≤ 0.05). Linear regression analysis was performed. The results suggest that the PCT and APACHE-II scores were not significantly associated. On the first and third postoperative days, the PCT levels were associated with increased odds of sepsis (AUC-ROCC, 95 % confidence interval 0.817-0.973, P = 0.000, and 0.755-0.944, P = 0.000, respectively). The outcomes of patients in the sepsis group were worse than those in the control group. PCT levels appear to be early markers of postoperative sepsis in elderly patients undergoing colorectal surgery for colorectal cancer during the ICU course. These findings could allow for early identification of postoperative septic complications and be used for prognostic evaluation of these patients.

C-reactive protein 2 days after laparoscopic gastric bypass surgery reliably indicates leaks and moderately predicts morbidity

BACKGROUND

The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery.

METHODS

The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

Forty-nine of 410 patients (12.0 %; 95 % confidence intervals [95 % CI], 9.2-15.5 %) developed surgery-related complications. Leaks occurred in 17 patients (4.1 %; 95 % CI, 2.6-6.5 %) at a median of 5 days after surgery. CRP levels 2 days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95 % CI, 0.60-0.89). Sensitivity was 0.53 (95 % CI, 0.31-0.74) and specificity was 0.91 (95 % CI, 0.79-0.96) on day 2 (cutoff level, 229 mg/l). The sensitivity for intestinal leaks was 1.00 (95 % CI, 0.51-1.00).

CONCLUSION

CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229 mg/l.

Diagnostic accuracy of C-reactive protein and white blood cell counts in the early detection of inflammatory complications after open resection of colorectal cancer: a retrospective study of 1,187 patients

PURPOSE

Although widely used, there is a lack of evidence concerning the diagnostic accuracy of C-reactive protein (CRP) and white blood cell counts (WBCs) in the postoperative period. The aim of this study was to evaluate the diagnostic accuracy of CRP and WBCs in predicting postoperative inflammatory complications after open resection of colorectal cancer.

METHODS

In this retrospective study, clinical data and the CRP and WBCs, routinely measured until postoperative day 5 (POD 5), were available for 1,187 patients who underwent colorectal cancer surgery between 1997 and 2009. Using the receiver-operating characteristic (ROC) methodology, the diagnostic accuracy was evaluated according to the area under the curve (AUC).

RESULTS

Three hundred forty-seven patients (29.2%; 95% CI, 26.7-31.9%) developed various inflammatory complications. Anastomotic leakage occurred in 8.0% (95% CI, 6.1-9.1%) of patients. The CRP level on POD 4 (AUC 0.76; 95% CI, 0.71-0.81) had the highest diagnostic accuracy for the early detection of inflammatory complications. With a cutoff of 123 mg/l, the sensitivity was 0.66 (95% CI, 0.56-0.74), and the specificity was 0.77 (95% CI, 0.71-0.82). The diagnostic accuracy of the WBC was significantly lower compared to CRP.

CONCLUSION

Measurement of CRP on POD 4 is recommended to screen for inflammatory complications. CRP values above 123 mg/l on POD 4 should raise suspicion of inflammatory complications, although the discriminatory performance was insufficient to provide a single threshold that could be used to correctly predict inflammatory complications in clinical practice. WBC measurement contributes little to the early detection of inflammatory complications.

Procalcitonin for reduced antibiotic exposure in the critical care setting: a systematic review and an economic evaluation

OBJECTIVE

Procalcitonin may be associated with reduced antibiotic usage compared to usual care. However, individual randomized controlled trials testing this hypothesis were too small to rule out harm, and the full cost-benefit of this strategy has not been evaluated. The purpose of this analysis was to evaluate the effect of a procalcitonin-guided antibiotic strategy on clinical and economic outcomes.

INTERVENTIONS

The use of procalcitonin-guided antibiotic therapy.

METHODS AND MAIN RESULTS

We searched computerized databases, reference lists of pertinent articles, and personal files. We included randomized controlled trials conducted in the intensive care unit that compared a procalcitonin-guided strategy to usual care and reported on antibiotic utilization and clinically important outcomes. Results were qualitatively and quantitatively summarized. On the basis of no effect in hospital mortality or hospital length of stay, a cost or cost-minimization analysis was conducted using the costs of procalcitonin testing and antibiotic acquisition and administration. Costs were determined from the literature and are reported in 2009 Canadian dollars. Five articles met the inclusion criteria. Procalcitonin-guided strategies were associated with a significant reduction in antibiotic use (weighted mean difference -2.14 days, 95% confidence interval -2.51 to -1.78, p < .00001). No effect was seen of a procalcitonin-guided strategy on hospital mortality (risk ratio 1.06, 95% confidence interval 0.86-1.30, p = .59; risk difference 0.01, 95% confidence interval -0.04 to +0.07, p = .61) and intensive care unit and hospital lengths of stay. The cost model revealed that, for the base case scenario (daily price of procalcitonin Can$49.42, 6 days of procalcitonin measurement, and 2-day difference in antibiotic treatment between procalcitonin-guided therapy and usual care), the point at which the cost of testing equals the cost of antibiotics saved is when daily antibiotics cost Can$148.26 (ranging between Can$59.30 and Can$296.52 on the basis of different assumptions in sensitivity analyses).

CONCLUSIONS

Procalcitonin-guided antibiotic therapy is associated with a reduction in antibiotic usage that, under certain assumptions, may reduce overall costs of care. However, the overall estimate cannot rule out a 7% increase in hospital mortality.

C-reactive protein as a predictor of postoperative infective complications following elective colorectal resection

AIM

C-reactive protein (CRP) may be useful in predicting postoperative complications [1]. We investigated the sensitivity and specificity of postoperative CRP for infective complications after elective colorectal surgery.

METHOD

One hundred and sixty consecutive patients (72 years old; interquartile range, 63-79) undergoing elective resection for colorectal cancer treated between September 2003 and October 2006 were studied. Details of the postoperative course were prospectively entered into a database. Of the 160 patients, 10 had incomplete CRP data and were excluded from further analysis.

RESULTS

Infective complications occurred in 21%, with an overall complication rate of 29%. Infective complications occurred as follows: respiratory (10), wound (9), urinary tract (2) and central line infection (1), anastomotic leakage (5), intra-abdominal abscess (3) and septicaemia of unknown origin (2). There were three postoperative deaths. The positive predictive value for infection of CRP > 145 mg/l on postoperative day 4 was 61%. The negative predictive value of CRP < 145 mg/l on postoperative day 4 for an infective complication was 96%.

CONCLUSION

A CRP > 145 mg/l on day 4 has high specificity and sensitivity for infective complications following elective colorectal resection.

C-reactive protein is an early predictor of septic complications after elective colorectal surgery

BACKGROUND

Nowadays, most patients who undergo colorectal surgery are discharged early. An early predictor of septic complications could avoid readmissions and decrease morbidity. CRP could be a good predictor allowing a safe discharge.

METHODS

A prospective, observational study was conducted from November 2007 to October 2008. All patients who underwent elective colorectal surgery were included. Clinical (temperature, pulse, abdominal tenderness, bowel movements) and laboratory data (C-reactive protein, leukocyte count) were recorded and evaluated as early predictors of septic complications (namely, anastomotic leaks). All detected leaks were considered fistulas, independently of their clinical significance. Clinical and inflammatory parameters were analyzed with univariate and multivariate techniques; logistic regression was performed and areas under the receiver operating characteristic curve were compared.

RESULTS

A total of 133 patients were included. The overall incidence of anastomotic leaks was 15.5% and mortality was 4.5%. C-reactive protein at postoperative days 2 and 4 was a good predictor of anastomotic leak (areas under the curve were 0.715 and 0.845, respectively) and other postoperative septic complications (areas under the curve were 0.804 and 0.787), showing the highest accuracy among clinical and laboratory data. A cutoff of 125 mg/l in the level of C-reactive protein at postoperative day 4 yielded a sensitivity of 81.8% and a negative predictive value of 95.8% for the detection of anastomotic leakage.

CONCLUSIONS

C-reactive protein is a simple way to ensure a safe discharge from hospital after elective colorectal surgery. Patients with CRP values >125 mg/l on the fourth postoperative day should not be discharged.

The Role of Procalcitonin in Gynaecological Surgery

We evaluated postoperative concentrations of inflammatory indicators, including procalcitonin, after gynaecological operations for benign and malignant tumours in patients with a normal postoperative course and assessed the utility of procalcitonin in differentiating between non-bacterial inflammation and bacteraemic complications in the postoperative period. This prospective study included 99 patients: 47 after a standard gynaecological operation (Piver I) and no postoperative infectious complications (group 1), 35 after a major procedure (Piver II or III) and no postoperative infectious complications (group 2), and five with postoperative sepsis after Piver II or III procedures (group 3). We also studied serum procalcitonin concentrations in a group of 12 patients (group 4) with terminal forms of gynaecological cancer who were hospitalized for palliative treatment but did not undergo surgery. Postoperative C-reactive protein (CRP) concentration corresponded with extent of tissue trauma in groups 1 and 2 and was significantly lower in group 1 than group 2. Inflammatory indicators were highest in groups 1 and 2 on postoperative day 2. In group 3, in which sepsis developed, values were highest on postoperative day 4. In particular, procalcitonin was > 2 ng/ml in all patients with postoperative sepsis by postoperative day 2 but was always ≤ 2 ng/ml in patients without sepsis. In contrast, high procalcitonin levels were noted in the patients in group 4 compared with group 3, with two-thirds of group 4 patients having levels > 2 ng/ml, with no signs of infection or raised CRP. It is concluded that, for early detection of postoperative infectious complications after gynaecological surgery, procalcitonin levels > 2 ng/ml are more specific than CRP.

Procalcitonin in preoperative diagnosis of abdominal sepsis

BACKGROUND AND AIMS

The present study attempted to identify the diagnostic significance of procalcitonin (PCT) in acute abdominal conditions as well as the range of concentrations relating to diagnosis of abdominal sepsis.

MATERIALS AND METHODS

This was prospective clinical study. The study included 98 consecutive patients with acute abdominal conditions, divided in sepsis and systemic inflammatory response syndrome (SIRS) group.

RESULTS

PCT concentrations on admission were significantly higher in the sepsis group than in the SIRS group (median [interquartile range] 2.32 [7.41] vs 0.45 ng/ml [2.62]). A cutoff value of 1.1 ng/ml yielded 72.4% sensitivity and 62.5% specificity. In a group of patients with abdominal symptoms lasting for more than 24 h, a cut-off value of 1.1 ng/ml yielded higher sensitivity (82.9%) and higher specificity (77.3%).

CONCLUSION

Our results suggest that PCT measurements may be useful for early, preoperative diagnosis of abdominal sepsis.

Procalcitonin for the clinical laboratory: a review

Procalcitonin measurement has been claimed as a helpful marker in bacterial infection and sepsis. It has obtained FDA approval and is now widely marketed in the United States and Europe. This review summarises the current assays available, the evidence for its use and possible future applications of the assay.

Early assessment of pancreatic infections and overall prognosis in severe acute pancreatitis by procalcitonin (PCT): a prospective international multicenter study

BACKGROUND

Pancreatic infections and sepsis are major complications in severe acute pancreatitis (AP) with significant impact on management and outcome. We investigated the value of Procalcitonin (PCT) for identifying patients at risk to develop pancreatic infections in severe AP.

METHODS

A total of 104 patients with predicted severe AP were enrolled in five European academic surgical centers within 96 hours of symptom onset. PCT was measured prospectively by a semi-automated immunoassay in each center, C-reactive protein (CRP) was routinely assessed. Both parameters were monitored over a maximum of 21 consecutive days and in weekly intervals thereafter.

RESULTS

In contrast to CRP, PCT concentrations were significantly elevated in patients with pancreatic infections and associated multiorgan dysfunction syndrome (MODS) who all required surgery (n = 10) and in nonsurvivors (n = 8) early after onset of symptoms. PCT levels revealed only a moderate increase in patients with pancreatic infections in the absence of MODS (n = 7), all of whom were managed nonoperatively without mortality. A PCT value of > or =3.5 ng/mL on 2 consecutive days was superior to CRP > or =430 mg/L for the assessment of infected necrosis with MODS or nonsurvival as determined by ROC analysis with a sensitivity and specificity of 93% and 88% for PCT and 40% and 100% for CRP, respectively (P < 0.01). The single or combined prediction of the two major complications was already possible on the third and fourth day after onset of symptoms with a sensitivity and specificity of 79% and 93% for PCT > or =3.8 ng/mL compared with 36% and 97% for CRP > or =430 mg/L, respectively (P = 0.002).

CONCLUSION

Monitoring of PCT allows early and reliable assessment of clinically relevant pancreatic infections and overall prognosis in AP. This single test parameter significantly contributes to an improved stratification of patients at risk to develop major complications.