Procalcitonin: potential role in diagnosis and management of sepsis

Procalcitonin contributes to hippocampal neuronal damage and impairment of LTP: implications for cognitive dysfunction in LPS-induced neuroinflammation rat model

Bacterial meningitis (BM) can lead to cognitive impairment, seriously affecting patients' quality of life. Our previous study demonstrated a significant increase in procalcitonin (PCT) levels in cerebrospinal fluid (CSF) in BM patients, but the functional implications remain unknown. We found high expression of PCT in the hippocampus of LPS-induced neuroinflammation models. PCT had a neurotoxic effect on the primarily cultured hippocampal neurons. The high dose of PCT induced neuronal apoptosis. The low dose of PCT impaired the arborization of hippocampal neurons and reduced the expression of the growth-associated protein-43 (GAP-43) and synaptophysin (SYN). Furthermore, long-term potentiation (LTP) in hippocampal brain slices was decreased after PCT perfusion ex vivo. Our results indicated that PCT had neurotoxic effects on neuronal survival and synaptic plasticity, potentially leading to cognitive impairment after BM.

Predictive value of serum procalcitonin level for the diagnosis of bloodstream infections in hematological patients

OBJECTIVES

Procalcitonin (PCT) is a critical diagnostic biomarker for bacterial infections in patients. Numerous studies have shown that PCT have high sensitivity and specificity for diagnosing bloodstream infection. However, the cut-off value of PCT for the diagnosis of bloodstream infections in patients with hematolgic diseases is still unclear and unreliable.

METHODS

We conducted a retrospective study involving 2299 cases with hematological diseases and who had been performed blood culture and PCT test within 24 h.

RESULTS

For patients with hematological diseases, the serum PCT was slightly elevated in the BSI group. We found that most hematological patients with bloodstream infection were in the stage of severe neutropenia. The main infected strains were Escherichia coli (n = 84, 21%), Klebsiella pneumoniae (n = 61, 15.25%) and Pseudomonas aeruginosa (n = 65, 16.25%), and the increasing trend of PCT level was more obvious in patients infected with Gram-negative bacteria. ROC analysis results showed that the area under the receiver operating characteristic curve for distinguishing bacterial infection from non-bacterial infection was 0.554 (95%CI: 0.522-0.585) with the diagnostic threshold of BSI (PCT > 0.5ng/mL).

CONCLUSIONS

In our study, low PCT levels were found in patients with hematological diseases, and a better cut-off value may be necessary to determine infection in hematology patients.

Simultaneous determination of procalcitonin and interleukin-6 in human serum samples with a point-of-care biosensing device

The simultaneous determination of two inflammatory diseases biomarkers, namely procalcitonin (PCT) and interleukin-6 (IL-6), in human serum samples employing a Point-of-Care device based on Multi Area Reflectance Spectroscopy is presented. Dual-analyte detection was achieved using silicon chips with two silicon dioxide areas of different thickness, one functionalized with an antibody specific for PCT and the other with an antibody specific for IL-6. The assay included reaction of immobilized capture antibodies with mixtures of PCT and IL-6 calibrators with the biotinylated detection antibodies, streptavidin and biotinylated-BSA. The reader provided for the automated execution of the assay procedure, as well as for the collection and processing of the reflected light spectrum, the shift of which is correlated to analytes concentration in the sample. The assay was completed in 35 min and the detection limits for PCT and IL-6 were 2.0 and 0.01 ng/mL respectively. The dual-analyte assay was characterized by high reproducibility (the intra- and inter-assay coefficients of variation were less than 10% for both analytes) and accuracy (the percent recovery values ranged from 80 to 113% for both analytes). Moreover, the values determined for the two analytes in human serum samples with the assay developed were in good agreement with the values determined for the same samples by clinical laboratory methods. These results support the potential of the proposed biosensing device application for inflammatory biomarkers determination at the Point-of-Need.

The Value of Peripheral Blood Leukocyte Parameters in the Early Diagnosis and Clinical Prognosis of Sepsis

Background

Early diagnosis of sepsis is the key to timely, targeted treatment. Cell population data (CPD) has been widely used in many diseases, but its predictive value for early diagnosis and the clinical outcome of sepsis remains unclear. Therefore, this paper discusses whether peripheral blood leukocyte parameters can be used as predictive indicators for early diagnosis and the clinical outcome of sepsis.

Methods

A retrospective study of 45 patients with sepsis, 53 patients with nonseptic infections, and 86 healthy check-ups admitted to Gansu Provincial Hospital from January 2021 to June 2022 was done using a hematology analyzer.

Results

The results of LYMPH#, HFLC#, IG#, NE-WX, LY-WX, LY-WY, and MO-WX showed better diagnostic efficiency in the sepsis group and nonseptic infection group. When the seven differential leukocyte parameters were used to establish diagnostic models, the sensitivity and specificity were 82.20% and 77.40%, respectively. Correlation analysis showed that LYMPH# and HFLC# were positively correlated with PCT (P < 0.05). The clinical outcome of sepsis showed that the leukocyte parameters of discharged WBC and LY-X had better predictive efficacy. When the two differential leukocyte parameters were used to establish diagnostic models, the sensitivity and specificity were 90.90% and 100.00%. Cox regression analysis showed that leukocyte parameters of discharged WBC and LY-X were independent predictors of clinical outcomes (P < 0.05).

Conclusion

Leucocyte parameters HFLC#, IG#, NE-WX, LY-WX, LY-WY, and MO-WX had a certain auxiliary effect on the early diagnosis of sepsis leukocyte parameters of discharged WBC and LY-X were independent predictors of clinical outcomes in patients with sepsis. Therefore, peripheral blood leukocyte parameters may have predictive value for early diagnosis and the clinical outcome of sepsis, but large-scale retrospective studies are still needed to prove our preliminary results.

A retrospective study of immunoglobulin E as a biomarker for the diagnosis of acute ischemic stroke with carotid atherosclerotic plaques

Objective

In this study, serum markers of acute ischemic stroke (AICS) with carotid artery plaque were retrospectively evaluated to establish a basis for discovering serological indicators for early warning of acute ischemic stroke (AICS).

Methods

A total of 248 patients with AICS were enrolled in Lanzhou University Second Hospital from January 2019 to December 2020. The study population included 136 males and 112 females, 64 ± 11 years of age. Of these, there were 90 patients with a transient ischemic attack (TIA), including 60 males and 30 females, aged 64 ± 8 years old. Patients with AICS were stratified by carotid ultrasound into a plaque group (n = 154) and a non-plaque group (n = 94). A total of 160 healthy subjects were selected as the control group. Serum lipoprotein-associated phospholipase A2 (Lp-PLA2), amyloid A (SAA), immunoglobulin E (IgE), D-dimer (D-D), total cholesterol (TC), triglyceride (TG), and low-density lipoprotein cholesterol (LDL-C) were collected from all subjects. Multivariate logistic regression was used to analyze the risk factors of AICS with carotid plaque. ROC curve was used to analyze the diagnostic efficacy of AICS with carotid plaque.

Results

The IgE, Lp-PLA2, SAA, LDL-C, TC, TG, and D-D levels in the AICS group were higher than those in the TIA group and healthy control group (P < 0.05). The IgE level was significantly higher than that in the healthy control group and TIA group. The IgE level in the AICS plaque group was significantly higher than that in the AICS non-plaque group (P < 0.01), and the Lp-PLA2 level was also different (P < 0.05). The incidence of AICS was positively correlated with Lp-PLA2, TC, IgE, TG, D-D, SAA and LDL-C (r = 0.611, 0.499, 0.478, 0.431, 0.386, 0.332, 0.280, all P < 0.05). The incidence of AICS with plaque was only positively correlated with IgE and Lp-PLA2 (r = 0.588, 0.246, P < 0.05). Logistic regression analysis showed that IgE and Lp-PLA2 were independent risk factors for predicting the occurrence of AICS with carotid plaque (P < 0.05). ROC curve analysis showed that the AUC of IgE (0.849) was significantly higher than other indicators; its sensitivity and specificity were also the highest, indicating that IgE can improve the diagnostic efficiency of AICS with carotid plaque.

Conclusion

IgE is a serum laboratory indicator used to diagnose AICS disease with carotid plaque, which lays a foundation for further research on potential early warning indicators of AICS disease.

Biomarkers during COVID-19: Mechanisms of Change and Implications for Patient Outcomes

As the COVID-19 (Coronavirus disease 19) pandemic spreads worldwide, the massive numbers of COVID-19 patients have created a considerable healthcare burden for every country. The clinical spectrum of SARS-CoV-2 infection is broad, ranging from asymptomatic to mild, moderate, severe, and critical. Most COVID-19 patients present with no or mild symptoms, but nearly one-fifth of all patients develop severe or life-threatening complications. In addition to localized respiratory manifestations, severe COVID-19 cases also show extra-pulmonary complications or induce multiorgan failure. Identifying, triaging, and treating patients at risk early is essential and urgent. This article reviews the potential prognostic value of various biomarkers at different clinical spectrum stages of COVID-19 infection and includes information on fundamental prognostic mechanisms as well as potential clinical implications. Biomarkers are measurable biochemical substances used to recognize and indicate disease severity or response to therapeutic interventions. The information they provide is objective and suitable for delivering healthcare providers with a means of stratifying disease state in COVID-19 patients. This, in turn, can be used to help select and guide intervention efforts as well as gauge the efficacy of therapeutic approaches. Here, we review a number of potential biomarkers that may be used to guide treatment, monitor treatment efficacy, and form individualized therapeutic guidance based on patient response. Implementation of the COVID-19 biomarkers discussed here may lead to significantly improved quality of care and patient outcomes for those infected with SARS-CoV-2 worldwide.

A diagnostic platform for rapid, simultaneous quantification of procalcitonin and C-reactive protein in human serum

Background

Early and accurate determination of bacterial infections as a potential cause for a patient's systemic inflammatory response is required for timely administration of appropriate treatment and antibiotic stewardship. Procalcitonin (PCT) and C-reactive protein (CRP) have both been used as biomarkers to infer bacterial infections, particularly in the context of sepsis. There is an urgent need to develop a platform for simultaneous quantification of PCT and CRP, to enable the potential use of these biomarkers at the point-of-care.

Methods

A multiplexed lateral flow assay (LFA) and a fluorescence optical reader were developed. Assay performance was validated by testing spiked antigens in the buffer, followed by a validation study comparing results with conventional assays (Roche Cobas e411 Elecsys PCT and Siemens ADVIA XPT CRP) in 25 archived remnant human serum samples.

Findings

A linear regression correlation of 0·97 (P < 0·01) was observed for PCT, and a correlation of 0·95 (P < 0·01) was observed for CRP using direct patient samples. We also validated our platform's ability to accurately quantify high-dose CRP in the hook effect range where excess unlabeled analytes occupy binding sites at test lines.

Interpretation

A fluorescence reader-based duplex LFA for simultaneous quantification of PCT and CRP was developed and successfully validated with clinical samples. The rapid, portable, and low-cost nature of the platform offers potential for differentiation of bacterial and viral infections in emergency and low-resource settings at the point-of-care.

Funding

NIH/NIBIB Award 1R01EB021331, and Academic Venture Fund from the Atkinson Center for a Sustainable Future at Cornell University.

Endogenous Carboxyhemoglobin Level Variation in COVID-19 and Bacterial Sepsis: A Novel Approach?

Background: The increased production of carbon monoxide (CO) in sepsis has been proven, but the blood level variations of carboxyhemoglobin (COHb) as a potential evolutionary parameter of COVID-19 and sepsis/septic shock have yet to be determined. This study aims to evaluate the serum level variation of COHb as a potential evolutionary parameter in COVID-19 critically ill patients and in bacterial sepsis. Materials and method: A prospective and observational study was conducted on two groups of patients: the bacterial sepsis group (n = 52) and the COVID-19 group (n = 52). We followed paraclinical parameters on Day 1 (D1) and Day 5 (D5) of sepsis/ICU admission for COVID-19 patients. Results: D1 of sepsis: statistically significant positive correlations between: COHb values and serum lactate (p = 0.024, r = 0.316), and total bilirubin (p = 0.01, r = 0.359). In D5 of sepsis: a statistically significant positive correlations between: COHb values and procalcitonin (PCT) (p = 0.038, r = 0.402), and total bilirubin (p = 0.023, r = 0.319). D1 of COVID-19 group: COHb levels were statistically significantly positively correlated with C-reactive protein CRP values (p = 0.003, r = 0.407) and with PCT values (p = 0.022, r = 0.324) and statistically significantly negatively correlated with serum lactate values (p = 0.038, r = −0.285). Conclusion: COHb variation could provide rapid information about the outcome of bacterial sepsis/septic shock, having the advantages of a favorable cost-effectiveness ratio, and availability as a point-of-care test.

Role of Polypeptide Inflammatory Biomarkers in the Diagnosis and Monitoring of COVID-19

The COVID-19 (coronavirus disease 2019) pandemic that took over the world in December 2019 has had everlasting devastating impacts on the lives of people globally. It manifests a huge symptom spectrum ranging from asymptomatic to critically ill patients with an unpredictable outcome. Timely diagnosis and assessment of disease severity is imperative for effective treatment. Possibilities exist that by the time symptoms appear the viral load might increase beyond control. However, it is advisable to get adequately diagnosed as soon as the first symptom appears. There is an immediate requirement of reliable biomarkers of COVID-19 manifesting an early onset for effective clinical management, stratification of high risk patients and ensuring ideal resource allocation. In this review, we attempt to explore and describe important polypeptide inflammatory biomarkers, namely C-reactive protein, Procalcitonin, Ferritin, Lactate Dehydrogenase, Serum amyloid A, Interleukin-6, Tumor necrosis factor-alpha and LIGHT used in the detection and management of COVID-19. Viral pathogenesis and the role of these inflammatory biomarkers is highlighted, based on the evidences available till date. An integrative data monitoring along with their correlation with the natural disease progression is of utmost importance in the management of COVID-19. So further research and in-depth analysis of these biomarkers is warranted in the present scenario.

UPLC-Q-TOF/MS-Based Plasma and Urine Metabolomics Contribute to the Diagnosis of Sepsis

In this study, we aimed to identify potential metabolic biomarkers that can improve the diagnostic accuracy of sepsis. Sixty-six patients including 30 septic and 36 nonsepsis patients from an intensive care unit were recruited. The global plasma and urine metabolomic profiles were determined by ultraperformance liquid chromatography coupled with a quadrupole time-of-flight mass spectrometry-based methodology. The risk factors, including both traditional physiological indicators and metabolic biomarkers, were investigated by binary logistic regression analysis and used to build a least absolute shrinkage and selection operator (Lasso) regression model to evaluate the ability of diagnosis. Fifty-five metabolites in plasma and 11 metabolites in urine were identified through orthogonal projections to latent structures discriminant analysis (OPLS-DA). Among them, ten (PE (20:4(5Z, 8Z, 11Z, 14Z)/P-18:0), harderoporphyrinogen, chloropanaxydiol, (Z)-2-octenal, N¹,N⁸-diacetylspermidine, 1-nitroheptane, venoterpine, α-CEHC, LysoPE (20:0/0:0), corticrocin) metabolites were identified as risk factors. The Lasso regression model incorporating these ten metabolic biomarkers and five traditional physiological indicators displayed better differentiation than the traditional model, represented by the elevated area under receiver operating characteristic curve (AUROC) from 96.80 to 100.0%. Furthermore, patients with septic shock presented a significantly lower level of PE-Cer (d16:1(4E)/19:0). This study suggests that metabolomic profiling could be an effective tool for sepsis diagnosis.

Peptidylarginine Deiminase 2 in Host Immunity: Current Insights and Perspectives

Peptidylarginine deiminases (PADs) are a group of enzymes that catalyze post-translational modifications of proteins by converting arginine residues into citrullines. Among the five members of the PAD family, PAD2 and PAD4 are the most frequently studied because of their abundant expression in immune cells. An increasing number of studies have identified PAD2 as an essential factor in the pathogenesis of many diseases. The successes of preclinical research targeting PAD2 highlights the therapeutic potential of PAD2 inhibition, particularly in sepsis and autoimmune diseases. However, the underlying mechanisms by which PAD2 mediates host immunity remain largely unknown. In this review, we will discuss the role of PAD2 in different types of cell death signaling pathways and the related immune disorders contrasted with functions of PAD4, providing novel therapeutic strategies for PAD2-associated pathology.

Early Elevation of Thioredoxin-1 Serum Levels Predicts 28-Day Mortality in Patients with Sepsis

Background

Sepsis is the leading cause of death in critically ill patients, and the prevention of which requires precise outcome prediction and early intervention. We evaluated the prognostic prediction value of serum thioredoxin-1 (Trx-1) as an anti-inflammatory factor in patients with sepsis.

Methods

As a prospective study, patients with sepsis admitted to the intensive care unit (ICU) of our hospital during 2020 were recruited. Medical history collection, sequential organ failure assessment (ΔSOFA), and laboratory tests were performed within 24 h of admission. Serum levels of Trx-1 and other inflammatory biomarkers were detected with samples dynamically collected before, during, and after septic shock. Patients were categorized as survivors and non-survivors according to survival status on day 28. Correlation between Trx-1 and other sepsis-associated parameters as well as the correlation of Trx-1 and other sepsis-associated parameters with 28-day mortality were evaluated. Prognostic factors were identified by Cox regression analyses.

Results

A total of 187 patients were recruited. Serum Trx-1 level was positively correlated with inflammatory factors (interleukin-6, C-reactive protein, procalcitonin) and index of sepsis severity (ΔSOFA score, partial pressure of oxygen/fraction of inspired oxygen), all of which were significantly higher in non-survivors than survivors. While Trx-1 level at different timepoints and its evolution over time significantly differed between survivors and non-survivors, the initial Trx-1 level outperformed the other parameters in predicting 28-day survival. With 38.27 ng/mL as the cutoff value, serum Trx-1 predicted 28-day survival with optimal sensitivity and specificity.

Conclusion

Early increases in serum levels of Trx-1 can predict 28-day mortality in sepsis patients in the ICU.

Distinguishing septic shock from non-septic shock in postsurgical patients using gene expression

OBJECTIVES

To obtain a gene expression signature to distinguish between septic shock and non-septic shock in postoperative patients, since patients with both conditions show similar signs and symptoms.

METHODS

Differentially expressed genes were selected by microarray analysis in the discovery cohort. These genes were evaluated by quantitative real time polymerase chain reactions in the validation cohort to determine their reliability and predictive capacity by receiver operating characteristic curve analysis.

RESULTS

Differentially expressed genes selected were IGHG1, IL1R2, LCN2, LTF, MMP8, and OLFM4. The multivariate regression model for gene expression presented an area under the curve value of 0.922. These genes were able to discern between both shock conditions better than other biomarkers used for diagnosis of these conditions, such as procalcitonin (0.589), C-reactive protein (0.705), or neutrophils (0.605).

CONCLUSIONS

Gene expression patterns provided a robust tool to distinguish septic shock from non-septic shock postsurgical patients and shows the potential to provide an immediate and specific treatment, avoiding the unnecessary use of broad-spectrum antibiotics and the development of antimicrobial resistance, secondary infections and increase health care costs.

Procalcitonin kinetics early after severe burn injury and its value in diagnosis of sepsis

PURPOSE

To investigate the clinical significance of procalcitonin (PCT) kinetics early after burn and the perioperative period, and to assess its diagnostic performance for sepsis in major burn patients.

METHODS

This retrospective study on major burn patents (≥40% total body surface area) admitted from 2014 to 2019 was conducted in Southwest Hospital, Chongqing, China. A total of 321 patients were included. The kinetics of PCT was analyzed during the 1st week after burn, the perioperative period, and at the onset of clinical suspected sepsis.

RESULTS

Serum PCT concentration rose immediately after burn injury. Factors associated with increased PCT level in the 1st week after burn include greater burn area (>70% TBSA) and lower age (≤14 years). Correlations between PCT kinetics after burn and the risk of early development of sepsis and mortality were observed. At the onset of sepsis, serum PCT increased significantly compared to its basal level in the 48 h before diagnosis. The area under the receiver operating characteristics curve of PCT concentration and its kinetic changes was 0.788 and 0.826, respectively. PCT kinetics showed better accuracy than PCT concentration in discrimination of Gram-positive sepsis. The optimal diagnostic thresholds for PCT concentration and its kinetics were 1.41 ng/mL, and a 1.34-fold elevation compared to the baseline level.

CONCLUSIONS

PCT kinetics in the early stage after burn was a prognostic factor for sepsis and mortality among major burn patients. Serum PCT levels could be a diagnostic biomarker for sepsis in major burn patients.

Postoperative serum procalcitonin versus C-reactive protein as a marker of postoperative infectious complications in pancreatic surgery: a meta-analysis

BACKGROUND

Aim of this meta-analysis was to compare diagnostic accuracy C-reactive protein and procalcitonin between postoperative days 3 and 5 to predict infectious complications post pancreatic surgery.

METHODS

A systemic literature search was performed using MEDLINE, EMBASE and SCOPUS to identify studies evaluating the diagnostic accuracy of procalcitonin and C-reactive protein to predict infectious complications between postoperative days 3 and 5 following pancreatic surgery. A meta-analysis was performed using random-effect model and pooled predictive parameters.

RESULTS

Fifteen studies consisting of 2212 patients were included in the final meta-analysis. Pooled sensitivity, specificity, area under curve and diagnostic odds ratio (DOR) for day 3 C-reactive protein were 62%, 67%, 0.772 and 6.54, respectively. Pooled sensitivity, specificity, area under curve and DOR for day 3 procalcitonin were 74%, 79%, 0.8453 and 11.03, respectively. Sensitivity, specificity, area under the curve and DOR for day 4 C-reactive protein were 60%, 68%, 0.8022 and 11.90, respectively. Sensitivity, specificity and DOR of postoperative day 5 procalcitonin level for predicting infectious complications were 83%, 70% and 12.9, respectively. Pooled sensitivity, specificity, Area Under Receiver Operating Curve and DOR were 50%, 70%, 0.777 and 10.19, respectively.

CONCLUSION

Postoperative procalcitonin is a better marker to predict postoperative infectious complications after pancreatic surgeries.

Rethinking animal models of sepsis - working towards improved clinical translation whilst integrating the 3Rs

Sepsis is a major worldwide healthcare issue with unmet clinical need. Despite extensive animal research in this area, successful clinical translation has been largely unsuccessful.

We propose one reason for this is that, sometimes, the experimental question is misdirected or unrealistic expectations are being made of the animal model.

As sepsis models can lead to a rapid and substantial suffering – it is essential that we continually review experimental approaches and undertake a full harm:benefit impact assessment for each study. In some instances, this may require refinement of existing sepsis models. In other cases, it may be replacement to a different experimental system altogether, answering a mechanistic question whilst aligning with the principles of reduction, refinement and replacement (3Rs).

We discuss making better use of patient data to identify potentially useful therapeutic targets which can subsequently be validated in preclinical systems. This may be achieved through greater use of construct validity models, from which mechanistic conclusions are drawn. We argue that such models could provide equally useful scientific data as face validity models, but with an improved 3Rs impact. Indeed, construct validity models may not require sepsis to be modelled, per se. We propose that approaches that could support and refine clinical translation of research findings, whilst reducing the overall welfare burden on research animals.

Serum Amylase and Lipase for the Prediction of Pancreatic Injury in Critically Ill Children Admitted to the PICU

OBJECTIVES

Pancreatic injury is multifactorial and potentially devastating for critically ill children. We aimed to evaluate whether serum amylase and lipase among critically ill children could serve as an independent biomarker to predict pancreatic injury.

DESIGN

Retrospective cohort.

SETTING

PICU of a tertiary, pediatric medical center.

PATIENTS

Seventy-nine autopsies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A group of 79 children who died of different causes were investigated by autopsy. They were divided into pancreatic injury group and pancreatic noninjury group according to autopsy findings. Data based on patients' demographics, vital signs, laboratory findings, and clinical features at admission were collected and compared. Logistic regression was used to identify predictive factors for pancreatic injury. Receiver operating characteristic curve was constructed for assessing serum amylase and serum lipase to predicting pancreatic injury. Forty-one patients (51.9%) exhibited the pathologic changes of pancreatic injury. The levels of lactate, erythrocyte sedimentation rate, alanine transaminase, aspartate transaminase, and troponin-I in the injury group were significantly higher than that in the noninjury group, whereas the level of calcium was significantly lower than that in the noninjury group (p < 0.05). Multivariable logistic regression analysis showed that serum amylase, serum lipase, and septic shock were significantly associated with the occurrence rate of pancreatic injury. The statistically significant area under the curve results were as follows: serum amylase: area under the curve = 0.731, at a cutoff value of 97.5, sensitivity = 53.7, and specificity = 81.6; and serum lipase: area under the curve = 0.727, at a cutoff value of 61.1, sensitivity = 36.6, and specificity = 92.1.

CONCLUSIONS

Serum amylase and lipase could serve as independent biomarkers to predict pancreatic injury in critically ill children.

Early Warning Indicators of Severe COVID-19: A Single-Center Study of Cases From Shanghai, China

Background: Patients with severe novel coronavirus disease (COVID-19) can likely develop comorbidities, which can lead to irreversible organ damage and, eventually, death. However, early indicators of disease progression remain unclear. This study aimed to identify early indicators of disease progression to provide a basis for improved prognostic prediction and disease management.

Methods: We examined 53 recovered adult COVID-19 patients who were treated at Shanghai Public Health Clinical Center between January 20, 2020, and February 20, 2020. The patients were categorized into the following four groups according to their condition at admission: mild condition (n = 3), moderate (n = 41), severe (n = 7), and critical (n = 2). They were also categorized according to disease progression as mild or moderate conditions that remained stable (n = 26), moderate disease that progressed to severe condition (n = 18), and continuously severe or critical (n = 9). We then focused on investigating the differences in the epidemiological and laboratory indicators between remained stable cases and progressed to severe condition cases.

Results: Mild or moderate patients were younger than severe or critical patients. The number of patients with shortness of breath and underlying diabetes and heart disease at admission was higher in the severe or critical group. This group also showed considerably lower or higher values in 28 laboratory indicators. In addition, mild and moderate patients who remained stable were younger than moderate patients progressing to severe disease. Men had a higher risk of disease progression. Patients who progressed had either higher or lower values in 11 laboratory indicators. Survival curve analysis showed that age, procalcitonin, D-dimer, serum C-reactive protein, lactate dehydrogenase, lymphocytes, neutrophils, CD4%, and CD4/CD8 ratio were significant predictors of progression to severe disease.

Conclusions: Lactate dehydrogenase, procalcitonin, etc. are early warning indicators of severe COVID-19. Age (>64 years), shortness of breath, past histories of diabetes and heart disease, and abnormality in 28 other indicators at admission are indicative of severe or progression toward severe COVID-19. Meanwhile, abnormalities in 11 indicators and an abnormal coagulation function index at admission are risk factors for progression to severe disease.

Combination of Glutamine and Ulinastatin Treatments Greatly Improves Sepsis Outcomes

Background

Sepsis is one of the most dangerous syndromes, has extremely high mortality, and is caused by the body’s extreme responses to an infection. The pathogenesis of sepsis is very complex and remains largely unknown and thus the treatments for sepsis are limited. Here, we evaluated the treatment results of two potential drugs, glutamine and ulinastatin, on sepsis.

Methods

CLP rat model was used to study sepsis. Gastrostomy was performed to deliver the drugs. Flow cytometry was employed to measure CD4 and CD8 levels. May–Grünwald–Giemsa staining was used to count the numbers of monocytes and neutrophils in the blood. ELISA assay was performed to assess the levels of PCT, IL-6, TNFα, and IL-1β.

Results

Sepsis was successfully induced with the standard CLP rat model. Both glutamine and ulinastatin treatments greatly improved the outcomes of sepsis, but the combination of both treatments had the maximum therapeutic effect. Mechanistically, PCT, IL-6, TNFα, and IL-1β levels were significantly diminished following glutamine and ulinastatin treatments, suggesting an inhibition of inflammatory responses. Further, CD4 and CD4/CD8 ratio, and the numbers of monocytes and neutrophils were greatly up-regulated by glutamine and ulinastatin, indicating an enhanced immunity.

Conclusion

Glutamine and ulinastatin treatments largely mitigate sepsis shock by suppressing the inflammatory responses of the body and strengthening the immune system. Combination of these two drugs could serve as a potential treatment for sepsis.

Protective effect of rhubarb combined with ulinastatin for patients with sepsis

BACKGROUND

Sepsis is the leading cause of death in critically ill patients. Ulinastatin (UTI), a protease inhibitor, and rhubarb, used as a traditional Chinese medication, are proved to be effective in treating sepsis, but the effect of the combination therapy of these two drugs on sepsis remains unclear. This study aimed to investigate the effect of the combination treatment of UTI and rhubarb on sepsis patients.

METHODS

A total of 75 septic patients were randomly divided into control group, UTI group, Rhubarb group, and UTI plus Rhubarb group. Clinical data and score of Acute Physiology and Chronic Health Evaluation II (APACHE II) were collected; lymphocyte subtypes in the peripheral blood were analyzed before and after the 5-day treatment in the Intensive Care Unit.

RESULTS

All the therapeutic interventions (UTI alone, rhubarb alone, or UTI plus rhubarb) significantly reduced the levels of C-Reactive protein, white blood cell density, lactic acid, and APACH II scores, and elevated the levels of CD4/CD8, but only UTI plus rhubarb treatment obviously decreased the level of procalcitonin.

CONCLUSION

This study suggested that the combination of UTI and rhubarb may be a promising therapeutic scheme to ameliorate sepsis.

The use of procalcitonin for the management of sepsis in Internal Medicine wards: current evidence

Procalcitonin (PCT) is a circulating polypeptide produced in response to bacterial infections. Studies conducted in the Intensive Care Unit (ICU) setting have demonstrated its utility as a biomarker of bacterial infection and sepsis. Thus, PCT is widely used to distinguish between sepsis and SIRS, and to guide antibiotic therapy. At present sepsis represents a frequent diagnosis among patients admitted to internal medicine (IM) departments. Basing on the knowledge derived from ICU studies, the use of PCT has become routine in non-intensive wards, contributing to improve the management of sepsis. However, some differences between the two populations of patients - the IM being older, affected by multiple chronic comorbidities and lacking of invasive monitoring - could limit the generalizability of ICU results. Most of the studies on PCT conducted in the IM setting have focused on chronic obstructive pulmonary disease, pneumonia and sepsis. Although PCT represents one of the best biomarker available in routine clinical practice, there are uncertainties on the optimal cut-offs to be used for starting or discontinuing antibiotic treatment in patients with suspected bacterial infection or sepsis, for predicting outcome and on the role of PCT variations during antibiotic treatment. Moreover, several diseases can produce an elevation of PCT levels, thus producing false positive results. This represents a narrative review summarizing current evidences on PCT for the management of sepsis in an Internal Medicine wards, highlighting differences with ICU, with a special focus on the role of PCT variations as predictor of outcomes in non-ICU wards.

Presepsin as a diagnostic marker of sepsis in children and adolescents: a systemic review and meta-analysis

Background

Early diagnosis of sepsis in pediatric patients is vital but remains a major challenge. Previous studies showed that presepsin is potentially a reliable diagnostic biomarker for sepsis in adult and neonates. However, there is no pooled analysis of its efficacy as a diagnostic biomarker for sepsis in children. The aims of the present meta-analysis were to assess the overall diagnostic accuracy of presepsin in pediatric sepsis and compare it to those for C-reactive protein (CRP) and procalcitonin (PCT).

Methods

A systematic literature search was performed in Medline/Pubmed, Embase, the Cochrane Library, and ISI Web of Science to identify relevant studies reporting the diagnostic accuracy of presepsin in patients with pediatric sepsis. Sensitivities and specificities were pooled by bivariate meta-analysis. Heterogeneity was evaluated by χ² test.

Results

We identified 129 studies in total. Most were disqualified on the basis of their titles/abstracts and duplication. Four studies were included in the final analysis. They comprised 308 patients aged between 1 mo and 18 y. The pooled diagnostic sensitivity and specificity of presepsin were 0.94 (95% confidence interval [CI]: 0.74–0.99) and 0.71 (95% CI: 0.35–0.92), respectively. The pooled diagnostic odds ratio, positive likelihood ratio (LR), and negative LR of presepsin were 32.87 (95% CI: 2.12–510.09), 3.24 (95% CI, 1.14–12.38), and 0.08 (95% CI, 0.01–0.74), respectively. Heterogeneity was found in both sensitivity (χ² = 11.17; P = 0.011) and specificity (χ² = 65.78; P < 0.001). No threshold effect was identified among the studies (r = − 0.938). The pooled sensitivity of presepsin (0.94) was higher than that of CRP (0.51) and PCT (0.76), whereas the overall specificity of presepsin (0.71) was lower than that of CRP (0.81) and PCT (0.76). The AUC of presepsin (0.925) was higher than that of CRP (0.715) and PCT (0.820).

Conclusion

Currently available evidence indicates that presepsin has higher sensitivity and diagnostic accuracy, but lower specificity, than PCT or CRP in detecting sepsis in children. However, these results must be carefully interpreted as the number of studies included was small and the studies were statistically heterogeneous.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4397-1) contains supplementary material, which is available to authorized users.

When not to start antibiotics: avoiding antibiotic overuse in the intensive care unit

BACKGROUND

Most intensive care unit (ICU) patients receive broad-spectrum antibiotics. While lifesaving in some, in others these treatments may be unnecessary and place patients at risk of antibiotic-associated harms.

OBJECTIVES

To review the literature exploring how we diagnose infection in patients in the ICU and address the safety and utility of a 'watchful waiting' approach to antibiotic initiation with selected patients in the ICU.

SOURCES

A semi-structured search of PubMed and Cochrane Library databases for articles published in English during the past 15 years was conducted.

CONTENT

Distinguishing infection from non-infectious mimics in ICU patients is uniquely challenging. At present, we do not have access to a rapid point-of-care test that reliably differentiates between individuals who need antibiotics and those who do not. A small number of studies have attempted to compare early aggressive versus conservative antimicrobial strategies in the ICU. However, this body of literature is small and not robust enough to guide practice.

IMPLICATIONS

This issue will not likely be resolved until there are diagnostic tests that rapidly and reliably identify the presence or absence of infection in the ICU population. In the meantime, prospective trials that identify clinical situations wherein it is safe to delay or withhold antibiotic initiation in the ICU until the presence of an infection is proven are warranted.

Biomarker Profiling of Neurovascular Diseases in Patients with Stage 5 Chronic Kidney Disease

Patients with stage 5 chronic kidney disease (CKD5D) have a higher risk of developing neurocognitive deficits. Stroke, cervical carotid artery disease (CCAD), and intracranial atherosclerotic disease (ICAD) are causes of such deficits in CKD5D. Chronic inflammation from renal failure elevates risk for these diseases through oxidative stress and vascular dysfunction. The adverse impact on the carotid and intracranial vasculatures contributes to the multifactorial pathophysiology of stroke. Eleven plasma biomarker levels in patients with CKD5D (n = 97) and healthy controls (n = 17-50) were measured using sandwich enzyme-linked immunosorbent assay (ELISA) method. Of the 97 patients with CKD5D, 24 had CCAD, 19 had ICAD, and 23 had acute stroke. Elevations in NACHT, LRR, and PYD domains-containing protein 3 (NALP3) levels in patients with CKD5D (+)CCAD (1.80 ± 0.11 ng/mL) compared to patients with (−)CCAD (1.55 ± 0.08 ng/mL) were statistically significant (P = .0299). Differences in D-dimer levels were also found to be statistically significant (P = .0258) between CKD5D (+)stroke (1.83 ± 0.42 μg/mL) and (−)stroke (0.89 ± 0.13 μg/mL) groups. The ages of the (+) neurovascular disease groups were found to be significantly elevated compared to the (−) neurovascular disease groups (P = .0002 carotid AD; P < .0001 ICAD; P = .0157 stroke). D-dimer levels were positively correlated with age in CKD5D (P = .0375). With the possible exception of NALP3 for CCAD, profiling levels of specific biomarkers for risk stratification of neurovascular diseases in the CKD5D population warrants further investigation.

Sepsis in Internal Medicine wards: current knowledge, uncertainties and new approaches for management optimization

Sepsis represents a global health problem in terms of morbidity, mortality, social and economic costs. Although usually managed in Intensive Care Units, sepsis showed an increased prevalence among Internal Medicine wards in the last decade. This is substantially due to the ageing of population and to multi-morbidity. These characteristics represent both a risk factor for sepsis and a relative contra-indication for the admission to Intensive Care Units. Although there is a lack of literature on the management of sepsis in Internal Medicine, the outcome of these patients seems to be gradually improving. This is due to Internists' increased adherence to guidelines and "bundles". The routine use of SOFA score helps physicians in the definition of septic patients, even if the optimal score has still to come. Point-of-care ultrasonography, lactates, procalcitonin and beta-d-glucan are of help for treatment optimization. The purpose of this narrative review is to focus on the management of sepsis in Internal Medicine departments, particularly on crucial concepts regarding diagnosis, risk assessment and treatment. Key Messages Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The prevalence of sepsis is constantly increasing, affecting more hospital patients than any other disease. At least half of patients affected by sepsis are admitted to Internal Medicine wards. Adherence to guidelines, routine use of clinical and lab scores and point-of-care ultrasonography are of help for early recognition of septic patients and treatment optimization.

Myeloperoxidase can differentiate between sepsis and non-infectious SIRS and predicts mortality in intensive care patients with SIRS

Background

Systemic inflammatory response syndrome (SIRS) is a clinical syndrome following inflammation. Clinically, it is difficult to distinguish SIRS following an infection, i.e., sepsis, from non-infectious SIRS. Myeloperoxidase is a hemeprotein stored in the neutrophil azurophilic granules and is one of the main pillars of neutrophil attack. Therefore, we hypothesized that myeloperoxidase can differentiate between sepsis and non-infectious SIRS in patients with systemic inflammatory response syndrome in the intensive care unit (ICU).

Methods

An observational single-center cohort study was conducted measuring myeloperoxidase in patients with SIRS in the first 48 h after admission. The outcomes were established using predefined definitions. Thirty-day mortality was retrospectively assessed.

Results

We found significantly higher levels of myeloperoxidase in patients with sepsis and septic shock compared to patients without sepsis (60 ng/ml versus 43 ng/ml, P = 0.002). Myeloperoxidase levels were related to 30-day mortality (P = 0.032), and high MPO levels on top of a high APACHE IV score further increased mortality risk.

Conclusions

We show that myeloperoxidase is a potentially novel biomarker for sepsis in the ICU. Myeloperoxidase could eventually help in diagnosing sepsis and predicting mortality. However, more research is necessary to confirm our results.

Accuracy of serum procalcitonin for the diagnosis of sepsis in neonates and children with systemic inflammatory syndrome: a meta-analysis

Background

A number of biomarkers have been studied for the diagnosis of sepsis in paediatrics, but no gold standard has been identified. Procalcitonin (PCT) was demonstrated to be an accurate biomarker for the diagnosis of sepsis in adults and showed to be promising in paediatrics. Our study reviewed the diagnostic accuracy of PCT as an early biomarker of sepsis in neonates and children with suspected sepsis.

Methods

A comprehensive literature search was carried out in Medline/Pubmed, Embase, ISI Web of Science, CINAHL and Cochrane Library, for studies assessing PCT accuracy in the diagnosis of sepsis in children and neonates with suspected sepsis. Studies in which the presence of infection had been confirmed microbiologically or classified as “probable” by chart review were included. Studies comparing patients to healthy subjects were excluded. We analysed data on neonates and children separately.

Our primary outcome was the diagnostic accuracy of PCT at the cut-off of 2-2.5 ng/ml, while as secondary outcomes we analysed PCT cut-offs <2 ng/ml and >2.5 ng/ml. Pooled sensitivities and specificities were calculated by a bivariate meta-analysis and heterogeneity was graphically evaluated.

Results

We included 17 studies, with a total of 1408 patients (1086 neonates and 322 children). Studies on neonates with early onset sepsis (EOS) and late onset sepsis (LOS) were grouped together. In the neonatal group, we calculated a sensitivity of 0.85, confidence interval (CI) (0.76; 0.90) and specificity of 0.54, CI (0.38; 0.70) at the PCT cut-off of 2.0-2.5 ng/ml. In the paediatric group it was not possible to undertake a pooled analysis at the PCT cut-off of 2.0-2.5 ng/ml, due to the paucity of the studies.

Conclusions

PCT shows a moderate accuracy for the diagnosis of sepsis in neonates with suspected sepsis at the cut-off of 2.0-2.5 ng/ml. More studies with high methodological quality are warranted, particularly in neonates, studies considering EOS and LOS separately are needed to improve specificity.

Trial registration

PROSPERO Identifier: CRD42016033809. Registered 30 Jan 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2396-7) contains supplementary material, which is available to authorized users.

Mass spectrometry for the discovery of biomarkers of sepsis

Sepsis is a serious medical condition that occurs in 30% of patients in intensive care units (ICUs). Early detection of sepsis is key to prevent its progression to severe sepsis and septic shock, which can cause organ failure and death. Diagnostic criteria for sepsis are nonspecific and hinder a timely diagnosis in patients. Therefore, there is currently a large effort to detect biomarkers that can aid physicians in the diagnosis and prognosis of sepsis. Mass spectrometry is often the method of choice to detect metabolomic and proteomic changes that occur during sepsis progression. These "omics" strategies allow for untargeted profiling of thousands of metabolites and proteins from human biological samples obtained from septic patients. Differential expression of or modifications to these metabolites and proteins can provide a more reliable source of diagnostic biomarkers for sepsis. Here, we focus on the current knowledge of biomarkers of sepsis and discuss the various mass spectrometric technologies used in their detection. We consider studies of the metabolome and proteome and summarize information regarding potential biomarkers in both general and neonatal sepsis.

Sepsis and septic shock

For more than two decades, sepsis was defined as a microbial infection that produces fever (or hypothermia), tachycardia, tachypnoea and blood leukocyte changes. Sepsis is now increasingly being considered a dysregulated systemic inflammatory and immune response to microbial invasion that produces organ injury for which mortality rates are declining to 15-25%. Septic shock remains defined as sepsis with hyperlactataemia and concurrent hypotension requiring vasopressor therapy, with in-hospital mortality rates approaching 30-50%. With earlier recognition and more compliance to best practices, sepsis has become less of an immediate life-threatening disorder and more of a long-term chronic critical illness, often associated with prolonged inflammation, immune suppression, organ injury and lean tissue wasting. Furthermore, patients who survive sepsis have continuing risk of mortality after discharge, as well as long-term cognitive and functional deficits. Earlier recognition and improved implementation of best practices have reduced in-hospital mortality, but results from the use of immunomodulatory agents to date have been disappointing. Similarly, no biomarker can definitely diagnose sepsis or predict its clinical outcome. Because of its complexity, improvements in sepsis outcomes are likely to continue to be slow and incremental.

Combination of C-reactive protein, procalcitonin and sepsis-related organ failure score for the diagnosis of sepsis in critical patients

OBJECTIVE

To measure the ability of a new bioscore to diagnose sepsis in a general critical care population.

METHODS

The study was done at an intensive care unit (ICU) from April to December 2012. Demographic and clinical patient information were recorded on admission to the ICU with blood samples taken for C-reactive protein (CRP), procalcitonin (PCT), interleukin-6, white blood cell count, as well as body temperature, age and the sepsis-related organ failure (SOFA) score. These parameters were used to create a scoring system. The scoring system then underwent analysis by univariate analysis and multivariate logistic regression analysis to identify which of these clinical parameters were statistically different in septic versus non-septic patients. The bioscore was then tested in a receiver operator characteristic curve to determine statistical significance of the scoring systems ability to predict sepsis. Finally, a bioscore cutoff value was defined to provide a level for sepsis diagnosis.

RESULTS

Three hundred patients were enrolled, of which 107 patients were septic and 193 patients were non-septic. Univariate logistic regression showed that age, gender, CRP, PCT and SOFA were risk factors for occurrence of sepsis. Multivariate analysis revealed CRP (AUC 0.729, 95 % CI 0.671-0.787, P < 0.001), PCT (AUC 0.711, 95 % CI 0.652-0.770, P < 0.001) and SOFA (AUC 0.670, 95 % CI 0.607-0.733, P < 0.001) to be statistically significant. The combination of these values in the bioscore had an AUC of 0.790 (95 % CI 0.739-0.834, P < 0.001). A bioscore of ≥2.65 was considered to be statistically significant in making a positive diagnosis of sepsis.

CONCLUSIONS

This bioscore using CRP, PCT and SOFA score may potentially be used in the future to help identify septic patients earlier, improving their access to timely treatment modalities.

[Evaluation of the interest of procalcitonin in the diagnosis of chorioamnionitis in preterm premature rupture of membranes. An observational and prospective study]

INTRODUCTION

Diagnosis of chorioamnionitis (CA) is difficult because all clinical and biological signs are rarely concordant. According to recent literature, PCT could act as a specific marker of bacterial infection. Our main objective was to assess whether PCT could improve our management of patients with preterm premature rupture of membranes (pPROM), allowing earlier and more specific diagnosis for CA.

METHODS

Patients with pPROM from 24 and 34weeks of amenorrhea were included, from November 2013 to October 2014. PCT was collected twice a week, from pPROM until delivery. Obstetricians were blinded from PCT results, in order not to influence the management of the patients. PCT values were then compared to clinical and other biological diagnostic markers (CRP and white blood cells count [WBC]).

RESULTS

Thirty patients were included, with 11 cases of histological CA and 5 early-onset neonatal sepsis. With a cut-off value of 0.05ng/mL, the sensitivity of PCT to detect histological CA was 54%, the specificity was 79% and the positive and negative predictive value were respectively 60% and 75%. The positive likelihood ratio was 2.57 and the negative likelihood ratio was 0.58. Using PCT values, our medical decision of foetal extraction would have change in 5 cases (in a wrong way in 3 of them).

CONCLUSION

PCT in the diagnostic of CA is not useful in the management of patients.