Serial Procalcitonin Predicts Mortality in Severe Sepsis Patients: Results From the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) Study

Evaluating the prognostic value of DECAF score and procalcitonin in patients with COPD exacerbation

OBJECTIVES

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) frequently result in emergency department (ED) visits, necessitating accurate risk stratification. The aim of this study was to evaluate and compare the prognostic utility of the DECAF score and serum procalcitonin levels in predicting clinical outcomes in patients with AECOPD.

METHODS

This retrospective cohort study encompassed AECOPD patients presenting to the ED over a three-year period who had serum procalcitonin levels measured. The primary outcome was one-month mortality, with secondary outcomes including ED re-admission, hospitalization, and intensive care unit (ICU) admission. Receiver operating characteristic (ROC) curve analysis was employed to assess the prognostic performance of DECAF score and procalcitonin, and differences between areas under the curve (AUC) were compared.

RESULTS

A total of 130 patients were analyzed, comprising 105 survivors and 25 non-survivors. The median DECAF score was significantly higher in non-survivors [4 (IQR: 3-4)] compared to survivors [3 (IQR: 2-4)] (p < 0.001). Similarly, median procalcitonin levels were elevated in non-survivors [0.26 ng/mL (IQR: 0.11-2.77)] relative to survivors [0.08 ng/mL (IQR: 0.04-0.21)] (p < 0.001). The AUC for the DECAF score was 0.758 (95 % CI: 0.673-0.842), while that for procalcitonin was 0.764 (95 % CI: 0.668-0.860). The difference between AUCs was 0.006 (95 % CI: -0.140 to 0.127), (p = 0.927). The negative predictive value (NPV) was 90.6 % for the 4-point DECAF score and 96.2 % for a 0.075 ng/mL procalcitonin cut-off. Notably, when used in combination, the NPV reached 100 % (95 % CI: 89.1-100).

CONCLUSIONS

The DECAF score and serum procalcitonin levels both exhibit robust prognostic capabilities in excluding adverse outcomes in AECOPD patients, with their predictive accuracy enhanced when used in tandem.

Clinical and Analytical Performance Evaluation of an Automated Procalcitonin Assay

BACKGROUND

Procalcitonin (PCT) measurement is useful for guiding antibiotic therapy and risk assessment in lower respiratory infections and/or sepsis. This study evaluated clinical and analytical performance of the Vitros® Immunodiagnostic Products B·R·A·H·M·S PCT assay (Vitros PCT).

METHODS

Precision, limits of blank (LoB), detection (LoD), and quantitation (LoQ) were determined for Vitros PCT, along with method comparison and clinical concordance with the B·R·A·H·M·S PCT™-sensitive KRYPTOR™ assay (KRYPTOR PCT). All-cause 28-day mortality was evaluated according to the change in PCT values (ΔPCT) from day 0 through day 4 in samples from 598 intensive care unit patients with sepsis.

RESULTS

Comparison of Vitros PCT and KRYPTOR PCT results yielded a Deming regression slope of 1.057, intercept of -0.010, and correlation coefficient (r) of 0.994. Precision analysis demonstrated within-laboratory coefficients of variation for Vitros PCT ranging from 3.1% to 6.4%. The LoD and observed LoQ were determined as 0.007 and 0.013 ng/mL, respectively. Overall agreement between assay methods was 98.5%, 98.0%, 97.4%, and 97.8%, at PCT clinical decision cutoffs of 0.100, 0.250, 0.500, and 2.00 ng/mL, respectively, with Cohen's Kappa coefficients (κ) > 0.91. ΔPCT values ≤80% vs >80% were associated with increased 28-day-all-cause mortality (P = 0.006).

CONCLUSIONS

Vitros PCT compares well with KRYPTOR PCT, showing excellent agreement at relevant clinical decision cutoffs that have been used for antibiotic decision-making and assessment of risk for sepsis progression. ΔPCT values determined with Vitros PCT were useful for evaluation of 28-day mortality risk in patients with severe sepsis.

Serial Procalcitonin Measurements for Determining Bacterial Infection and Mortality in Cirrhotic Patients With Systemic Inflammatory Response Syndrome

INTRODUCTION

The utility of serial procalcitonin (PCT) measurements in cirrhotic patients with systemic inflammatory response syndrome (SIRS) is not well understood. The aim of this study was to assess the effectiveness of serial PCT measurements for diagnosing bacterial infections and predicting 30-day mortality in this population.

METHODS

We prospectively studied 120 cirrhotic patients with SIRS, 64.2% of whom had bacterial infections. Serial PCT levels were measured within the first 72 hours of admission.

RESULTS

Patients with bacterial infections had significantly higher PCT levels at admission, 24 hours, and 72 hours compared with those without infections. PCT values >0.5 ng/mL within 72 hours demonstrated high sensitivity (81.8-87.5%) but moderate specificity (27.9-44.2%) for diagnosing bacterial infections. Serial PCT monitoring, including the 72-hr/baseline ratio and changes in PCT over 72 hours, provided insights into the evolution of bacterial infections and short-term mortality. Patients with a PCT 72-hour/baseline ratio >0.8 had higher 30-day mortality than those with a ratio <0.5 (50.0% vs 25.6%; odds ratio 3.91, 95% CI 1.40-10.97). Patients whose PCT levels decreased by >50% had lower 30-day mortality than those with increasing levels (23.3% vs 46.7%; odds ratio 0.25, 95% CI 0.08-0.74). Patients with Model for End-Stage Liver Disease scores >15 and bacterial infections who experienced a PCT decrease of <50% had higher 30-day mortality than those with greater reductions (57.7% vs 25.0%, P = 0.021).

DISCUSSION

Serial PCT measurements within 72 hours of admission are useful for determining bacterial infections and mortality in cirrhotic patients with SIRS. PCT monitoring may optimize antibiotic use and enhance early risk stratification, potentially improving patient outcomes.

Soluble Urokinase Plasminogen Activator Receptor: A Promising Biomarker for Mortality Prediction Among Critical ED Patients

Patients admitted to the emergency department (ED) are a highly diverse group in terms of the risk of death. In overcrowded EDs, it becomes crucial to quickly and reliably estimate the risk of death or significant health deterioration. For this purpose, the concentration of soluble urokinase plasminogen activator receptor (suPAR) in plasma has been studied in recent years in various patient populations. In the present study, we tested the hypothesis that measuring suPAR upon the ED admission of critically ill patients can identify those at the highest mortality risk. To verify this hypothesis, we analyzed the relationship between suPAR plasma concentration, other biochemical parameters, and Early Warning Scores (EWSs) on admission and survival to hospital discharge. The study group consisted of 61 ED patients with priority 1 in the Manchester Triage System (MTS), excluding patients with illness caused by environmental factors. Positive correlations between suPAR and inflammatory parameters such as CRP and PCT, as well as the warning scales MEWS, MEDS, and qSOFA, were confirmed. Plasma suPAR concentration on admission was found to be a promising predictor of in-hospital mortality. The study indicated the potential prognostic value of suPAR as the mortality risk predictor for a specific population of critically ill ED patients.

Optical Bionanosensors for Sepsis Diagnostics

Sepsis is a global health challenge, characterized by a dysregulated immune response, leading to organ dysfunction and death. Despite advances in medical care, sepsis continues to claim a significant toll on human lives, with mortality rates from 10-25% for sepsis and 30-50% for septic shock, making it a leading cause of death worldwide. Current diagnostic methods rely on clinical signs, laboratory parameters, or microbial cultures and suffer from delays and inaccuracies. Therefore, there is a pressing need for novel diagnostic tools that can rapidly and accurately identify sepsis. This review highlights advances in biosensor development that could ultimately lead to faster and more accurate sepsis diagnostics. The focus is on nanomaterial-based optical approaches that promise rapid diagnostics without the need for large equipment or trained personnel. An overview of sepsis is provided, highlighting potential molecular targets and the challenges they present for assay development. The requirements for an ideal point-of-care test (POC) are discussed, including speed, simplicity, and cost-effectiveness. Different nanomaterials suitable for various optical detection methods are reviewed and innovative nanosensors are discussed for sepsis diagnostics, focusing on chemical design and approaches to increase selectivity by multiplexing.

Study of the Role of C-reactive Protein/Procalcitonin Ratio as a Prognostic Tool in ICU Patients with Sepsis: A Prospective Observational Study

Background

Prediction of prognosis in sepsis is an essential research area aiming to improve disease outcomes. In this study, we investigated the role of the C-reactive protein (CRP)/procalcitonin (PCT) ratio as a prognostic tool in sepsis patients.

Materials and methods

This prospective observational study was conducted at the intensive care unit (ICU) of Alexandria Main University Hospital in the period from January to June 2024. One hundred and seventy patients with a diagnosis of sepsis were enrolled. Sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHEII) score and CRP/PCT ratio were calculated on admission (day 1), and as a follow-up on day 3. Patients were subsequently divided into survivor and non-survivor groups, and the data were compared.

Results

The CRP/PCT ratio was significantly lower, on admission and on follow-up, in non-survivor patients than in survivor patients. The ratio median (minimum-maximum) in non-survivors was 4.82 (1.51-23.28) vs 11.23 (1.85-136.7) in survivors on admission, and it was 7.37 (2.27-26.36) in non-survivors vs 11.37 (2.78-110.9) in survivors on day 3. The ratio was significantly lower in patients with septic shock than in non-septic shock patients. The ratio had a significant negative correlation with both SOFA and APACHEII scores. The receiver operating characteristic (ROC) curve showed high accuracy of the day 1 CRP/PCT ratio to predict mortality [area under curve (AUC = 0.835)], which is comparable to the day 1 SOFA score (AUC = 0.878) and higher than the day 1 PCT and day 1 APACHE scores.

Conclusion

Our results suggest a potential role for the CRP/PCT ratio, on admission and on follow-up, as a marker for predicting prognosis in sepsis patients, where low ratio values can predict poor disease outcome.

How to cite this article

Abdellatif EM, Hamouda EH. Study of the Role of C-reactive Protein/Procalcitonin Ratio as a Prognostic Tool in ICU Patients with Sepsis: A Prospective Observational Study. Indian J Crit Care Med 2024;28(12):1130-1138.

Caught Between Stewardship and Resistance: How to Treat Acute Complicated Diverticulitis in Areas of Low Antimicrobial Susceptibility?

Antimicrobial resistance is one of the main threats to public health, with multidrug-resistant (MDR) pathogens on the rise across continents. Although treatment guidelines generally recommend antimicrobial therapy for acute complicated diverticulitis, they do not specify treatment pathways according to local or national resistance profiles. There is sparse data regarding specific pathogens involved in Hinchey II-IV patients who undergo surgery. This study seeks to address these issues and determine how often and what types of MDR bacteria occur in patients undergoing emergency surgery. We prospectively enrolled patients admitted between 2020-2023 and who underwent emergency surgery for complicated acute diverticulitis. We analysed the inflammatory response parameters at admission, the type of surgery employed for source control, identified pathogens in the peritoneal samples, their antimicrobial susceptibility, the efficacy of antimicrobial empiric therapy, and mortality. Gram-negative bacteria were identified most often, with Escherichia coli being mostly MDR (43.9%) or extended-spectrum beta-lactamase producing (ESBL +ve) (24.4%), while most strains of Klebsiella pneumoniae were extended-spectrum beta-lactamase positive (ESBL +ve) (80%) and MDR (80%). Of the Enterococcus spp., 57.14% were vancomycin-resistant (VRE) strains. Patients with Hinchey III/IV were significantly more associated with MDR. Patients with multiple pathogens were significantly associated with ESBL+/VRE strains. Age, leucocytosis, and procalcitonin levels at admission were good indicators for mortality prediction, which occurred in four cases. In an age when antibiotic stewardship is advisable especially in emergency settings, the treatment should be tailored according to local profiles of MDR to ensure adequate outcomes for patients.

Procalcitonin Guided Antibiotic Stewardship

Despite infection and sepsis being a major public health challenge, early detection and timely management are often hindered by several factors. These includes the similarity of clinical presentations between infectious and non-infectious conditisons, as well as limitations of current diagnostic methods such as lengthy turnaround times and low sensitivity. Consequently, there is increasing interest in identifying biomarkers that can quickly and accurately differentiate bacterial sepsis from other inflammatory processes, whether infectious or non-infectious. Procalcitonin has emerged as one of the most extensively studied and utilized biomarkers in managing infection and sepsis, especially within the framework of antibiotic stewardship. This review aims to examine the role of Procalcitonin in guiding antibiotic stewardship. It explores the production and release of procalcitonin and its relevance in the context of infection and sepsis. The discussion focus on the clinical and economic impacts of using procalcitonin to guide the initiation and discontinuation of antibiotics in managing these conditions.

Serum C-reactive protein and procalcitonin levels in patients with pneumonia and anastomotic leakage in the postoperative period after esophagectomy

OBJECTIVE

Despite being a less-invasive procedure, esophagectomy can cause severe infectious complications, such as pneumonia and anastomotic leakage. Herein, we aimed to clarify the inflammatory characteristics of pneumonia/anastomotic leakage after esophagectomy by assessing the difference between the postoperative trends of serum C-reactive protein (CRP) and procalcitonin (PCT) levels in patients with pneumonia/anastomotic leakage using the values on the consecutive postoperative day (POD).

METHODS

This study included 439 patients who underwent minimally invasive esophagectomy. Serum CRP and PCT levels were measured on PODs 1-7, 10, and 14. Pneumonia and anastomotic leakage were defined as Clavien-Dindo grades ≥ 2.

RESULTS

Pneumonia and anastomotic leakage occurred in 96 and 51 patients, respectively. The CRP and PCT levels peaked on POD 3 (11.6 ± 6.8 mg/dL) and POD 2 (0.69 ± 2.9 ng/mL), respectively. Between PODs 3 and 14, CRP levels were significantly higher in patients with pneumonia and anastomotic leakage than in those without complications (P < 0.001). Between PODs 3 and 14, PCT levels were significantly higher in patients with pneumonia; however, on most PODs, there were no significant differences in PCT levels between patients with and without anastomotic leakage.

CONCLUSION

Inflammatory reactions caused by pneumonia may be more intense than those caused by anastomotic leakage after esophagectomy. Postoperative trends in serum CRP and PCT levels may vary depending on the complication type. Pneumonia and anastomotic leakage after esophagectomy can be potentially distinguished by the postoperative trend of PCT values before detailed examinations, such as computed tomography and endoscopy.

Mortality prediction model from combined serial lactate, procalcitonin and calprotectin levels in critically ill patients with sepsis: A retrospective study according to Sepsis-3 definition

OBJECTIVE

1) To evaluate the ability of baseline and on 24 h serum calprotectin, in comparison to canonical biomarkers (lactate and procalcitonin), for prognosis of 28-day mortality in critically ill septic patients; and 2) To develop a predictive model combining the three biomarkers.

DESIGN

A single-center, retrospective study.

SETTING

Intensive Care Unit of a university hospital.

PATIENTS OR PARTICIPANTS

One hundred and seventy three septic pacientes were included.

INTERVENTIONS

Measurement of baseline lactate, procalcitonin and calprotectin level and procalcitonin and calprotectin levels on 24 h.

MAIN VARIABLES OF INTEREST

Demographics and comorbidities, SOFA score on ICU admission, baseline lactate, procalcitonin and calprotectin on admission and on 24 h and 28-day mortality.

RESULTS

1) On ICU admission, lactate was the only biomarker achieving a significant accuracy (AUC: 0.698); 2) On 24 h, no differences were found on procalcitonin and calprotectin levels. Procalcitonin and calprotectin clearances were significantly lower in non-survivors and both achieved a moderate performance (AUCs: 0.668 and 0.664, respectively); 3) A biomarker based-model achieved a significant accuracy (AUC: 0.766), trending to increase (AUC: 0.829) to SOFA score alone; y 4) Baseline lactate levels and procalcitonin and calprotectin clearance were independent predictors for the outcome.

CONCLUSIONS

1) Baseline and on 24 h calprotectina and procalcitonin levels lacked ability in predicting 28-day mortality; 2) Accuracy of clearance of both biomarkers was moderate; and 3) Combination of SOFA score and the predictive biomarker based-model showed a high prognostic accuracy.

Point-of-care procalcitonin trends in suspected neonatal late-onset infection: a prospective observational study

BACKGROUND

Procalcitonin-guided antimicrobial decision-making has been shown to be safe in adult intensive care settings. Most antimicrobial exposure in neonatal units is in culture-negative conditions. We hypothesise that Procalcitonin aids antimicrobial stewardship efforts in suspected Late-Onset Neonatal Sepsis.

METHODS

Neonates were enrolled if they were aged over 72 h and were placed on antibiotics for a suspected infection. Procalcitonin levels were taken at set timepoints for the duration of antimicrobial exposure. Three subgroups were created: non-infectious episodes, blood culture-negative infectious episodes, and bloodstream infections.

RESULTS

Eighty-five suspected infectious episodes were recruited across two tertiary neonatal and paediatric intensive care units. There was a significant difference between the median PCT in bloodstream infections (BSI) compared to non-infectious episodes (2.13 versus 0.26 µg/L, p < 0.001). A cut-off of 0.5 µg/L had sensitivity 92.9% and specificity 68% for bloodstream infections at 24 h. The difference between median PCT values at 24 h was significant (0.27 vs 7.08; p < 0.001) for feed intolerance vs. NEC Grade IIIa-IIIb subgroups.

CONCLUSION

Procalcitonin levels taken 24 h following evaluation for late-onset neonatal infection are useful in out ruling BSI or severe Necrotising Enterocolitis. Up to 30% of antimicrobial exposure could be avoided with the use of Procalcitonin levels in low-risk neonates.

IMPACT

This study demonstrates the utility of serial Procalcitonin measurements in antimicrobial stewardship efforts in the Neonatal Unit. Procalcitonin can be used to aid in antimicrobial decision making in suspected Late-Onset neonatal infection. Procalcitonin testing at twenty-four hours in episodes of Gastrointestinal deterioration can out rule Bells Grade III Necrotising Enterocolitis.

The utility of an algorithm based on procalcitonin monitoring in patients with sepsis

OBJECTIVE

The aim of the study was to develop and validate an algorithm based on procalcitonin (PCT) monitoring to predict the prognosis of patients with sepsis.

DESIGN

The design was a retrospective and observational prospective study.

SETTING

The study was set in intensive care units (ICUs) in 2 different hospitals in Spain.

PATIENTS

Patients in the study included 101 patients with sepsis aged ≥18 years.

INTERVENTIONS

In the retrospective study, PCT results from patients admitted to the ICU in 2011-2012 were collected. In the prospective study, PCT was determined at specific time points as indicated by the algorithm from March 2018 to April 2019. The primary outcome measure, 28-day mortality, was the main variable of interest.

RESULTS

The study developed an algorithm based on early PCT monitoring for predicting the prognosis of patients with sepsis. The algorithm was initially developed retrospectively in 1 cohort and subsequently validated prospectively in another cohort.

CONCLUSIONS

The developed algorithm provides information on the prognosis of patients with sepsis, distinguishing between those with a good prognosis and those with a poor prognosis (defined as mortality).

Cost-effectiveness of Procalcitonin (PCT) guidance for antibiotics management of adult sepsis patients in the Egyptian context

BACKGROUND

Sepsis, which is described as a life-threatening organ malfunction brought on by an unbalanced host response to infection, continues to be a significant healthcare issue that affects millions of individuals each year. It is well-known that sepsis can affect anyone around the world, but the employed survey results showed that there are significant regional variations in sepsis incidence as well as mortality rates. Although there are no definite estimates for Egypt, the highest rates were in Low-Middle-Income Countries (LMICs). Procalcitonin (PCT) is a host response marker with high specificity for bacterial infections, unlike C-reactive protein (CRP) or white blood cell count (WBC), which represent the traditional methods of detecting inflammation and infection. Its dynamic profile and superior prognostic prediction make it invaluable for assessing response to antibiotic treatment and improving clinical care for sepsis patients. Our main purpose was to evaluate the cost-effectiveness of PCT guidance compared to no PCT guidance in the antibiotic management of adult sepsis patients according to the Egyptian context.

METHODS

We developed a decision tree model to compare the PCT-guided antibiotic management duration endpoint versus the conventional laboratory culture-based antibiotic management in adult sepsis patients. We employed the"Delphi technique" to reach a satisfactory consensus regarding the resources attributed to each compared alternative. The primary measure of the study was the additional cost associated with each Quality-Adjusted Life Year (QALY) gained by sepsis survivors over a one-year time horizon. Base-case, deterministic and probabilistic sensitivity analyses were conducted using TreeAge, Software.

RESULTS

Base-case analysis showed no dominance for either alternative and resulted in an Incremental Cost-Effectiveness Ratio (ICER) value of 297,783.57 Egyptian Pounds per Quality Adjusted Life Year (L.E/QALY) in favor of the PCT guidance alternative, Deterministic sensitivity analysis revealed that the highest impact magnitudes on ICER reside with seven input parameters, the top two parameters that had the most significant influence were the costs of ICU stay with and without PCT guidance. The CEAC showed a slightly higher probability in terms of acceptability in favor of the no PCT guidance choice along the WTP scale till reaching equal probabilities at the willingness-to-pay (WTP) value point of 390,000 (state currency) after which the - probability supports the PCT guidance choice.

CONCLUSIONS

In the Egyptian context, PCT guidance has no cost-effectiveness domination over no PCT guidance in Antibiotics management for adult sepsis patients. This may be attributed to the high cost of PCT investigation that shall be resolved by standardization of its cost when applying the approach of DRG cost packages.

Presepsin Does Not Predict Risk of Death in Sepsis Patients Admitted to the Intensive Care Unit: A Prospective Single-Center Study

Background: Sepsis is defined as life-threatening organ dysfunction caused by an abnormal host response to infection. The study aimed to evaluate the utility of presepsin (P-SEP) in predicting the risk of death in patients with sepsis at the time of intensive care unit (ICU) admission. Methods: Adult patients were included in the study if they met SEPSIS-3 criteria at ICU admission. Demographic and clinical data were collected. The following inflammatory parameters were determined: C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), and presepsin (P-SEP). Material was collected for microbiological testing depending on the suspected source of infection. The primary endpoint was patient death before ICU discharge. The secondary endpoint was a positive microbiological test result. Results: Eighty-six patients were included in the study. Thirty patients (35%) died before discharge from the ICU. There was no difference in P-SEP, CRP, PCT, and IL-6 values between patients who survived and those who died (p > 0.05 for all). P-SEP, CRP, PCT, and IL-6 were determined at ICU admission and did not accurately predict the risk of death in ROC curve analysis (p > 0.05 for all). Confirmation of the location of the focus of bacterial infection by microbiological testing was obtained in 43 (49%) patients. P-SEP, PCT, CRP, and IL-6 were significantly higher in patients with positive microbiological findings. Conclusions: In patients with suspected sepsis admitted to the Intensive Care Unit, presepsin does not accurately predict the risk of in-hospital death, but it can predict a positive microbiological culture.

Developing Augmented Pro-SOFA and Pro-SAPS Models by Integrating Biomarkers PCT, NLR, and CRP with SOFA and SAPS-III Scores

Background

Sepsis, a life-threatening condition characterized by a dysregulated immune response to infection, remains a significant clinical challenge globally. This study aims to enhance the predictive accuracy of existing sepsis severity scores by developing augmented versions of the SOFA and SAPS-III models, termed Pro-SOFA and Pro-SAPS, through the integration of biomarkers procalcitonin (PCT), neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP).

Methods

This prospective observational study was conducted in the medical ICU of a tertiary care hospital in southern India from August 2022 to December 2023. A total of 301 adult patients suspected or confirmed to have sepsis were assessed for eligibility, with 171 patients completing the study. Demographic and clinical data were collected; SOFA and SAPS-III scores were calculated and augmented with PCT, NLR, and CRP to develop Pro-SOFA and Pro-SAPS models. The performance of these models was evaluated using Brier scores, AUC, and net reclassification index (NRI).

Results

The augmented Pro-SOFA and Pro-SAPS models demonstrated superior predictive accuracy compared to their original counterparts. The Brier scores for Pro-SOFA and Pro-SAPS were 0.181 and 0.165, respectively, indicating better calibration than the original scores. The Pro-SAPS showed significant improvement over the original SAPS-III score (NRI = 0.50, SE = 0.14, p < 0.01). Similarly, Pro-SOFA outperformed the original SOFA (NRI = 0.49, SE = 0.13, p < 0.01).

Conclusion and clinical significance

Integrating PCT, CRP, and NLR with SOFA and SAPS-III scores to develop Pro-SOFA and Pro-SAPS significantly improves the predictive accuracy for sepsis mortality and can thus potentially improve sepsis outcomes.

How to cite this article

Nandakumar A, Sudeep S, Sreemohan AC, Vijayakumar S, Sudhakaran GJ, Gutjahr G, et al. Developing Augmented Pro-SOFA and Pro-SAPS Models by Integrating Biomarkers PCT, NLR, and CRP with SOFA and SAPS-III Scores. Indian J Crit Care Med 2024;28(10):935-941.

Prognostic accuracy of lactate and procalcitonin in addition to national early warning score in patients with suspected sepsis - A cross-sectional study in a tertiary care center

Background

Sepsis, a major global health concern, leads to millions of deaths annually, hence the need for early and reliable prognostic tools to assess patient risk and guide clinical decision making becomes crucial. This cross-sectional study evaluated the prognostic accuracy of integrating blood lactate and serum procalcitonin (PCT) levels with the National Early Warning Score (NEWS) for predicting mortality in sepsis patients. The objective was to assess whether this lactate and procalcitonin integrated with NEWS score (LP NEWS) could serve as a more effective early prognostic tool compared to established severity scores.

Methods

Spanning 12 months, the study enrolled adult patients meeting the criteria of sepsis in the ICU and medicine ward of a tertiary care hospital in North India. Data collection included demographics, clinical characteristics, and blood samples for lactate and PCT at admission. NEWS, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and LP-NEWS scores were calculated with treatment administered per Surviving Sepsis-3 guidelines.

Results

The research included 200 participants, uncovering significant correlations between blood lactate, PCT levels, and mortality. Survivors had a mean lactate of 2.12 ± 0.70 and PCT of 11.27 ± 11.75, while nonsurvivors had 3.30 ± 1.17 and 30 ± 18.48, respectively (P < 0.001). LP-NEWS significantly differentiated survivors from nonsurvivors (8.23 ± 2.02 vs. 14.12 ± 2.23), with a cutoff of 11 showing 96.9% sensitivity and 88.5% specificity for predicting mortality. LP-NEWS had the highest odds ratio = 3.12, P < 0.001, and area under the receiver operating characteristic curve value (0.966), outperforming APACHE II and SOFA scores.

Conclusion

The LP-NEWS score which integrates blood lactate and serum PCT levels could serve as an effective standalone bedside score, particularly in the initial risk stratification of sepsis.

Elevations in presepsin, PCT, hs-CRP, and IL-6 levels predict mortality among septic patients in the ICU

This study aimed to investigate whether changes in presepsin, procalcitonin, high-sensitivity C-reactive protein, and interleukin 6 levels predict mortality in septic patients in the intensive care unit. This study enrolled septic patients between November 2020 and December 2021. Levels of presepsin, procalcitonin, high-sensitivity C-reactive protein, and interleukin 6 were measured on the first (PSEP_0, PCT_0, hsCRP_0, IL-6_0) and third days (PSEP_3, PCT_3, hsCRP_3, IL-6_3). Follow-up was performed on days 3, 7, 14, 21, and 28 after enrollment. The outcome was all-cause death. The study included 119 participants, and the mortality was 18.5%. In univariable Cox proportional hazards regression analysis, ΔPSEP (= PSEP_3 - PSEP_0) > 211.49 pg/mL (hazard ratio, 2.70; 95% confidence interval, 1.17-6.22), ΔPCT (= PCT_3 - PCT_0) > -0.13 ng/mL (hazard ratio, 7.31; 95% confidence interval, 2.68-19.80), ΔhsCRP (= hsCRP_3 - hsCRP_0) > -19.29 mg/L (hazard ratio, 6.89; 95% confidence interval, 1.61-29.40), and ΔIL-6 (= IL-6_3 - IL-6_0) > 1.00 pg/mL (hazard ratio, 3.13; 95% confidence interval, 1.35-7.24) indicated an increased risk of mortality. The composite concordance index for alterations in all 4 distinct biomarkers was highest (concordance index, 0.83; 95% confidence interval, 0.76-0.91), suggesting the optimal performance of this panel in mortality prediction. In decision curve analysis, compared with the Acute Physiology and Chronic Health Evaluation II and Sequential (sepsis-related) Organ Failure Assessment scores, the combination of the 4 biomarkers had a larger net benefit. Interestingly, interleukin 6 was predominantly produced by monocytes upon lipopolysaccharide stimulation in peripheral blood mononuclear cells. ΔPSEP, ΔPCT, ΔhsCRP, and ΔIL-6 are reliable biomarkers for predicting mortality in septic patients in the intensive care unit, and their combination has the best performance.

COMPARISON OF OXIRIS AND CONVENTIONAL CONTINUOUS RENAL REPLACEMENT THERAPY IN MANAGING SEVERE ABDOMINAL INFECTIONS: IMPACT ON SEPTIC SHOCK MORTALITY

ABSTRACT

Objective: The objective of this study is to assess and compare the efficacy of oXiris with conventional continuous renal replacement therapy (CRRT) in managing severe abdominal infections. Methods: A retrospective analysis encompassing cases from 2017 to 2023 was conducted at the Department of Critical Care Medicine within the First Affiliated Hospital of Fujian Medical University. Parameters including heart rate (HR), mean arterial pressure (MAP), oxygenation index, lactate (Lac), platelet count, neutrophil ratio, procalcitonin, C-reactive protein (CRP), interleukin 6 (IL-6), norepinephrine dosage, Acute Physiology and Chronic Health Evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA) were recorded prior to treatment initiation, at 24 h, and 72 h after treatment for both the oXiris and conventional CRRT groups. In addition, the duration of respiratory support, CRRT treatment, length of stay in the intensive care unit (ICU), total hospitalization period, and mortality rates at 14 and 28 days for both groups were recorded. Results: 1) Within the conventional CRRT group, notable enhancement was observed solely in Lac levels at 24 h after treatment compared with pretreatment levels. In addition, at 72 h after treatment, improvements were evident in HR, Lac, CRP, and IL-6 levels. 2) Conversely, the oXiris group exhibited improvements in HR, MAP, Lac, oxygenation index, neutrophil ratio, and IL-6 at 24 h after treatment when compared with baseline values. In addition, reductions were observed in APACHE II and SOFA scores. At 72 h after treatment, all parameters demonstrated enhancement except for platelet count. 3) Analysis of the changes in the indexes (Δ) between the two groups at 24 h after treatment revealed variances in HR, MAP, Lac, norepinephrine dosage, CRP levels, IL-6 levels, APACHE II scores, and SOFA scores. 4) The Δ indexes at 72 h after treatment indicated more significant improvements following oXiris treatment for both groups, except for procalcitonin. 5) The 14-day mortality rate (24.4%) exhibited a significant reduction in the oXiris group when compared with the conventional group (43.6%). However, no significant difference was observed in the 28-day mortality rate between the two groups. 6) Subsequent to multifactorial logistic regression analysis, the results indicated that oXiris treatment correlated with a noteworthy decrease in the 14-day and 28-day mortality rates associated with severe abdominal infections, by 71.3% and 67.6%, respectively. Conclusion: oXiris demonstrates clear advantages over conventional CRRT in the management of severe abdominal infections. Notably, it reduces the fatality rates, thereby establishing itself as a promising and potent therapeutic option.

Predicting Mortality in Sepsis: The Role of Dynamic Biomarker Changes and Clinical Scores-A Retrospective Cohort Study

BACKGROUND

The prognostic value of baseline inflammatory markers in sepsis remains controversial, with conflicting evidence regarding their association with mortality. The dynamic changes in these markers over time might offer additional insights into disease progression and patient outcomes.

METHODS

This retrospective observational study included 138 patients with severe infections. The inflammatory biomarkers procalcitonin (PCT), C-reactive protein (CRP), and lactate (LAC) were measured at three time points: upon hospital admission (baseline), approximately 24-48 h after admission (second measurement; M2), and 48-72 h after admission (third measurement; M3). The primary outcome was 30-day mortality. A Mann-Whitney U test was used to compare the biomarker levels between the survivors and non-survivors. A Spearman's correlation was used to assess the relationships between the baseline parameters. A logistic regression and a receiver operating characteristic (ROC) curve analysis were employed to evaluate the prognostic value of the baseline markers and their dynamic changes.

RESULTS

The baseline LAC and SOFA score were significantly associated with 30-day mortality. The percentage decrease in PCT, CRP, and LAC from the baseline to M3 emerged as strong predictors of survival, with the ROC curve analysis demonstrating superior discriminatory ability compared to the baseline values. CRP_Delta exhibited the highest AUC (0.903), followed by PCT_Delta (0.843) and LAC_Delta (0.703).

CONCLUSIONS

The dynamic changes in these inflammatory biomarkers, particularly PCT, CRP, and LAC, offer valuable prognostic information beyond their baseline levels in predicting 30-day mortality in severe infections. These findings highlight the importance of monitoring biomarker trends for early risk stratification and potential treatment guidance.

Changes of Procalcitonin Kinetics According to Renal Clearance in Critically Ill Patients with Primary Gram-Negative Bloodstream Infections

Objective

This study aimed to investigate the relationship between procalcitonin (PCT) kinetic and estimated glomerular filtration rates (eGFR) in critically ill patients who had Gram-negative primary bloodstream infection (GN-BSI) and responded to the antimicrobial therapy.

Materials and Methods

This single-centered study was retrospective and observational. Critically ill GN-BSI patients over 18 years old who had clinical and microbiological responses to antibiotic treatment were included in the study. Patients were divided into two groups according to eGFR (eGFR <30 mL/min/1.73m2 and ≥30 mL/min/1.73m2) and compared for PCT kinetic at seven different measurement points as initial, first, third, fifth, seventh, tenth, and fourteenth days.

Results

The study included 138 patients. Initial PCT levels were higher in patients with eGFR <30 mL/min/1.73m2 (4.58 [1.36-39.4] ng/mL) than in eGFR ≥30 mL/min/1.73m2 (0.91 [0.32-10.2]) (p<0.001). This elevation was present at all measurement points (p<0.05). The decrease in PCT values by ≥30% (26.0% vs 47.9%; p=0.024) on the third day and ≥50% (69.2% vs 76.6%; p=0.411) on the fifth day was less in the low eGFR (<30 mL/min/1.73m2) group. The effect of low GFR on serum PCT kinetic was present in both fermenter and non-fermenter GN-BSIs but was more prominent in the fermenter group.

Conclusion

Serum PCT levels during therapy were higher in patients with low eGFR. Early PCT (<5 days) response was not obtained in non-fermenter GN-BSI patients with low eGFR. Antibiotic revision decisions should be made more carefully in patients with low eGFR due to high initial PCT levels and slow PCT kinetic.

Comparative Analysis of C-reactive Protein and Procalcitonin as Biomarkers for Prognostic Assessment in Pediatric Sepsis

Background Sepsis poses a critical medical challenge due to its profound systemic inflammatory response, which frequently results in organ dysfunction and high mortality rates, especially in pediatric patients. The condition requires prompt recognition and aggressive management to mitigate its severe outcomes. Methods This prospective study enrolled 248 pediatric patients admitted with sepsis to the pediatric intensive care unit (PICU) at our tertiary care center. Patients were randomly assigned to either the C-reactive protein (CRP) or procalcitonin (PCT) groups, with biomarker levels measured upon admission (hour zero) and again at 72 hours post-admission. Clinical parameters such as the need for ionotropic support, use of steroids, incidence of acute kidney injury (AKI), requirement for invasive ventilation, patient outcomes, and changes in antibiotic management were assessed based on these biomarker levels. Results Procalcitonin-positive sepsis cases demonstrated notable clinical severity compared to their C-reactive protein counterparts, showing significantly lower systolic blood pressure (p = 0.012), heightened need for ionotropic support (p < 0.0001), and more pronounced liver and renal dysfunction as indicated by elevated serum bilirubin (p = 0.001) and creatinine levels (p = 0.0058). The incidence of AKI was also higher in procalcitonin-positive cases. Despite these severe clinical parameters, there were no significant differences in the length of the PICU stay or in patient outcomes concerning discharge and mortality rates. Procalcitonin levels effectively guided antibiotic management, resulting in therapy adjustments in a substantial proportion of cases, with 67 (54%) experiencing downgrades and 33 (27%) requiring upgrades based on procalcitonin levels measured 72 hours post-admission. Conclusion Procalcitonin proves to be a valuable biomarker in assessing the severity and management of sepsis in pediatric patients. It correlates significantly with clinical parameters such as blood pressure, the need for ionotropic support, and markers of organ dysfunction.

Time-restricted feeding protects against cisplatin-induced acute kidney injury in mice

BACKGROUND

Time-restricted feeding (TRF), devoid of calorie restriction, is acknowledged for promoting metabolic health and mitigating various chronic metabolic diseases. While TRF exhibits widespread benefits across multiple tissues, there is limited exploration into its impact on kidney function. In this study, our aim was to investigate the potential ameliorative effects of TRF on kidney damage in a mouse model of cisplatin-induced acute kidney injury (AKI).

METHODS

Cisplatin-induced AKI was induced through intraperitoneal injection of cisplatin into C57BL/6 male mice. Mice undergoing TRF were provided unrestricted access to standard chow daily but were confined to an 8-hour feeding window during the dark cycle for 2 weeks before cisplatin injection. The mice were categorized into four groups: control, TRF, cisplatin, and TRF + cisplatin.

RESULTS

The tubular damage score and serum creatinine levels were significantly lower in the TRF + cisplatin group compared to the cisplatin group. The TRF + cisplatin group exhibited reduced expression of phosphorylated nuclear factor kappa B, inflammatory cytokines, and F4/80-positive macrophages compared to the cisplatin group. Furthermore, oxidative stress markers for DNA, protein, and lipid were markedly decreased in the TRF + cisplatin group compared to the cisplatin group. TUNEL-positive tubular cells, cleaved caspase-3 expression, and the Bax/Bcl-2 ratio in the TRF + cisplatin group were lower than those in the cisplatin group.

CONCLUSION

TRF, without calorie restriction, effectively mitigated kidney damage by suppressing inflammatory reactions, oxidative stress, and tubular apoptosis in a mouse model of cisplatin-induced AKI. TRF holds promise as a novel dietary intervention for preventing cisplatin-induced AKI.

Neutrophil-to-Lymphocyte Ratio and Procalcitonin in Sepsis Patients: Do They Have Any Prognostic Significance?

INTRODUCTION

Biomarkers like white blood cells, C-reactive protein, procalcitonin, and interleukin-1 are used in patients with sepsis for early diagnosis, differentiating various infections, making decisions to start antibiotics and evaluate their response, and to prognosticate morbidity and mortality. Despite the availability of these biomarkers, the prognosis of patients with sepsis in the ICU remains poor. Hence, this study was carried out to test the efficacy of procalcitonin and neutrophil-to-lymphocyte ratio (NLR) to prognosticate mortality and morbidity in terms of incidence of organ dysfunction and length of ICU stay in sepsis patients.

METHODS

In this prospective observational study, we measured NLR and procalcitonin at days one, three, and seven of sepsis patients and divided them into four groups: low NLR and high procalcitonin (LNHP), high NLR and high procalcitonin (HNHP), high NLR and low procalcitonin (HNLP), and low NLR and low procalcitonin (LNLP). Mortality at 28 days was noted as the primary outcome.

RESULTS

Out of 85 patients included in the study, five were lost to follow-up. Although no statistically significant difference was found in the primary outcome between all four groups, regression analysis showed that rising NLR and procalcitonin values were associated with a significant increase in mortality.

CONCLUSION

Serial values of NLR and procalcitonin are more important in predicting severity in comparison to a single value at presentation and can be used as a prognostic marker in sepsis patients.

Analytical Evaluation of Point-of-Care Finecare™ Procalcitonin Rapid Quantitative Test in Sepsis Population as Compared with Elecsys® BRAHMS Procalcitonin Immunoassay

The study compared two plasma procalcitonin (PCT) assays, the point of care (POC) Finecare™ Procalcitonin Rapid Quantitative Test and the Elecsys® BRAHMS PCT immunoassay, in sepsis ICU patients. Forty-one plasma samples were analyzed, showing a strong correlation (r = 0.98) and no significant difference in PCT values. The mean POC PCT value was 4.46 ng/mL (SD 8.68), and for laboratory BRAHMS PCT, it was 4.67 ng/mL (SD 10.03). The study found a strong linear relationship between plasma POC PCT and laboratory BRAHMS PCT (r = 0.98). Different regression methods showed varying intercepts and slopes: Ordinary Least Squares had an intercept of 0.49 and a slope of 0.85; Deming regression showed an intercept of 0.43 and a slope of 0.86; Passing-Bablok regression showed an intercept of 0.02 and a slope of 1.08. Precision results for cut-offs of 0.5 ng/mL were a coefficient of variation (CV) of 5%, and for 2.5 ng/mL, the CV was 2.5%. The Pearson correlation coefficient (r) for linearity was ≥0.99. The study revealed no significant difference between the POC Finecare™ PCT and Elecsys® BRAHMS PCT immunoassay in sepsis samples from ICU patients, supported by strong correlation, minimal bias, a consistent CV, and linearity.

Evaluation of Serial Procalcitonin Levels for the Optimization of Antibiotic Use in Non-Critically Ill COVID-19 Patients

BACKGROUND

Procalcitonin (PCT) has been used as a biomarker to guide antibiotic therapy in various patient populations. However, its role in optimizing antibiotic use in COVID-19 patients has not been well studied to date. Thus, we aimed to evaluate the use of serial PCT monitoring as an antimicrobial stewardship tool for COVID-19 patients.

METHODS

This retrospective study included 240 COVID-19 patients who were admitted to a tertiary medical institution in Saudi Arabia between January 2020 and February 2022. Patients who received empiric antibiotic therapy for community-acquired pneumonia (CAP) and had serial procalcitonin levels were included. The patients were divided into two groups: the normal procalcitonin arm (PCT level < 0.5 ng/mL) and the elevated PCT arm (PCT level > 0.5 ng/mL). The primary and secondary outcomes were the effect of PCT monitoring on the duration of antibiotic exposure and the length of hospital stay, respectively. To measure the accuracy of PCT, the receiver-operating characteristic area under the curve (ROC-AUC) was determined.

RESULTS

Among the included patients, 142 were in the normal procalcitonin arm (median PCT, 0.12 ng/mL), and 78 were in the elevated PCT arm (median PCT, 4.04 ng/mL). The baseline characteristics were similar between the two arms, except for the higher prevalence of kidney disease in the elevated PCT arm. There was no statistically significant difference in the duration of antibiotic exposure between the normal and elevated PCT arms (median duration: 7 days in both arms). However, the length of hospital stay was significantly shorter in the normal PCT arm (median stay, 9 days) than in the elevated PCT arm (median stay, 13 days; p = 0.028). The ROC-AUC value was 0.54 (95% CI: 0.503-0.595).

CONCLUSIONS

Serial PCT monitoring did not lead to a reduction in the duration of antibiotic exposure in COVID-19 patients. However, it was associated with a shorter hospital stay. These findings suggest that PCT monitoring may be useful for optimizing antibiotic use and improving outcomes in COVID-19 patients. While PCT-guided algorithms have the potential to enable antibiotic stewardship, their role in the context of COVID-19 treatment requires further investigation.

Utility of Serum Procalcitonin and Its Clearance in Predicting Outcomes in COVID-19 Patients

Introduction Identification of coronavirus disease 2019 (COVID-19) patients at risk of worse clinical outcomes is crucial to improving patient care. Various biochemical markers have been used to predict outcomes in such patients. We aimed to evaluate the role of serum PCT (procalcitonin) and the utility of PCT clearance (PCTc) in predicting the outcome of patients with COVID-19 illness. Methods We prospectively included 39 patients with severe or critical COVID-19 illness with an age equal to more than 18 years. In addition to routine baseline investigations, serum PCT was measured at admission (PCT1) and day 5 of hospitalization (PCT2). PCTc was calculated using the formula [Formula: see text]. Results We observed that serum PCT at admission was significantly higher in non-survivors (median: 1.9 ng/ml IQR: 0.51-4.23) compared to survivors (median 0.35 (IQR: 0.1-1.2), p 0.002). On serial serum-PCT estimation, non-survivors had persistently elevated serum-PCT (median PCT1:1.9 ng/ml (IQR: 0.51-4.23) to median PCT2: 1.9ng/ml (IQR: 0.83-2.72), p 0.51) than survivors (median PCT1:0.35ng/ml (IQR: 0.1-1.19) to median PCT2: 0.15ng/ml (IQR: 0.05-0.29), p 0.01). However, no difference in serum PCTc was observed between the two groups (median: 35.3% (IQR: 12.5-84.9) in survivors vs. 71.7% (33.3-91.7) in non-survivors, p = 0.165). Conclusion Serum PCT is a potential biochemical marker that could predict outcomes in COVID-19 patients. Measurement of serial serum PCT and estimation of PCT clearance may serve as better predictors than a single value; however, well-designed studies are required to identify the definite role of serum PCT in COVID-19 patients of varying severity.

The Role of Biomarkers in the Diagnosis and Management of Pneumonia

Biomarkers are used in the diagnosis, severity determination, and prognosis for patients with community-acquired pneumonia (CAP). Selected biomarkers may indicate a bacterial infection and need for antibiotic therapy (C-reactive protein, procalcitonin, soluble triggering receptor expressed on myeloid cells). Biomarkers can differentiate CAP patients who require hospital admission and severe CAP requiring intensive care unit admission. Biomarker-guided antibiotic therapy may limit antibiotic exposure without compromising outcome and thus improve antibiotic stewardship. The authors discuss the role of biomarkers in diagnosing, determining severity, defining the prognosis, and limiting antibiotic exposure in CAP and ventilator-associated pneumonia patients.

Advances in sepsis biomarkers

Sepsis, a dysregulated host immune response to an infectious agent, significantly increases morbidity and mortality for hospitalized patients worldwide. This chapter reviews (1) the basic principles of infectious diseases, pathophysiology and current definition of sepsis, (2) established sepsis biomarkers such lactate, procalcitonin and C-reactive protein, (3) novel, newly regulatory-cleared/approved biomarkers, such as assays that evaluate white blood cell properties and immune response molecules, and (4) emerging biomarkers and biomarker panels to highlight future directions and opportunities in the diagnosis and management of sepsis.

Exploring the Impact of Model-Informed Precision Dosing on Procalcitonin Concentrations in Critically Ill Patients: A Secondary Analysis of the DOLPHIN Trial

Model-informed precision dosing (MIPD) might be used to optimize antibiotic treatment. Procalcitonin (PCT) is a biomarker for severity of infection and response to antibiotic treatment. The aim of this study was to assess the impact of MIPD on the course of PCT and to investigate the association of PCT with pharmacodynamic target (PDT) attainment in critically ill patients. This is a secondary analysis of the DOLPHIN trial, a multicentre, open-label, randomised controlled trial. Patients with a PCT value available at day 1 (T1), day 3 (T3), or day 5 (T5) after randomisation were included. The primary outcome was the absolute difference in PCT concentration at T1, T3, and T5 between the MIPD and the standard dosing group. In total, 662 PCT concentrations from 351 critically ill patients were analysed. There was no statistically significant difference in PCT concentration between the trial arms at T1, T3, or T5. The median PCT concentration was highest in patients who exceeded 10× PDT at T1 [13.15 ng/mL (IQR 5.43-22.75)]. In 28-day non-survivors and in patients that exceeded PDT at T1, PCT decreased significantly between T1 and T3, but plateaued between T3 and T5. PCT concentrations were not significantly different between patients receiving antibiotic treatment with or without MIPD guidance. The potential of PCT to guide antibiotic dosing merits further investigation.

Diagnostic Accuracy of Procalcitonin in Bacterial Infections of the CNS: An Updated Systematic Review, Meta-Analysis, and Meta-Regression

OBJECTIVES

To evaluate diagnostic accuracy of serum and cerebrospinal fluid (CSF) procalcitonin for diagnosing CNS bacterial infections.

DATA SOURCES

We searched MEDLINE, Cochrane Central Register of Controlled Trials, and International Web of Science databases from January 1, 2016, to September 30, 2022.

STUDY SELECTION

Randomized controlled trials and observational studies, either prospective or retrospective, focusing on procalcitonin as a biomarker for CNS infections.

DATA EXTRACTION

We screened and extracted studies independently and in duplicate. We assessed risk of bias using the revised Quality Assessment for Studies of Diagnostic Accuracy tool. Data for diagnostic sensitivity and specificity were pooled using the bivariate or hierarchical model, as appropriate.

DATA SYNTHESIS

Of 5,347 citations identified, 23 studies were included. Overall, CSF procalcitonin showed slightly higher pooled sensitivity, specificity, and positive likelihood ratio compared with serum procalcitonin. In adults, pooled sensitivity of CSF procalcitonin was 0.89 (95% CI, 0.71-0.96), specificity 0.81 (95% CI, 0.66-0.91); pooled sensitivity of serum procalcitonin was 0.82 (95% CI, 0.58-0.94), specificity 0.77 (95% CI, 0.60-0.89). In children, pooled sensitivity of CSF procalcitonin was 0.96 (95% CI, 0.88-0.99), specificity 0.91 (95% CI, 0.72-0.97); pooled sensitivity of serum procalcitonin was 0.90 (95% CI, 0.75-0.97), specificity 0.83 (95% CI, 0.67-0.92). In post-neurosurgical patients, pooled sensitivity of CSF procalcitonin was 0.82 (95% CI, 0.53-0.95), specificity 0.81 (95% CI, 0.63-0.91); pooled sensitivity of serum procalcitonin was 0.65 (95% CI, 0.33-0.88), specificity 0.61 (95% CI, 0.41-0.78). Logistic regression revealed between-study heterogeneity higher for serum than CSF procalcitonin. For the latter, threshold variability was found as source of heterogeneity.

CONCLUSIONS

In children and critical post-neurosurgical patients, CSF procalcitonin gains superior sensitivity and specificity compared with serum procalcitonin. Overall, CSF procalcitonin appears to have a higher pooled positive likelihood ratio compared with serum procalcitonin.

Procalcitonin and qSOFA as a Marker of Mortality in Sepsis

BACKGROUND

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The qSOFA and procalcitonin are currently used for both diagnostic as well as prognostic purposes.

OBJECTIVE

To explore the combined use of day one procalcitonin level and qSOFA scores for prognostication of sepsis-related mortality.

DESIGN

This was a prospective observational study.

PARTICIPANTS

All patients who fulfilled the inclusion criteria for sepsis with an age of more than 16 years were enrolled in the study.

RESULTS

In this study of 211 patients, 15 patients died (7.1%) during hospital stay. Among the 15 patients who died, the highest mortality of 29.4% was seen in patients with qSOFA of "3", qSOFA of "2" had a mortality of 12.8%, qSOFA of "1" had a mortality of 1% and qSOFA of "0" had zero mortality. In this study, procalcitonin had a statistically significant positive correlation/association with both qSOFA and mortality.

CONCLUSION

The qSOFA and procalcitonin at presentation to the emergency department in septic patients have a significant correlation with mortality in patients hospitalized with sepsis. Obtaining these two parameters at presentation will help in managing aggressively these patients who at presentation have higher qSOFA and procalcitonin levels.

U-SHAPED ASSOCIATION BETWEEN SERUM CALCIUM LEVELS AND 28-DAY MORTALITY IN PATIENTS WITH SEPSIS: A RETROSPECTIVE ANALYSIS OF THE MIMIC-III DATABASE

ABSTRACT

Background: Serum calcium levels disorder have been reported to be associated with poor prognosis in different diseases. Studies on the association between serum calcium and outcomes of septic patients remained limited. The aim of this study is to investigate the association between serum calcium and 28-day mortality in septic patients. Method: Patients diagnosed with sepsis in the Medical Information Mart for Intensive Care III database were included. Patients were divided into five groups according to the quintiles of serum calcium levels, and their baseline characteristics were compared. Multivariate Cox regression models were used to assess the association between serum calcium and 28-day mortality. Smooth curve fitting and segmented regression models were used to visualize the association between serum calcium levels and 28-day mortality risk. The 28-day survival probability between five groups was analyzed using Kaplan-Meier curves. Results: A total of 3,016 patients with sepsis were enrolled, and the 28-day mortality rate was 35.64%. After adjusting for confounders, compared with the reference quintile (Q4: 9.00-9.50), the lowest serum calcium level quintile (Q1: 5.70-8.20) was independently associated with an increased risk of 28-day mortality (hazard ratio [HR], 2.12; 95% CI, 1.76-2.56). Smooth spline fitting revealed a U-shaped association between serum calcium and 28-day mortality. When serum calcium was <9.0 mg/dL, 28-day mortality risk increased by 58% per unit decrease in serum calcium (HR, 0.42; 95% CI, 0.37-0.48). When serum calcium was >9.0 mg/dL, the 28-day mortality risk increased by 12% per unit increase in serum calcium (HR, 1.12; 95% CI, 1.04-1.20). Conclusion: A U-shaped association was observed between serum calcium levels and 28-day mortality in septic patients. Lower or higher serum calcium levels were associated with increased risk of 28-day mortality in septic patients.

Procalcitonin Use for Predicting Mortality and Morbidity of Patients Diagnosed With Sepsis Within the Intensive Care Unit

Objective Infections leading to severe sepsis and septic shock are among the top five causes requiring admission to the intensive care unit (ICU). Up to 40% of ICU admissions contain a sepsis diagnosis. Without a clear marker to diagnose and manage sepsis, procalcitonin has been extensively studied for its usefulness in the management of bacterial infections. These studies, however, have been focused toward how it can be used to help guide when antibiotics should be initiated and de-escalated. There, however, has not been a study on how this biomarker could be used to predict mortality, and morbidity and help guide a need for antibiotic escalation. Design A retrospective chart review was conducted on patients admitted to the ICU at Northeast Georgia Medical Center between January 1, 2019, to June 30, 2021. Inclusion criteria were all patients above the age of 18 admitted to the ICU with a diagnosis of sepsis and having at least two procalcitonin drawn within 10 days of each other. Exclusion criteria were any patient with a diagnosis of COVID-19. Data Analysis was conducted to identify how delta procalcitonin could identify mortality and morbidity and if there was any change in antibiotics based on the delta procalcitonin.  Conclusion There was a statistically significant association between a delta positive procalcitonin and increased ICU length of stay. There was no statistical significance in expiration based on the antibiotic change in relationship to delta positive change in procalcitonin.

Using risk factors and markers to predict bacterial respiratory co-/superinfections in COVID-19 patients: is the antibiotic steward's toolbox full or empty?

BACKGROUND

Adequate diagnosis of bacterial respiratory tract co-/superinfection (bRTI) in coronavirus disease (COVID-19) patients is challenging, as there is insufficient knowledge about the role of risk factors and (para)clinical parameters in the identification of bacterial co-/superinfection in the COVID-19 setting. Empirical antibiotic therapy is mainly based on COVID-19 severity and expert opinion, rather than on scientific evidence generated since the start of the pandemic.

PURPOSE

We report the best available evidence regarding the predictive value of risk factors and (para)clinical markers in the diagnosis of bRTI in COVID-19 patients.

METHODS

A multidisciplinary team identified different potential risk factors and (para)clinical predictors of bRTI in COVID-19 and formulated one or two research questions per topic. After a thorough literature search, research gaps were identified, and suggestions concerning further research were formulated. The quality of this narrative review was ensured by following the Scale for the Assessment of Narrative Review Articles.

RESULTS

Taking into account the scarcity of scientific evidence for markers and risk factors of bRTI in COVID-19 patients, to date, COVID-19 severity is the only parameter which can be associated with higher risk of developing bRTI.

CONCLUSIONS

Evidence on the usefulness of risk factors and (para)clinical factors as predictors of bRTI in COVID-19 patients is scarce. Robust studies are needed to optimise antibiotic prescribing and stewardship activities in the context of COVID-19.

Evaluation of the relationship between procalcitonin level and the causative pathogen in intensive care patients with sepsis

Aim: This study was designed to investigate how procalcitonin (PCT) levels are affected by different pathogens in patients with sepsis. Materials & methods: A total of 110 Gram-positive sepsis, 62 Gram-negative sepsis and 27 fungal sepsis patients were included in the study. Kaplan-Meier and ROC curve analysis was performed to assess PCT levels. Results: PCT levels were 2.36 ng/ml in Gram-negative patients, 0.79 ng/ml in Gram-positive patients and 0.89 ng/ml in fungal patients. The area under the curve for PCT was 0.608, the cutoff value was 1.34, sensitivity was 56.50% the specificity was 56.50%. Conclusion: PCT survival levels of 7.71 ng/ml in Gram-negative patients, 2.65 ng/ml in Gram-positive patients and 1.16 ng/ml in fungal patients can be evaluated to predict survival.

Biomarkers in the intensive care setting: A focus on using procalcitonin and C-reactive protein to optimize antimicrobial duration of therapy

Managing the critically ill patient with infection is complex, requiring clinicians to synthesize considerable information relating to antimicrobial efficacy and treatment duration. The use of biomarkers may play an important role in identifying variation in treatment response and providing information about treatment efficacy. Though a vast number of biomarkers for clinical application have been described, procalcitonin and C-reactive protein (CRP) are the most thoroughly investigated in the critically ill. However, the presence of heterogeneous populations, variable end points, and incongruent methodology in the literature complicates the use of such biomarkers to guide antimicrobial therapy. This review focuses on an appraisal of evidence for use of procalcitonin and CRP to optimize antimicrobial duration of therapy (DOT) in critically ill patients. Procalcitonin-guided antimicrobial therapy in mixed critically ill populations with varying degrees of sepsis appears to be safe and might assist in reducing antimicrobial DOT. Compared to procalcitonin, fewer studies exist examining the impact of CRP on antimicrobial DOT and clinical outcomes in the critically ill. Procalcitonin and CRP have been insufficiently studied in many key intensive care unit populations, including surgical patients with concomitant trauma, renally insufficient populations, the immunocompromised, and patients with septic shock. We believe the available evidence is not strong enough to warrant routine use of procalcitonin or CRP to guide antimicrobial DOT in critically ill patients with infection. So long as its limitations are recognized, procalcitonin could be considered to tailor antimicrobial DOT on a case-by-case basis in the critically ill patient.

Troponin I as an Independent Biomarker of Outcome in Children with Systemic Inflammatory Response

Cardiac troponin-I (cTnI) is a biomarker of myocardial injury with implications for clinical outcomes. May other contributing factors that could affect outcomes have not been uniformly considered in pediatric studies. We hypothesized that there is an association between admission serum cTnI and outcomes in critically ill children taking into account the magnitude of the acute systemic inflammatory response syndrome (SIRS), serum lactate concentrations, and nutritional status. Second, we tested for potential factors associated with elevated serum cTnI. This was a prospective cohort study in 104 children (median age: 21.3 months) consecutively admitted to a pediatric intensive care unit (PICU) of a teaching hospital with SIRS and without previous chronic diseases. Primary outcome variables were PICU-free days, ventilator-free days, and 30-day mortality. Exposure variables were serum cTnI concentration on admission, revised pediatric index of mortality (PIM2), pediatric logistic organ dysfunction (PELOD-2), hypotensive shock, C-reactive protein, procalcitonin, and serum lactate on admission, and malnutrition. Elevated cTnI (>0.01 μg/L) was observed in 24% of patients, which was associated with the reduction of ventilator-free days (β coefficient = - 4.97; 95% confidence interval [CI]: -8.03; -1.91) and PICU-free days (β coefficient = - 5.76; 95% CI: -8.97; -2.55). All patients who died had elevated serum cTnI. The increase of 0.1 μg/L in cTnI concentration resulted in an elevation of 2 points in the oxygenation index (β coefficient = 2.0; 95% CI: 1.22; 2.78, p  < 0.001). The PIM2 score, hypotensive shock in the first 24 hours, and serum lactate were independently associated with elevated cTnI on admission. We conclude that elevated serum cTnI on admission is independently associated with adverse outcomes in children with SIRS and without associated chronic diseases.

One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers

INTRODUCTION

Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals.

AREAS COVERED

In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care.

EXPERT OPINION

In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.

Rapid identification of sepsis in the emergency department

Objectives

Recent research has helped define the complex pathways in sepsis, affording new opportunities for advancing diagnostics tests. Given significant advances in the field, a group of academic investigators from emergency medicine, intensive care, pathology, and pharmacology assembled to develop consensus around key gaps and potential future use for emerging rapid host response diagnostics assays in the emergency department (ED) setting.

Methods

A modified Delphi study was conducted that included 26 panelists (expert consensus panel) from multiple specialties. A smaller steering committee first defined a list of Delphi statements related to the need for and future potential use of a hypothetical sepsis diagnostic test in the ED. Likert scoring was used to assess panelists agreement or disagreement with statements. Two successive rounds of surveys were conducted and consensus for statements was operationally defined as achieving agreement or disagreement of 75% or greater.

Results

Significant gaps were identified related to current tools for assessing risk of sepsis in the ED. Strong consensus indicated the need for a test providing an indication of the severity of dysregulated host immune response, which would be helpful even if it did not identify the specific pathogen. Although there was a relatively high degree of uncertainty regarding which patients would most benefit from the test, the panel agreed that an ideal host response sepsis test should aim to be integrated into ED triage and thus should produce results in less than 30 minutes. The panel also agreed that such a test would be most valuable for improving sepsis outcomes and reducing rates of unnecessary antibiotic use.

Conclusion

The expert consensus panel expressed strong consensus regarding gaps in sepsis diagnostics in the ED and the potential for new rapid host response tests to help fill these gaps. These finding provide a baseline framework for assessing key attributes of evolving host response diagnostic tests for sepsis in the ED.

AACC Guidance Document on the Clinical Use of Procalcitonin

BACKGROUND

Procalcitonin (PCT), a peptide precursor of the hormone calcitonin, is a biomarker whose serum concentrations are elevated in response to systemic inflammation caused by bacterial infection and sepsis. Clinical adoption of PCT in the United States has only recently gained traction with an increasing number of Food and Drug Administration-approved assays and expanded indications for use. There is interest in the use of PCT as an outcomes predictor as well as an antibiotic stewardship tool. However, PCT has limitations in specificity, and conclusions surrounding its utility have been mixed. Further, there is a lack of consensus regarding appropriate timing of measurements and interpretation of results. There is also a lack of method harmonization for PCT assays, and questions remain regarding whether the same clinical decision points may be used across different methods.

CONTENT

This guidance document aims to address key questions related to the use of PCT to manage adult, pediatric, and neonatal patients with suspected sepsis and/or bacterial infections, particularly respiratory infections. The document explores the evidence for PCT utility for antimicrobial therapy decisions and outcomes prediction. Additionally, the document discusses analytical and preanalytical considerations for PCT analysis and confounding factors that may affect the interpretation of PCT results.

SUMMARY

While PCT has been studied widely in various clinical settings, there is considerable variability in study designs and study populations. Evidence to support the use of PCT to guide antibiotic cessation is compelling in the critically ill and in some lower respiratory tract infections but is lacking in other clinical scenarios, and evidence is also limited in the pediatric and neonatal populations. Interpretation of PCT results requires guidance from multidisciplinary care teams of clinicians, pharmacists, and clinical laboratorians.

Biomarkers for risk stratification and antibiotic stewardship in elderly patients

PURPOSE

Optimal treatment of infections in the elderly patients population is challenging because clinical symptoms and signs may be less specific potentially resulting in both, over- and undertreatment. Elderly patients also have a less pronounced immune response to infection, which may influence kinetics of biomarkers of infection.

METHODS

Within a group of experts, we critically reviewed the current literature regarding biomarkers for risk stratification and antibiotic stewardship in elderly patients with emphasis on procalcitonin (PCT).

RESULTS

The expert group agreed that there is strong evidence that the elderly patient population is particularly vulnerable for infections and due to ambiguity of clinical signs and parameters in the elderly, there is considerable risk for undertreatment. At the same time, however, this group of patients is particularly vulnerable for off-target effects from antibiotic treatment and limiting the use of antibiotics is therefore important. The use of infection markers including PCT to guide individual treatment decisions has thus particular appeal in geriatric patients. For the elderly, there is evidence that PCT is a valuable biomarker for assessing the risk of septic complications and adverse outcomes, and helpful for guiding individual decisions for or against antibiotic treatment. There is need for additional educational efforts regarding the concept of "biomarker-guided antibiotic stewardship" for health care providers caring for elderly patients.

CONCLUSION

Use of biomarkers, most notably PCT, has high potential to improve the antibiotic management of elderly patients with possible infection for improving both, undertreatment and overtreatment. Within this narrative review, we aim to provide evidence-based concepts for the safe and efficient use of PCT in elderly patients.

Antimicrobial Stewardship Techniques for Critically Ill Patients with Pneumonia

Pneumonia is common in the intensive care unit (ICU), infecting 27% of all critically ill patients. Given the high prevalence of this disease state in the ICU, optimizing antimicrobial therapy while minimizing toxicities is of utmost importance. Inappropriate antimicrobial use can increase the risk of antimicrobial resistance, Clostridiodes difficile infection, allergic reaction, and other complications from antimicrobial use (e.g., QTc prolongation, thrombocytopenia). This review article aims to discuss methods to optimize antimicrobial treatment in patients with pneumonia, including the following: procalcitonin use, utilization of methicillin-resistant Staphylococcus aureus nares testing to determine need for vancomycin therapy, utilization of the Biofire^® FilmArray^® pneumonia polymerase chain reaction (PCR), and microbiology reporting techniques.

Efficacy and safety of acupuncture as a complementary therapy for sepsis: a systematic review and meta-analysis

BACKGROUND

Sepsis is a life-threatening organ dysfunction caused by dysregulation of the host response to infection. Acupuncture is used for treatment of inflammatory diseases; however, its effectiveness and safety as a complementary therapy for sepsis has not been fully explored.

METHODS

Data were retrieved from eight databases. Randomized controlled trials (RCTs) that compared acupuncture plus conventional therapies versus conventional therapies alone were included. Pre-specified primary outcomes were mortality at 28 days and Acute Physiologic and Chronic Health Evaluation (APACHE) II scores.

RESULTS

A total of 17 studies with 1099 participants were included in this study. In terms of the primary outcomes, acupuncture plus routine therapy reduced mortality at 28 days (risk ratio (RR)): 0.69, 95% confidence interval (CI): 0.52 to 0.91, p < 0.001) and APACHE II scores (mean difference (MD): -2.84, 95% CI: -4.09 to -1.58, p < 0.001) at day 7 after treatment compared with routine therapy alone. In terms of secondary outcomes, acupuncture plus routine therapy reduced white blood cell counts and levels of procalcitonin (PCT), tumor necrosis factor (TNF)-α, interleukin (IL)-6 and lactic acid and intra-abdominal pressure (IAP), and improved CD3+, CD4+ and monocytes of human leukocyte antigen (HLA)-DR at day 7 after treatment compared with routine therapy alone. However, acupuncture plus routine therapy had no significant effects on levels of IL-10, C-reactive protein (CRP), CD8+ and CD4+/CD8+ ratios compared with routine therapy alone. Quality of evidence was low to very low for all parameters (GRADE).

CONCLUSION

The available evidence showed that combination of acupuncture and routine therapy may have benefit for sepsis compared with use of routine therapy only. Due to the low degree of certainty regarding its effects, further research is required.

TRIAL REGISTRATION NUMBER

ICRD42019141491 (PROSPERO).

Trends in the Use of Procalcitonin at US Children's Hospital Emergency Departments

OBJECTIVES

Procalcitonin (PCT) was approved by the Food and Drug Administration in 2016. We assessed changes in PCT utilization over time in emergency departments (EDs) at US Children's Hospitals and identified the most common conditions associated with PCT testing.

METHODS

We performed a cross-sectional study of children <18 years of age presenting to 1 of 33 EDs contributing data to the Pediatric Health Information System between 2016 and 2020. We examined trends in PCT utilization during an ED encounter between institutions and over the study period. Using All Patients Refined Diagnosis Related Groups, we identified the most common conditions for which PCT was obtained (overall, and relative to the performance of a complete blood count).

RESULTS

The overall rate of PCT testing increased from 0.2% of all ED visits in 2016 to 1.8% in 2020. Across hospitals, the proportion of ED encounters with PCT obtained ranged from 0.0005% to 4.3% with marked variability in overall use. Among children who had PCT testing performed, the most common diagnoses were fever (10.7%), infections of the upper respiratory tract (9.2%), and pneumonia (5.9%). Relative to the performance of a complete blood count, rates of PCT testing were highest among children with sepsis (28.7%), fever (21.4%), pulmonary edema/respiratory failure (17.3%), and bronchiolitis/respiratory syncytial virus pneumonia (15.6%).

CONCLUSIONS

PCT utilization in the ED has increased over the past 5 years with variation between hospitals. PCT is most frequently obtained for children with respiratory infections and febrile illnesses.

Clinical characteristics associated with mortality of COVID-19 patients admitted to an intensive care unit of a tertiary hospital in South Africa

BACKGROUND

Over 130 million people have been diagnosed with Coronavirus disease 2019 (COVID-19), and more than one million fatalities have been reported worldwide. South Africa is unique in having a quadruple disease burden of type 2 diabetes, hypertension, human immunodeficiency virus (HIV) and tuberculosis, making COVID-19-related mortality of particular interest in the country. The aim of this study was to investigate the clinical characteristics and associated mortality of COVID-19 patients admitted to an intensive care unit (ICU) in a South African setting.

METHODS AND FINDINGS

We performed a prospective observational study of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to the ICU of a South African tertiary hospital in Cape Town. The mortality and discharge rates were the primary outcomes. Demographic, clinical and laboratory data were analysed, and multivariable robust Poisson regression model was used to identify risk factors for mortality. Furthermore, Cox proportional hazards regression model was performed to assess the association between time to death and the predictor variables. Factors associated with death (time to death) at p-value < 0.05 were considered statistically significant. Of the 402 patients admitted to the ICU, 250 (62%) died, and another 12 (3%) died in the hospital after being discharged from the ICU. The median age of the study population was 54.1 years (IQR: 46.0-61.6). The mortality rate among those who were intubated was significantly higher at 201/221 (91%). After adjusting for confounding, multivariable robust Poisson regression analysis revealed that age more than 48 years, requiring invasive mechanical ventilation, HIV status, procalcitonin (PCT), Troponin T, Aspartate Aminotransferase (AST), and a low pH on admission all significantly predicted mortality. Three main risk factors predictive of mortality were identified in the analysis using Cox regression Cox proportional hazards regression model. HIV positive status, myalgia, and intubated in the ICU were identified as independent prognostic factors.

CONCLUSIONS

In this study, the mortality rate in COVID-19 patients admitted to the ICU was high. Older age, the need for invasive mechanical ventilation, HIV status, and metabolic acidosis were found to be significant predictors of mortality in patients admitted to the ICU.

Procalcitonin decrease predicts survival and recovery from dialysis at 28 days in patients with sepsis-induced acute kidney injury receiving continuous renal replacement therapy

Procalcitonin (PCT) is a biomarker for diagnosing infections and guiding antibiotic therapy. In this study, we investigated whether PCT can predict survival and recovery at 28 days in critically ill patients with sepsis-induced acute kidney injury (SIAKI) receiving continuous renal replacement therapy (CRRT). We examined 649 patients with SIAKI who underwent CRRT in our intensive care unit. In a multivariable Cox regression analysis, a single PCT level at CRRT initiation was not associated with survival in all patients. However, the higher % PCT decrease over 72 hours after CRRT initiation was independently associated with the higher chance of 28-day survival (per 10% decrease, hazard ratio [HR] for mortality: 0.87, 95% confidence interval [CI]: 0.85-0.89; P < 0.001). Among the survivors, the % PCT decrease over 72 hours after CRRT initiation, not a single PCT level at CRRT initiation, was independently associated with recovery from dialysis (per 10% decrease, HR for renal recovery: 1.28, 95% CI:1.21-1.36; P < 0.001). This study demonstrated that the higher % PCT decrease was independently associated with the higher chance of survival and recovery from dialysis at 28 days in critically ill patients with SIAKI receiving CRRT. Thus, a decrease in the PCT level, not a single PCT level at CRRT initiation, could be a valuable tool for predicting prognosis in these patients.

Long-term risk and predictors of cerebrovascular events following sepsis hospitalization: A systematic review and meta-analysis

Background

Long-term risk and predictors of cerebrovascular events following sepsis hospitalization have not been clearly elucidated. We aim to determine the association between surviving sepsis hospitalization and cerebrovascular complications in adult sepsis survivors.

Method

We searched MEDLINE, Embase, Scopus, Web of Sciences, Cochrane library, and Google scholar for studies published from the inception of each database until 31 August 2022.

Results

Of 8,601 screened citations, 12 observational studies involving 829,506 participants were analyzed. Surviving sepsis hospitalization was associated with a significantly higher ischemic stroke [adjusted hazard ratio (aHR) 1.45 (95% CI, 1.23-1.71), I ² = 96], and hemorrhagic stroke [aHR 2.22 (95% CI, 1.11-4.42), I ² = 96] at maximum follow-up compared to non-sepsis hospital or population control. The increased risk was robust to several sensitivity analyses. Factors that were significantly associated with increased hazards of stroke were: advanced age, male gender, diabetes mellitus, hypertension, coronary artery disease, chronic heart failure, chronic kidney disease, chronic obstruction pulmonary disease, and new-onset atrial fibrillation. Only diabetes mellites [aHR 1.80 (95% CI, 1.12-2.91)], hypertension [aHR 2.2 (95% CI, 2.03-2.52)], coronary artery disease [HR 1.64 (95% CI, 1.49-1.80)], and new-onset atrial fibrillation [aHR 1.80 (95% CI, 1.42-2.28)], were associated with > 50% increase in hazards.

Conclusion

Our findings showed a significant association between sepsis and a subsequent risk of cerebrovascular events. The risk of cerebrovascular events can be predicated by patient and sepsis-related baseline variables. New therapeutic strategies are needed for the high-risk patients.

How to best use procalcitonin to diagnose infections and manage antibiotic treatment

Objectives

Procalcitonin (PCT) is a host-response biomarker that has shown clinical value for assessing the likelihood of bacterial infections and guiding antibiotic treatment. Identifying situations where PCT can improve clinical care is therefore highly important.

Methods

The aim of this narrative review is to discuss strategies for the usage and integration of PCT into clinical routine, based on the most recent clinical evidence.

Results

Although PCT should not be viewed as a traditional diagnostic marker, it can help differentiate bacterial from non-bacterial infections and inflammation states – particularly in respiratory illness. Several trials have found that PCT-guided antibiotic stewardship reduces antibiotic exposure and associated side-effects among patients with respiratory infection and sepsis. Studies have demonstrated that patient-specific decisions regarding antibiotic usage is highly complex. Factors to consider include: the clinical situation (with a focus on the pretest probability for bacterial infection), the acuity and severity of presentation, as well as PCT test results. Low PCT levels help rule out bacterial infection in patients with both low pretest probability for bacterial infection and low-risk general condition. In high-risk individuals and/or high pretest probability for infection, empiric antibiotic treatment is mandatory. Subsequent monitoring of PCT helps track the resolution of infection and guide decisions regarding early termination of antibiotic treatment.

Conclusions

PCT possesses high potential to improve decision-making regarding antibiotic treatment – when combined with careful patient assessment, evidence-based clinical algorithms, and continuous notification and regular feedback from all antibiotic stewardship stakeholders. Medical Journals such as Clinical Chemistry and Laboratory Medicine (CCLM) have played a critical role in reviewing and dissemination the high-quality evidence about assays for PCT measurement, observational research regarding association with outcomes among different populations, and interventional research proofing its effectiveness for patient care.