Toward a holistic approach for diagnosing sepsis in the emergency department

Clinical usefulness of presepsin and monocyte distribution width (MDW) kinetic for predicting mortality in critically ill patients in intensive care unit

BACKGROUND

In this study, we explored the accuracy of two new sepsis biomarkers, monocyte distribution width (MDW) and presepsin (PSP), compared to traditional ones, C-reactive protein (CRP) and Procalcitonin (PCT), to identify sepsis and predict intra-hospital mortality by analyzing their kinetic at different time points during hospitalization stay.

METHODS

We enrolled 104 patients admitted to the intensive care unit (ICU) of University Hospital "Paolo Giaccone", Palermo. Among these, 30 (29%) had a clinical diagnosis of sepsis. MDW, PCT, CRP, and PSP were evaluated at admission (T0), after 24 h (T24), 48 h (T48), 72 h (T72), at day 5 (T5), and at discharge (TD).

RESULTS

Patients with sepsis displayed higher levels of PCT and PSP than patients without sepsis at each timepoint; differently, CRP displayed statistically significant differences only at T0, while MDW only at T0 and T24. Patients with increasing levels of PSP displayed lower median survival time than patients with decreasing levels; differences reached statistical significance only at 48 h (20 vs. 29 days, log rank test, p = 0.046). Interestingly, PSP was an independent predictor of ICU mortality at 48 and 72 h after hospital admission. Also, the kinetic of PSP had prognostic value, with increased values at 48 h after admission being associated with reduced survival.

CONCLUSION

Our findings support the role of PSP and its kinetic as a predictor of ICU mortality.

Presepsin in the diagnosis of sepsis

OBJECTIVES

Sepsis is a life-threatening condition characterized by organ dysfunction. It occurs due to the host's dysregulated response to an infection. Clinicians use inflammatory biomarkers to evaluate patients at risk of sepsis in various settings.

METHODS

We included studies focusing on the diagnostic accuracy of presepsin in patients under suspicion of sepsis. The bivariate model of Reitsma was used for the quantitative synthesis, and summary estimates were calculated. The Zhou-Dendukuri approach was followed to assess heterogeneity. Subgroup analyses were performed based on settings and diagnostic criteria.

RESULTS

The summary sensitivity for diagnosing sepsis was 0.805 (95 % CI: 0.759-0.844), while the false positive rate (FPR) was 0.174 (95 % CI: 0.124-0.239). The area under the curve (AUC) for the summary receiver operating characteristic (SROC) curve was 0.875, with a slightly lower partial AUC of 0.833. The analysis using the Zhou-Dendukuri approach revealed low heterogeneity (I2 = 15.9 %). Subgroup analyses showed no significant differences in SROC curves and summary estimates between the ED and ICU settings, although the ED subgroup exhibited higher heterogeneity (I2 = 52.7 % vs. 20.2 %). The comparison between the diagnostic criteria, Sepsis 1 and Sepsis 3, demonstrated similar summary estimates and SROC curves. The examination of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool revealed a high risk of bias regarding the participants and their applicability. Also, there was an increased risk of bias in all the studies concerning the index test.

CONCLUSION

Based on our research, presepsin is a promising biomarker for triage and early diagnosis of sepsis.

Presepsin: Hope in the Quest for the Holy Grail

How to cite this article: Samprathi A, Samprathi M, Reddy M. Presepsin: Hope in the Quest for the Holy Grail. Indian J Crit Care Med 2022;26(6):664-666.

Scavenging of bacteria or bacterial products by magnetic particles functionalized with a broad-spectrum pathogen recognition receptor motif offers diagnostic and therapeutic applications

Sepsis is a dysregulated host response of severe bloodstream infections, and given its frequency of occurrence and high mortality rate, therapeutic improvements are imperative. A reliable biomimetic strategy for the targeting and separation of bacterial pathogens in bloodstream infections involves the use of the broad-spectrum binding motif of human GP-340, a pattern-recognition receptor of the scavenger receptor cysteine rich (SRCR) superfamily that is expressed on epithelial surfaces but not found in blood. Here we show that these peptides, when conjugated to superparamagnetic iron oxide nanoparticles (SPIONs), can separate various bacterial endotoxins and intact microbes (E. coli, S. aureus, P. aeruginosa and S. marcescens) with high efficiency, especially at low and thus clinically relevant concentrations. This is accompanied by a subsequent strong depletion in cytokine release (TNF, IL-6, IL-1β, Il-10 and IFN-γ), which could have a direct therapeutic impact since escalating immune responses complicates severe bloodstream infections and sepsis courses. SPIONs are coated with aminoalkylsilane and capture peptides are orthogonally ligated to this surface. The particles behave fully cyto- and hemocompatible and do not interfere with host structures. Thus, this approach additionally aims to dramatically reduce diagnostic times for patients with suspected bloodstream infections and accelerate targeted antibiotic therapy. STATEMENT OF SIGNIFICANCE: Sepsis is often associated with excessive release of cytokines. This aspect and slow diagnostic procedures are the major therapeutic obstacles. The use of magnetic particles conjugated with small peptides derived from the binding motif of a broad-spectrum mucosal pathogen recognition protein GP-340 provides a highly efficient scavenging platform. These peptides are not found in blood and therefore are not subject to inhibitory mechanisms like in other concepts (mannose binding lectine, aptamers, antibodies). In this work, data are shown on the broad bacterial binding spectrum, highly efficient toxin depletion, which directly reduces the release of cytokines. Host cells are not affected and antibiotics not adsorbed. The particle bound microbes can be recultured without restriction and thus be used directly for diagnostics.

Prognostic value of serum amyloid A in COVID-19: A meta-analysis

BACKGROUND

There is still a lack of large-scale clinical studies and evidence-based evidence to prove the relationship between serum amyloid A (SAA) and the severity and prognosis of patients with new coronavirus pneumonia (COVID-19).

METHODS

We searched PubMed, Cochrane Library, Excerpta Medica Database, and Web of Science for original articles from December 1, 2019 to December 19, 2020. Search criteria include free text search, explosive MESH/EMTREE terms, and all synonyms for SAA and COVID-19. There are no language restrictions on the searched documents. Statistical methods were performed using Stata 14.0 software, and RevMan 5.4 software provided by the Cochrane Collaboration for meta-analysis. The 10 included studies in the literature were classified according to the severity of the novel coronavirus treatment guidelines, with mild/moderate categorized as nonsevere and severe/critical as severe, and the data were meta-analyzed using multiple subgroup standard deviations combined. Severe and nonsevere were finally divided into 2 groups, and the combined data were meta-analyzed according to the standardized mean difference.

RESULTS

The results of the meta-analysis given by random effects showed that SAA levels were significantly higher in severe vs nonsevere (standardized mean difference 1.20 [95% confidence interval 0.91-1.48]), which was statistically significant (P < .001). The 3 literatures studied (random effect size 0.11 [95% confidence interval 0.05-0.19]; I2 = 56.68%) and were statistically significant, z = 5.46 P < .01, suggesting that the risk of death occurs at higher levels with increasing SAA values, with the risk of death in the severe group being 11% higher than in the nonsevere group.

CONCLUSION

SAA can be considered as a biomarker for predicting the severity and prognosis of COVID-19. SAA can be used for early warning of the poor prognosis of COVID-19 and for monitoring the recovery process, which has important clinical value.

Challenges and Opportunities for Clustered Regularly Interspaced Short Palindromic Repeats Based Molecular Biosensing

Clustered regularly interspaced short palindromic repeats, CRISPR, has recently emerged as a powerful molecular biosensing tool for nucleic acids and other biomarkers due to its unique properties such as collateral cleavage nature, room temperature reaction conditions, and high target-recognition specificity. Numerous platforms have been developed to leverage the CRISPR assay for ultrasensitive biosensing applications. However, to be considered as a new gold standard, several key challenges for CRISPR molecular biosensing must be addressed. In this paper, we briefly review the history of biosensors, followed by the current status of nucleic acid-based detection methods. We then discuss the current challenges pertaining to CRISPR-based nucleic acid detection, followed by the recent breakthroughs addressing these challenges. We focus upon future advancements required to enable rapid, simple, sensitive, specific, multiplexed, amplification-free, and shelf-stable CRISPR-based molecular biosensors.

Two-center comparison of 10 fully-automated commercial procalcitonin (PCT) immunoassays

Background This two-center study was designed to verify comparability of procalcitonin (PCT) values among 10 different commercial immunoassays. Methods A total number of 176 routine lithium-heparin plasma samples were divided in identical aliquots and simultaneously analyzed with 10 different PCT immunoassays, including Kryptor BRAHMS PCT sensitive, Abbott Architect BRAHMS PCT, Beckman Coulter Access PCT (on Access and DXI), BioMérieux Vidas BRAHMS PCT, Diasorin Liaison BRAHMS PCT, Fujirebio Lumipulse G BRAHMS PCT, Roche BRAHMS PCT (on Cobas E801), Diazyme PCT (on Roche Cobas C702) and SNIBE Maglumi PCT. Results Highly significant correlation was always found across multiple comparisons, with correlation coefficients comprised between 0.918 and 0.997 (all p < 0.001). Bland and Altman plots analysis revealed highly variable bias among immunoassays, ranging between ±0.2% and ±38.6%. Diazyme PCT on Roche Cobas C702 and SNIBE Maglumi PCT displayed the larger overestimation, whilst PCT values were underestimated by Cobas BRAHAMS PCT. The agreement was always >80% (all p < 0.001), but varied largely across multiple comparisons, ranging between 90%-99% at 0.1 μg/L, 81%-99% at 0.25 μg/L, 83%-100% at 0.5 μg/L, 94%-100% at 2.0 μg/L and 90%-99% at 10 μg/L, respectively. The larger disagreement was observed comparing Diazyme PCT and Maglumi PCT with the other methods. Conclusions Although we found acceptable correlation among 10 commercial PCT immunoassays, the limited agreement at clinical decision thresholds remains a major issue, especially at lower end of PCT concentration, thus potentially contributing to jeopardize the clinical value of this biomarker.

Laboratory findings in SARS-CoV-2 infections: State of the art

SUMMARY OBJECTIVE The scientific community is constantly assessing the clinical and laboratory manifestations of COVID-19 in the organism. In view of the fragmentation of the large amount of information, knowledge gaps in relation to laboratory markers, and scarcity of papers in Portuguese, we propose a Literature review on laboratory changes observed in patients infected with SARS-CoV-2. METHODS Analysis of articles published between December 2019 and May 2020 on the PubMed and SciELO databases. The articles were identified, filtered, and evaluated based on the approach to the subject, language, and impact. Then, the articles were subjected to a thorough reading, in full, by 4 (four) independent researchers. RESULTS Leukopenia and lymphopenia were included in most studies, even in case definitions. Platelet count and platelet-lymphocyte ratio, at peak platelet, were associated with advanced age and longer hospital stay. Eosinopenia showed a sensitivity of 74.7% and specificity of 68.7% and, together with increased CRP, these are one of the future prospects for screening for disease. A high level of procalcitonin may indicate bacterial co-infection, leading to a worse prognosis. COVID-19 manifests itself with increased levels of many inflammatory markers such as IL-1, IL-2, IL-6, IL-7, IL-12, IP10, IFN-γ, MIP1A, MCP1, GSCF, TNF-α, and MCP1/CCL2, as well as LDH, ESR, D-dimer, CK, ALT, and AST. CONCLUSION There is a need for further studies on the new SARS-CoV-2. So far, there is no consensus regarding laboratory findings and their usefulness, whether as a prognostic marker, mortality, or disease severity.

Laboratory predictors of death from coronavirus disease 2019 (COVID-19) in the area of Valcamonica, Italy

Background Comprehensive information has been published on laboratory tests which may predict worse outcome in Asian populations with coronavirus disease 2019 (COVID-19). The aim of this study is to describe laboratory findings in a group of Italian COVID-19 patients in the area of Valcamonica, and correlate abnormalities with disease severity. Methods The final study population consisted of 144 patients diagnosed with COVID-19 (70 who died during hospital stay and 74 who survived and could be discharged) between March 1 and 30, 2020, in Valcamonica Hospital. Demographical, clinical and laboratory data were collected upon hospital admission and were then correlated with outcome (i.e. in-hospital death vs. discharge). Results Compared to patients who could be finally discharged, those who died during hospital stay displayed significantly higher values of serum glucose, aspartate aminotransferase (AST), creatine kinase (CK), lactate dehydrogenase (LDH), urea, creatinine, high-sensitivity cardiac troponin I (hscTnI), prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (APTT), D-dimer, C reactive protein (CRP), ferritin and leukocytes (especially neutrophils), whilst values of albumin, hemoglobin and lymphocytes were significantly decreased. In multiple regression analysis, LDH, CRP, neutrophils, lymphocytes, albumin, APTT and age remained significant predictors of in-hospital death. A regression model incorporating these variables explained 80% of overall variance of in-hospital death. Conclusions The most important laboratory abnormalities described here in a subset of European COVID-19 patients residing in Valcamonica are highly predictive of in-hospital death and may be useful for guiding risk assessment and clinical decision-making.