Procalcitonin Levels in Survivors and Nonsurvivors of Sepsis: Systematic Review and Meta-Analysis

Prognostic Value of Procalcitonin in Febrile People Living with Human Immunodeficiency Virus (PLWH) Admitted to the Emergency Department

Background and Objectives: The management of HIV patients presenting with fever in the Emergency Department (ED) remains a challenging clinical scenario. Accurate risk stratification and prognostic indicators are crucial for timely intervention and improved patient outcomes. Procalcitonin (PCT) has emerged as a promising biomarker for assessing the severity and prognosis of various infectious diseases. The study aimed to evaluate the prognostic value of procalcitonin (PCT) in HIV patients admitted to the Emergency Department for clinical suspicion of infection and assess its association with in-hospital mortality. Methods: A retrospective analysis was conducted on febrile HIV-positive patients admitted to the Emergency Department. Clinical data were collected from 2018 to 2022. Patients were categorized based on PCT levels (>0.5 ng/dL), clinical findings, comorbidities, and viro-immunological status. Results: We investigated data from 289 HIV-positive patients (74% male). The median age of the sample was 54 years [IQR: 42-62], 100 (35%) patients presented detectable viremia, and the median value of CD4+ T lymphocytes was 358 [IQR: 104-531]. Elevated PCT levels (≥0.5 ng/dL) were detected in 69 (23.8%) patients. A significant association was observed between elevated PCT and increased mortality risk (p < 0.05). The mortality rate among patients with detectable HIV viremia was higher compared to those with undetectable viremia (p = 0.02). Moreover, deceased patients had statistically lower CD4+ values compared to survivors (61 [IQR: 14-186] vs. 370 [IQR: 136-548], p < 0.001). Conclusions: In febrile HIV patients admitted to the Emergency Department, elevated procalcitonin levels, low CD4+, and detectable viremia are associated with an increased risk of in-hospital mortality.

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.

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.

Conventional and unconventional T-cell responses contribute to the prediction of clinical outcome and causative bacterial pathogen in sepsis patients

Sepsis is characterized by a dysfunctional host response to infection culminating in life-threatening organ failure that requires complex patient management and rapid intervention. Timely diagnosis of the underlying cause of sepsis is crucial, and identifying those at risk of complications and death is imperative for triaging treatment and resource allocation. Here, we explored the potential of explainable machine learning models to predict mortality and causative pathogen in sepsis patients. By using a modelling pipeline employing multiple feature selection algorithms, we demonstrate the feasibility of identifying integrative patterns from clinical parameters, plasma biomarkers, and extensive phenotyping of blood immune cells. While no single variable had sufficient predictive power, models that combined five and more features showed a macro area under the curve (AUC) of 0.85 to predict 90-day mortality after sepsis diagnosis, and a macro AUC of 0.86 to discriminate between Gram-positive and Gram-negative bacterial infections. Parameters associated with the cellular immune response contributed the most to models predictive of 90-day mortality, most notably, the proportion of T cells among PBMCs, together with expression of CXCR3 by CD4+ T cells and CD25 by mucosal-associated invariant T (MAIT) cells. Frequencies of Vδ2+ γδ T cells had the most profound impact on the prediction of Gram-negative infections, alongside other T-cell-related variables and total neutrophil count. Overall, our findings highlight the added value of measuring the proportion and activation patterns of conventional and unconventional T cells in the blood of sepsis patients in combination with other immunological, biochemical, and clinical parameters.

Increasing Rate of Fatal Streptococcus pyogenes Bacteriemia-A Challenge for Prompt Diagnosis and Appropriate Therapy in Real Praxis

Streptococcus pyogenes, group A streptococci (GAS) bacteriaemia, is a life-threatening infection with high mortality, requiring fast diagnosis together with the use of appropriate antibiotic therapy as soon as possible. Our study analysed data from 93 patients with GAS bacteraemia at the General University Hospital in Prague between January 2006 and March 2024. In the years 2016-2019 there was an increase in GAS bacteraemia. Mortality in the period 2006-2019 was 21.9%; in the period 2020-2024, the mortality increased to 41.4%, p = 0.08. At the same time, in the post-2020 period, the time from hospital admission to death was reduced from 9.5 days to 3 days. A significant predictor of worse outcome in this period was high levels of procalcitonin, >35.1 µg/L (100% sensitivity and 82.35% specificity), and lactate, >5 mmol/L (90.91% sensitivity and 91.67% specificity). Myoglobin was a significant predictor in both compared periods, the AUC was 0.771, p = 0.044, and the AUC was an even 0.889, p ≤ 0.001, respectively. All isolates of S. pyogenes were susceptible to penicillin, and resistance to clindamycin was 20.3% from 2006-2019 and 10.3% in 2020-2024. Appropriate therapy was initiated in 89.1%. and 96.6%, respectively. We hypothesise that the increase in mortality after 2020 might be due to a decrease in the immune status of the population.

Elevated circulating PCSK9 level is associated with 28-day mortality in patients with sepsis: a prospective cohort study

OBJECTIVES

Pro-protein convertase subtilisin/kexin 9 (PCSK9) decreases the clearance of the pathogenic lipids, supporting the potential role of PCSK9 in the prognosis of sepsis.

METHODS

In this prospective cohort study, patients with sepsis were consecutively recruited from 1 to 2020 to 30 September 2021 at the First People's Hospital of Huaihua, China. All the eligible patients were categorized into low-PCSK9 and high-PCSK9 groups, based on their PCSK9 levels at admission. Time-dependent receiver operating characteristic curves and Cox proportional hazards regression were used to evaluate the association between PCSK9 level and 28-day mortality of sepsis.

RESULTS

Of the 203 enrolled patients, 56 (27.59%) died during the 28-day follow-up. The PCSK9 level was positively related to the C-reactive protein level. The cut-off point of PCSK9 levels for 28-day mortality risk was 370 ng/ml. Through comparison between high-PCSK9 (> 370 ng/ml) with low-PCSK9 (≤ 370 ng/ml) groups, the adjusted HR for mortality was 2.56 (95% CI: 1.25-5.23, p = 0.01).

CONCLUSIONS

The 28-day mortality of sepsis increased significantly as the baseline circulating PCSK9 level exceeded 370 ng/ml, indicating circulating PCSK9 levels may be a potential biomarker to predict the prognosis of sepsis.

Prognostic value of APTT combined with fibrinogen and creatinine in predicting 28-Day mortality in patients with septic shock caused by acute enteric perforation

BACKGROUND

Septic shock is one of the leading causes of mortality in intensive care units. This retrospective study was carried out to evaluate the association of clinical available factors with 28-day mortality.

PATIENTS AND METHOD

In this observational study, patients with perioperative septic shocks secondary to intra-abdominal infection caused by enteric perforation were included. A total of 328 sepsis patients were admitted to the surgical intensive care units from January 2012 to December 2016. A total of 138 patients met the enrolment criteria and were included in the study. The data of demographic, clinical and laboratory were all recorded.

RESULT

All these 138 patients received abdominal surgery prior to surgical intensive care units caused by acute enteric perforation. These patients were all met the diagnostic criteria of septic shock according to Sepsis-3. Statistical analysis showed that lactic acid, blood platelet, fibrinogen, creatinine and activated partial thromboplastin time were found to be associated with 28-day mortality. A combination of serum activated partial thromboplastin time combined with fibrinogen and creatinine could predict in-hospital 28-day mortality. The area under the curve of serum activated partial thromboplastin time combined with fibrinogen and creatinine is 0.875 (0.806-0.944).

CONCLUSION

In conclusion, this pilot study demonstrated that these factors can predict the prognosis of septic shock caused by enteric perforation. In order to reduce the mortality, surgeons and intensive care units physician may consider these data in perioperative period.

Biomarkers in sepsis-looking for the Holy Grail or chasing a mirage!

Sepsis is defined as a life-threatening organ dysfunction caused by the dysregulated host response to infection. It is a complex syndrome and is characterized by physiologic, pathologic and biochemical abnormalities in response to an infection. Diagnosis of sepsis is based on history, physical examination and other investigations (including biomarkers) which may help to increase the certainty of diagnosis. Biomarkers have been evaluated in the past for many diseases and have been evaluated for sepsis as well. Biomarkers may find a possible role in diagnosis, prognostication, therapeutic monitoring and anti-microbial stewardship in sepsis. Since the pathophysiology of sepsis is quite complex and is incompletely understood, a single biomarker that may be robust enough to provide all information has not been found as of yet. However, many biomarkers have been studied and some of them have applications at the bedside and guide clinical decision-making. We evaluated the PubMed database to search for sepsis biomarkers for diagnosis, prognosis and possible role in antibiotic escalation and de-escalation. Clinical trials, meta-analyses, systematic reviews and randomized controlled trials were included. Commonly studied biomarkers such as procalcitonin, Soluble urokinase-type plasminogen activator (Supar), presepsin, soluble triggering receptor expressed on myeloid cells 1, interleukin 6, C-reactive protein, etc., have been described for their possible applications as biomarkers in septic patients. The sepsis biomarkers are still an area of active research with newer evidence adding to the knowledge base continuously. For patients presenting with sepsis, early diagnosis and prompt resuscitation and early administration of anti-microbials (preferably within 1 h) and source control are desired goals. Biomarkers may help us in the diagnosis, prognosis and therapeutic monitoring of septic patients. The marker redefining our view on sepsis is yet a mirage that clinicians and researchers continue to chase.

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.

The predictive utility of cytokines, procalcitonin and C-reactive protein among febrile pediatric hematology and oncology patients with severe sepsis or septic shock

Severe sepsis and septic shock are life-threatening for pediatric hematology and oncology patient receiving chemotherapy. Th1/Th2 cytokines, C-reactive protein (CRP), and procalcitonin (PCT) are all thought to be associated with disease severity. The aim of this study was to prospectively verify the utility of Th1/Th2 cytokines and compare them with PCT and CRP in the prediction of adverse outcomes. Data on patients were collected from January 1, 2011, to December 31, 2020. Blood samples were taken for Th1/Th2 cytokine, CRP, and PCT measurements at the initial onset of infection. Severe infection (SI) was defined as severe sepsis or septic shock. Th1/Th2 cytokine levels were determined by using flow cytometric bead array technology. In total, 7,735 febrile episodes were included in this study. For SI prediction, the AUCs of IL-6, IL-10 and TNF-α were 0.814, 0.805 and 0.624, respectively, while IL-6 and IL-10 had high sensitivity and specificity. IL-6 > 220.85 pg/ml and IL-10 > 29.95 pg/ml had high odds ratio (OR) values of approximately 3.5 in the logistic regression. Within the subgroup analysis, for bloodstream infection (BSI) prediction, the AUCs of IL-10 and TNF-α were 0.757 and 0.694, respectively. For multiorgan dysfunction syndrome (MODS) prediction, the AUC of CRP was 0.606. The AUC of PCT for mortality prediction was 0.620. In conclusion, IL-6 and IL-10 provide good predictive value for the diagnosis of SI. For children with SI, IL-10 and TNF-α are associated with BSI, while CRP and PCT are associated with MODS and death, respectively.

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.

CGRP physiology, pharmacology, and therapeutic targets: migraine and beyond

Calcitonin gene-related peptide (CGRP) is a neuropeptide with diverse physiological functions. Its two isoforms (α and β) are widely expressed throughout the body in sensory neurons as well as in other cell types, such as motor neurons and neuroendocrine cells. CGRP acts via at least two G protein-coupled receptors that form unusual complexes with receptor activity-modifying proteins. These are the CGRP receptor and the AMY1 receptor; in rodents, additional receptors come into play. Although CGRP is known to produce many effects, the precise molecular identity of the receptor(s) that mediates CGRP effects is seldom clear. Despite the many enigmas still in CGRP biology, therapeutics that target the CGRP axis to treat or prevent migraine are a bench-to-bedside success story. This review provides a contextual background on the regulation and sites of CGRP expression and CGRP receptor pharmacology. The physiological actions of CGRP in the nervous system are discussed, along with updates on CGRP actions in the cardiovascular, pulmonary, gastrointestinal, immune, hematopoietic, and reproductive systems and metabolic effects of CGRP in muscle and adipose tissues. We cover how CGRP in these systems is associated with disease states, most notably migraine. In this context, we discuss how CGRP actions in both the peripheral and central nervous systems provide a basis for therapeutic targeting of CGRP in migraine. Finally, we highlight potentially fertile ground for the development of additional therapeutics and combinatorial strategies that could be designed to modulate CGRP signaling for migraine and other diseases.

Procalcitonin as prognostic factor in patients with Fournier’s gangrene

Introduction:

Fournier’s Gangrene (FG) has still a mortality rate up to 45%. Several studies identified prognostic factors but there is a knowledge gap concerning procalcitonin (PCT) levels and mortality risk in FG. This study is aimed to assess the role of PCT as prognostic factor in FG.

Materials and methods:

The medical records of 20 male FG patients admitted at the Department of Urology of “Cattinara” Hospital, University of Trieste between January 2019 and November 2020 were retrospectively reviewed. Clinical, demographic, microbiological data were collected. The Fournier’s Gangrene Severity Index (FGSI) was calculated for each patient.

Results:

Thirteen (65%) of 20 patients survived. Median age was 58 years (IQR 51–88), 15 patients (75%) had a Charlson Comorbidity Index (CCI) score ⩾2, 1 (5%) equal to 0, 4 to 1 (20%). Median FGSI score was 6 (IQR 2–12) and median PCT 0.8 ng/ml (IQR 0.04–2.12). At multivariate analysis PCT levels >0.05 ng/ml were associated with an increased overall mortality risk (OR 2.14, CI 1.25–4.27, p = 0.002). CCI score ⩾2 (OR 1.51, CI 1.01–2.59, p = 0.04), Streptococcical etiology (OR 3.41, CI 2.49–4.61, p = 0.002) and FGSI score >9 (OR 1.41, CI 1.19–2.21, p = 0.004) were associated with unfavorable outcome.

Conclusion:

PCT might be a prognostic factor in FG. CCI and FGSI are useful tools in mortality risk stratification. Streptococcical etiology is associated with unfavorable outcome. Further larger clinical trials are pending.

Current Status of Antibiotic Stewardship and the Role of Biomarkers in Antibiotic Stewardship Programs

The importance of antibiotic stewardship is increasingly emphasized in accordance with the increasing incidences of multidrug-resistant organisms and accompanying increases in disease burden. This review describes the obstacles in operating an antibiotic stewardship program (ASP), and whether the use of biomarkers within currently available resources can help. Surveys conducted around the world have shown that major obstacles to ASPs are shortages of time and personnel, lack of appropriate compensation for ASP operation, and lack of guidelines or appropriate manuals. Sufficient investment, such as the provision of full-time equivalent ASP practitioners, and adoption of computerized clinical decision systems are useful measures to improve ASP within an institution. However, these methods are not easy in terms of both time commitments and cost. Some biomarkers, such as C-reactive protein, procalcitonin, and presepsin are promising tools in ASP due to their utility in diagnosis and forecasting the prognosis of sepsis. Recent studies have demonstrated the usefulness of algorithmic approaches based on procalcitonin level to determine the initiation or discontinuation of antibiotics, which would be helpful in decreasing antibiotics use, resulting in more appropriate antibiotics use.

Predictive Value of Ionized Calcium for Prognosis of Sepsis in Very Low Birth Weight Infants

Purpose

Previous studies have shown that ionized calcium (iCa) is strongly correlated with critical illnesses, including sepsis. However, there are few studies on the association of iCa levels and sepsis in very low birth weight infants (VLBWI). Therefore, the aim of this study was to investigate the role of iCa in assessing the severity of sepsis and in predicting the prognosis of sepsis in VLBWI.

Patients and Methods

249 eligible VLBWI with sepsis were included in the present study and were divided into good and poor prognosis groups according to prognosis. We collected complete laboratory and clinical data. The lowest iCa measured during the first 24h from sepsis onset was recorded, and the Pediatric Risk of Mortality (PRISM III) score was calculated for each newborn.

Results

Neonatal mortality was higher in the hypocalcemia group (32.80% vs 12.80%, P < 0.001), and iCa levels were negatively correlated with PRISM III scores (r= −0.819, P < 0.001). The result of multiple logistic regression analysis showed that iCa was an independent predictor of poor prognosis (odds ratio [OR]= 0.558, 95% confidence interval [CI], 0.406–0.768, P < 0.001). Furthermore, our data demonstrated that iCa was also an independent predictor for the occurrence of death in VLBWI with sepsis who have a poor prognosis (OR= 0.659, 95% CI, 0.445–0.977, P =0.038). ROC curve analysis showed that iCa had good discriminatory power in predicting the poor prognosis (AUC=0.739, 95% CI, 0.664–0.813, P <0.001) in VLBWI with sepsis.

Conclusion

iCa levels correlate with the severity of sepsis and can be an independent predictor of poor prognosis in VLBWI with sepsis.

Regulation and Dysregulation of Endothelial Permeability during Systemic Inflammation

Systemic inflammation can be triggered by infection, surgery, trauma or burns. During systemic inflammation, an overshooting immune response induces tissue damage resulting in organ dysfunction and mortality. Endothelial cells make up the inner lining of all blood vessels and are critically involved in maintaining organ integrity by regulating tissue perfusion. Permeability of the endothelial monolayer is strictly controlled and highly organ-specific, forming continuous, fenestrated and discontinuous capillaries that orchestrate the extravasation of fluids, proteins and solutes to maintain organ homeostasis. In the physiological state, the endothelial barrier is maintained by the glycocalyx, extracellular matrix and intercellular junctions including adherens and tight junctions. As endothelial cells are constantly sensing and responding to the extracellular environment, their activation by inflammatory stimuli promotes a loss of endothelial barrier function, which has been identified as a hallmark of systemic inflammation, leading to tissue edema formation and hypotension and thus, is a key contributor to lethal outcomes. In this review, we provide a comprehensive summary of the major players, such as the angiopoietin-Tie2 signaling axis, adrenomedullin and vascular endothelial (VE-) cadherin, that substantially contribute to the regulation and dysregulation of endothelial permeability during systemic inflammation and elucidate treatment strategies targeting the preservation of vascular integrity.

Evaluation of qSOFA score, and conjugated bilirubin and creatinine levels for predicting 28‑day mortality in patients with sepsis

Sepsis is a dangerous disease that develops rapidly and has a high mortality rate. A timely and accurate assessment of the patient's condition is beneficial in improving prognosis and reducing mortality. Therefore, the present study was designed to investigate the potential association between quick sequential organ failure assessment (qSOFA) scores and biochemical indicators, such as conjugated bilirubin (CB) and creatinine levels, with the 28-day prognosis of patients with sepsis in a retrospective observational study. All cases were divided into survival and non-survival groups on the 28th day after diagnosis. The qSOFA scores, and CB and creatinine levels were significantly higher in the non-survival group than in the survival group (both P<0.01). Cox regression models identified CB [hazard ratio (HR), 1.006; P=0.002] and creatinine levels (HR, 1.002; P=0.024) as independent factors affecting 28-day mortality. The area under the curve (AUC) for CB and creatinine levels plus qSOFA score was 0.792 (95% confidence interval, 0.745-0.834), which was larger than the values for CB level, creatinine level and qSOFA score alone (all P<0.01) in the prognosis of 28-day mortality. The cut-off value of CB and creatinine levels plus qSOFA score for the 28-day mortality was 0.275 (-2.466 + 0.012 x CB + 0.002 x creatinine + 1.289 x qSOFA). Patients with lower combined predictor values had a better prognosis as demonstrated by Kaplan-Meier survival curves (log-rank test, 10.060; P=0.002). In both the septic shock and sepsis groups, the combined predictor value was higher in the non-survival group than in the survival group (P<0.001). Therefore, an increase in the combined predictor value of CB and creatinine levels plus qSOFA score may be an important predictor of disease progression and prognosis in patients with sepsis and septic shock.

Use of infection biomarkers in the emergency department

The use of infection biomarkers in the emergency department is discussed in terms of their possible contributions to diagnostic-prognostic uncertainties, appropriate antibiotic treatments, and triage and follow-up planning. Procalcitonin (PCT), C-reactive protein (CRP), proadrenomedullin (proADM), and presepsin are among the most discussed infection biomarkers for use in the emergency department. Due to the variable sensitivity results and cutoff values, there are insufficient data to recommend the widespread use of CRP and procalcitonin (PCT) for the diagnosis and prognosis of infection in the emergency department. However, these biomarkers can be used for appropriate antibiotic use in selected infection groups, such as community-acquired pneumonia, especially to reduce unnecessary antibiotic prescribing. With its prognostic superiority over other biomarkers and its contribution to prognostic score systems in community-acquired pneumonia (CAP), proADM can be used to predict hospitalization, preferably within the scope of clinical studies. Although presepsin has been shown to have some advantages over other biomarkers to rule out sepsis, there are insufficient data for its clinical use in the emergency department.

The Prognostic Value of Serum Soluble TREM-1 on Outcome in Adult Patients with Sepsis

Increased soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) levels have been reported in patients with sepsis. We tested the hypotheses that serum sTREM-1 levels increase in the early phase of sepsis and decrease after sepsis under appropriate treatment and that sTREM-1 levels can predict therapeutic outcomes. One hundred and fifty-five patients prospectively underwent blood samples including biochemical data, sTREM-1, and biomarkers on endothelial dysfunction as well as clinical severity index examinations. Blood samples from Days 1, 4, and 7 after admission were checked. For comparison, 50 healthy subjects were selected as healthy control. Those patients who had sepsis had significantly higher sTREM-1 levels than those of healthy control. sTREM-1 levels positively correlated with biomarkers for endothelial dysfunction (ICAM-1, VCAM-1, and E-selectin) and lactate level as well as clinical severity index (maximum 24 h APACHE score and Sequential Organ Failure Assessment (SOFA) score) upon admission. sTREM-1 concentrations were significantly higher from Day 1 to Day 7 in the non-survivors than in the survivors. A stepwise logistic regression analysis showed only sTREM-1 level and maximum 24 h SOFA score upon admission were significantly associated with fatality. Area under the receiver operating characteristic curve analysis for the diagnostic accuracy of sTREM-1 in sepsis-related fatality gave a value of 0.726, with a cutoff value of 384.6 pg/mL (sensitivity = 80.8% and specificity = 61.5%). sTREM-1 level may be valuable in auxiliary diagnosis, and it can serve as a useful biomarker as a screening service and follow-up therapeutic outcomes in sepsis.

Procalcitonin measurement in West Nile virus neuroinvasive disease: A first case series

West Nile virus neuroinvasive disease (WNV-NID) is challenging to diagnose. Procalcitonin (PCT) is a useful diagnostic test to identify bacterial infections. We present four cases of WNV-NID with serum PCT measurements.

METHODS

Daily (days 1-7) serum PCT (bioMérieux) was examined for critically ill patients with sepsis enrolled in a provincial sepsis study. Patients with identified WNV-NID are descriptively analyzed in this case series. PCT values of ≥0.5 ng/mL were suggestive of bacterial infection.

RESULTS

Four patients with WNV-NID were identified. Those with viral infections alone had consistently low PCT values ranging from 0.09 ng/mL to 0.34 ng/mL. Those with documented bacterial co-infections had initially elevated PCT levels that decreased by more than 50% with antimicrobial therapy.

CONCLUSION

These cases are the first to report serial PCT measurements in confirmed cases of WNV-NID and support a low serum PCT in WNV-NID.

Prognostic Value of Variations in Serum Biomarkers and Prognostic Scores Values Between Admission and Second Day in Intensive Care Unit Septic Patients

Objective To determinate the prognostic value of procalcitonin (PCT) and C-reactive protein (CRP) changes during the first two days of admission to the ICU with sepsis and/or septic shock, and to compare it with changes in Acute Physiology And Chronic Health Evaluation II (APACHE-II) and Sepsis-related Organ Failure Assessment (SOFA) prognostic scores. Methods A single-center prospective observational study was performed. Fifty consecutive patients admitted to the ICU, diagnosed of severe sepsis/septic shock were included. We considered risk factors for infection: diabetes mellitus, chronic obstructive pulmonary disease (COPD), previous antibiotic treatment, central intravascular catheter, bladder catheter, active neoplasia. Results Median aged 67(52-75) years with median APACHE-II 19(14-25) points and SOFA scores 7(5-11) points on admission, and 28-day mortality of 42%. When we studied the relationship between mortality and the changes between the day of admission and the second day of the variables studied, we found that APACHE-II (p = 0.001) and SOFA (p = 0.002) between admission and second day raised significantly in no survivors, with no significant changes in CRP and PCT. Multivariate analysis showed that mortality was significantly associated to changes in SOFA score (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.18-3.86) and to the presence of one or more risk factors for infection (OR, 6.01; 95% CI, 1.01-35.78) but not with PCT changes. Mortality was also related to the variations between the day of admission and the fifth day on APACHE-II (p = 0.002), SOFA (p < 0.001) and PCT (p = 0.012). Conclusions Changes in SOFA and APACHE-II scores between admission and second day in ICU septic patients are more sensitive mortality predictors than the observed changes in CRP and PCT values. Changes in PCT levels between the day of ICU admission and the fifth day are significantly related to mortality and may be useful as an additional marker in patient outcome.

Association between admission serum procalcitonin and the occurrence of acute kidney injury in patients with septic shock: A retrospective cohort study

BACKGROUND

Procalcitonin (PCT) is an effective and sensitive diagnostic biomarker that can facilitate the early detection of infection and septicemia, but whether it can similarly be utilized to predict the development of acute kidney injury (AKI) in patients suffering from septic shock remains to be established. Herein, the relationship between serum PCT at admission and the onset of AKI in septic shock patients was thus evaluated following adjustment for other potential covariates.

METHODS

This was a retrospective cohort study of 303 septic shock patients treated in a Chinese hospital between May 2015 and May 2019. All patients in whom PCT levels were measured on admission and who did not exhibit AKI or chronic kidney disease at the time of admission were assessed for AKI development within one week following intensive care unit (ICU) admission as per the KDIGO criteria. The relationship between serum PCT at admission and AKI incidence was then assessed for these patients.

RESULTS

These 303 patients were an average of 64 years old, and were 59.7% male. Of these patients, 50.5% developed AKI within the first 7 days following ICU admission. A dully-adjusted binary logistic regression analysis revealed PCT levels at admission to be associated with AKI following adjustment for potential confounding factors (odds ratio (OR) = 1.01, 95%CI (1.01,1.02), p = 0.0007). Receiver operating characteristic curve analysis further indicated that a PCT cutoff level of 52.59 ng/ml at admission was able to predict the incidence of AKI with respective sensitivity and specificity values of 50% and 84%. Interaction analysis revealed no significant interactive relationship between PCT and AKI, suggesting that serum PCT levels represent an early predictor of AKI incidence in septic shock patients.

CONCLUSIONS

Serum PCT at the time of admission can be used as a predictor of AKI in patients suffering from septic shock.

Prognostic Role of Serum Procalcitonin Measurement in Adult Patients Admitted to the Emergency Department with Fever

Background and Objectives. Fever is one of the most common presenting complaints in the Emergency Department (ED). This study aimed at evaluating the prognostic role of serum Procalcitonin (PCT) measurement among adult patients admitted to the ED with fever. Materials and Methods. This is a retrospective cross-sectional study including all consecutive patients admitted to ED with fever and subsequently hospitalized in a period of six-year (January 2014 to December 2019). Inclusion criteria were age > 18 years, fever (T ≥ 38 °C) or chills within 24 h from presentation to the ED as the main symptom, and availability of a PCT determination obtained <24 h since ED access. The primary endpoint was overall in-hospital mortality. Results. Overall, 6595 patients were included in the study cohort (3734 males, 55.6%), with a median age of 71 [58-81] years. Among these, based on clinical findings and quick sequential organ failure assessment (qSOFA), 422 were considered septic (36.2% deceased), and 6173 patients non-septic (16.2% deceased). After correction for baseline covariates, a PCT > 0.5 ng/mL was an independent risk factor for all-cause in-hospital death in both groups (HR 1.77 [1.27-2.48], and 1.80 [1.59-2.59], respectively). Conclusions. Among adult patients admitted with fever, the PCT assessment in ED could have reduced prognostic power for patients with a high suspicion of sepsis. On the other hand, it could be useful for sepsis rule-out for patients at low risk. In these latter patients, the prognostic role of PCT is higher for those with a final diagnosis of bloodstream infection.

The Prognostic Value of Presepsin for Sepsis in Abdominal Surgery: A Prospective Study

INTRODUCTION

Rapid diagnosis accompanied by appropriate treatment is essential in the therapy of sepsis. However, there is no blood marker available, which reliably predicts sepsis and associated mortality. Therefore, the aim of the present study was to evaluate presepsin and endotoxin in comparison with established blood markers in patients undergoing emergency visceral surgery for abdominal infection.

PATIENTS AND METHODS

This prospective study included 31 patients with abdominal infection undergoing emergency surgery between March and August 2014. The Sepsis-2 and Sepsis-3 definitions of sepsis were used. Blood markers (presepsin, endotoxin, C-reactive protein, procalcitonin (PCT), interleukin 6 (IL-6), white blood count) were analyzed preoperatively and correlated with the clinical course and mortality. Additionally, a combination of the three markers, which performed best, was tested.

RESULTS

Twenty patients (64.5%) in the analyzed cohort developed sepsis from an abdominal focus according to the latest sepsis definition. Out of the analyzed blood markers, presepsin exhibited the highest area under the curve, sensitivity, and specificity for the prediction of the development of sepsis. Moreover, presepsin had the highest predictive value for mortality as opposed to both endotoxin and previously established blood markers (i.e., PCT, IL-6). The multimarker approach, which included PCT, IL-6, and presepsin, showed no additional predictive value over presepsin alone.

CONCLUSION

The present study suggests that presepsin is a novel predictor of sepsis and mortality from sepsis in patients undergoing surgery for intra-abdominal infections. The findings of the present study should be validated in a larger cohort.

Perioperative management after elective cardiac surgery: the predictive value of procalcitonin for infective and noninfective complications

Objective: Procalcitonin (PCT) has been associated with adverse outcomes after cardiac surgery. Nevertheless, there is no consensus on thresholds and timing of PCT measurement to predict adverse outcomes. Materials & methods: A total of 960 patients undergoing elective cardiac surgery were retrospectively evaluated. PCT levels were measured from the first to the seventh postoperative day (POD). The onset of complications was recorded. Results: Complications occurred in 421 (44%) patients. PCT on the third POD was associated with the occurrence of any kind of complications (odds ratio: 1.06; p: 0.037), and noninfectious complications (odds ratio: 1.05; p: 0.035), after adjusting. PCT above the median value at the third POD (>0.33 μg/l) predicted postoperative complications (incidence rate ratio: 1.13; p = 0.035). Conclusion: PCT seems to predict postoperative complications in cardiac surgery. The determination at the third POD yields the greatest sensitivity and specificity.

Effects of Neutrophil-to-Lymphocyte Ratio Combined With Interleukin-6 in Predicting 28-Day Mortality in Patients With Sepsis

Background

The current study aimed to evaluate the relationship between the neutrophil-to-lymphocyte ratio (NLR) combined with interleukin (IL)-6 on admission day and the 28-day mortality of septic patients.

Material and Methods

We conducted an observational retrospective study. Patients with presumed sepsis were included. We observed the correlation of studied biomarkers (NLR, IL-6, PCT, and CRP) and the severity scores (APACHE II and SOFA scores) by plotting scatter plots. The relationships of the studied biomarkers and 28-day mortality were evaluated by using Cox regression model, receiver-operating characteristic (ROC) curve, and reclassification analysis.

Results

A total of 264 patients diagnosed with sepsis were enrolled. It was revealed that IL-6 had the strongest correlation with both APACHE II and SOFA scores, followed by the NLR and PCT, and there was no obvious correlation between CRP and the illness severity. NLR and IL-6 were independent predictors of the 28-day mortality in septic patients in the Cox regression model [NLR, odds ratio 1.281 (95% CI 1.159-1.414), P < 0.001; IL-6, odds ratio 1.017 (95% CI 1.005-1.028), P=0.004]. The area under the ROC curve (AUC) of NLR, IL-6 and NLR plus IL-6 (NLR_IL-6) was 0.776, 0.849, and 0.904, respectively.

Conclusion

Our study showed that the levels of NLR and IL-6 were significantly higher in the deceased patients with sepsis. NLR and IL-6 appeared to be independent predictors of 28-day mortality in septic patients. Moreover, NLR combined with IL-6 could dramatically enhance the prediction value of 28-day mortality.

Circulating Neutrophil-Derived Microparticles Associated with the Prognosis of Patients with Sepsis

Introduction

Because of its high morbidity and mortality, sepsis remains the leading cause of death in the ICU. Microparticles (MP) have been largely studied as potential diagnostic or prognostic markers in various diseases including sepsis.

Objective

The biological and clinical relevance of neutrophil-derived microparticles (NDMPs) within the MP population remains unclear. The objective of this study was to elucidate the relationship between plasma NDMPs and the prognosis of patients with sepsis and/or septic shock.

Methods

The study was designed as an observational, noninterventional clinical study. The cohort for this study included 40 sepsis and 40 septic shock patients together with 10 healthy controls admitted to the Intensive Care Unit (ICU) and the Health Surveillance Center in the Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China, from January to November 2018, respectively. The degree of critical disease for sepsis and septic shock was evaluated, with data analyses conducted from 2018 to 2019.

Results

On days 1, 3 and 5 post-admission a series of data including plasma NDMP levels, patient demographics, TNF-α levels, IL-6 levels, sTREM-1 levels, and the sepsis severity score measurements were collected. A survival curve was plotted against levels of plasma NDMPs. Levels of NDMPs were observed to be higher in the septic shock patients than in the sepsis patients on days 1, 3, and 5 post-ICU admission (p < 0.05). NDMP levels were significantly increased in sepsis and septic shock patients with a parallel increase in pro-inflammatory mediators and sepsis severity score (p < 0.05) as well as mortality.

Conclusion

Our data suggest that NDMPs may be a biomarker of sepsis severity and mortality although its implications on sepsis prognosis warrant further study.

Prognostic value of plasma pentraxin 3 levels in patients with septic shock admitted to intensive care

Objective

To evaluate the usefulness of a new marker, pentraxin, as a prognostic marker in septic shock patients.

Materials and methods

Single-centre prospective observational study that included all consecutive patients 18 years or older who were admitted to the intensive care unit (ICU) with septic shock. Serum levels of procalcitonin (PCT), C-reactive protein (CRP) and pentraxin (PTX3) were measured on ICU admission.

Results

Seventy-five septic shock patients were included in the study. The best predictors of in-hospital mortality were the severity scores: SAPS II (AUC = 0.81), SOFA (AUC = 0.79) and APACHE II (AUC = 0.73). The ROC curve for PTX3 (ng/mL) yielded an AUC of 0.70, higher than the AUC for PCT (0.43) and CRP (0.48), but lower than lactate (0.79). Adding PTX3 to the logistic model increased the predictive capacity in relation to SAPS II, SOFA and APACHE II for in-hospital mortality (AUC 0.814, 0.795, and 0.741, respectively). In crude regression models, significant associations were found between in-hospital mortality and PTX3. This positive association increased after adjusting for age, sex and immunosuppression: adjusted OR T3 for PTX3 = 7.83, 95% CI 1.35–45.49, linear P trend = 0.024.

Conclusion

Our results support the prognostic value of a single determination of plasma PTX3 as a predictor of hospital mortality in septic shock patients.

Early Differential Value of Plasma Presepsin on Infection of Trauma Patients

OBJECTIVE

Early differential diagnosis of an infection in a trauma patient is likely to have a significant influence on the prognosis. In the present study, we evaluated the early differential value of plasma presepsin, procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBCs) on infection in trauma patients.

METHODS

Trauma patients were divided into noninfected (n = 89) and infected trauma groups (n = 68); healthy adult volunteers (n = 60) and patients having sterile surgery (n = 60) were enrolled as the controls. Plasma presepsin, PCT, CRP, and WBC counts were measured and the injury severity score (ISS) was calculated.

RESULTS

Plasma presepsin levels within the first 3 d of admission were only significantly increased in the infected trauma group, but not in the noninfected trauma and sterile groups. This indicated that presepsin might have an ability to differentiate the infection in trauma patients; however, plasma PCT, CRP, and WBCs were significantly increased in both the infected and noninfected trauma patients. Binary logistic regression analysis showed that only increased plasma presepsin, PCT, and ISS were significantly associated with an increased likelihood of infection in trauma patients. Both presepsin and PCT were valuable for diagnosing infection; presepsin had a higher area under the curve than PCT.

CONCLUSION

Presepsin might be a superior biomarker for early differentiation of infection in trauma patients; however, trauma stress elevates PCT, CRP, and WBCs even in the absence of infection; therefore, caution is advised when using these indicators to diagnose infection.

Utility of Procalcitonin as a Biomarker for Sepsis in Children

Sepsis is a complex process defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. It is associated with significant morbidity and mortality rates in both adults and children, and emphasis has been placed on its early recognition and prompt provision of antimicrobials. Owing to limitations of current diagnostic tests (i.e., poor sensitivity and delayed results), significant research has been conducted to identify sepsis biomarkers. Ideally, a biomarker could reliably and rapidly distinguish bacterial infection from other, noninfectious causes of systemic inflammatory illness. In doing so, a sepsis biomarker could be used for earlier identification of sepsis, risk stratification/prognostication, and/or guidance of antibiotic decision-making. In this minireview, we review one of the most common clinically used sepsis biomarkers, procalcitonin, and its roles in sepsis management in these three areas. We highlight key findings in the adult literature but focus the bulk of this review on pediatric sepsis. The challenges and limitations of procalcitonin measurement in sepsis are also discussed.

Biomarker combination and SOFA score for the prediction of mortality in sepsis and septic shock: A prospective observational study according to the Sepsis-3 definitions

Biomarkers are valuable tools for the prediction of mortality in patients with sepsis. However, the use of a single biomarker to predict patient outcomes is challenging owing to the complexity and redundancy of the immune response to infections.We aimed to conduct a prospective observational analysis to investigate the prognostic value of pentraxin 3, interleukin 6, procalcitonin, and lactate combined in predicting the 28-day mortality rate in patients with sepsis or septic shock (n = 160; sepsis, 78; sepsis shock, 82). Two methods (the frequency sum of values above the cutoff, and the multivariate logistic regression model) were used to assess the prognostic value of the biomarker combination.In the receiver operating characteristic curve analyses, the combination of the 4 biomarkers was better than the Sequential Organ Failure Assessment (SOFA) score in predicting the 28-day mortality rate, regardless of whether the frequency sum of values above the cutoff or the multivariate logistic model was used for the analysis. The addition of the SOFA score to the biomarker combination did not result in a better performance for the prediction of mortality.The combined biomarker approach showed good performance in predicting 28-day all-cause mortality among patients diagnosed with either sepsis or septic shock according to the Sepsis-3 definitions. Furthermore, it was superior to the SOFA score in predicting mortality.

Calprotectin is superior to procalcitonin as a sepsis marker and predictor of 30-day mortality in intensive care patients

Sepsis is the most frequent cause of death in the intensive care unit (ICU). A rapid and correct diagnosis and initiation of therapy is crucial for improving patient outcomes. The aim of this study was to compare the performance of calprotectin with the more widely used sepsis biomarker procalcitonin (PCT) in ICU patients. The performance of calprotectin and PCT as sepsis and prognostic markers for 30-d mortality was compared in a prospective, observational study in an eight-bed ICU. We investigated concentrations of the biomarkers in plasma collected at admission from all ICU patients admitted during a year (2012-2013, n = 271) together with simplified acute physiology 3 scores (SAPS3) and sequential organ failure assessment (SOFA) scores. The receiver operating characteristic (ROC) analysis showed a higher area under the curve (AUC) value for calprotectin (0.79) than for PCT (0.49) when used as a sepsis marker. The calprotectin concentrations at admission were higher in non-survivors than in survivors at day 30. In our study, calprotectin was superior to PCT for distinguishing between ICU patients with sepsis and non-sepsis patients. Calprotectin also had higher predictive ability regarding 30-d mortality.

Prediction of mortality in adult patients with sepsis using six biomarkers: a systematic review and meta-analysis

Background

Angiopoietin-1 (Ang-1) and 2 (Ang-2), high mobility group box 1 (HMGB1), soluble receptor for advanced glycation endproducts (sRAGE), soluble triggering receptor expressed on myeloid cells 1 (sTREM1), and soluble urokinase-type plasminogen activator receptor (suPAR) have shown promising results for predicting all-cause mortality in critical care patients. The aim of our systematic review and meta-analysis was to assess the prognostic value of these biomarkers for mortality in adult patients with sepsis.

Methods

A systematic literature search of the MEDLINE, PubMed, EMBASE, and Cochrane Library databases, for articles in English published from 01.01.1990 onwards, was conducted. The systematic review focused exclusively on observational studies of adult patients with sepsis, any randomized trials were excluded. For the meta-analysis, only studies which provide biomarker concentrations within 24 h of admission in sepsis survivors and nonsurvivors were included. Results are presented as pooled mean differences (MD) between nonsurvivors and survivors with 95% confidence interval for each of the six biomarkers. Studies not included in the quantitative analysis were narratively summarized. The risk of bias was assessed in all included studies using the Quality in Prognosis Studies (QUIPS) tool.

Results

The systematic literature search retrieved 2285 articles. In total, we included 44 studies in the qualitative analysis, of which 28 were included in the meta-analysis. The pooled mean differences in biomarker concentration (nonsurvivors − survivors), measured at onset of sepsis, are listed as follows: (1) Ang-1: − 2.9 ng/ml (95% CI − 4.1 to − 1.7, p < 0.01); (2) Ang-2: 4.9 ng/ml (95% CI 2.6 to 7.1, p < 0.01); (3) HMGB1: 1.2 ng/ml (95% CI 0.0 to 2.4, p = 0.05); (4) sRAGE: 1003 pg/ml (95% CI 628 to 1377, p < 0.01); (5) sTREM-1: 87 pg/ml (95% CI 2 to 171, p = 0.04); (6) suPAR: 5.2 ng/ml (95% CI 4.5 to 6.0, p < 0.01).

Conclusions

Ang-1, Ang-2, and suPAR provide beneficial prognostic information about mortality in adult patients with sepsis. The further development of standardized assays and the assessment of their performance when included in panels with other biomarkers may be recommended.

Trial registration This study was recorded on PROSPERO, prospective register of systematic reviews, under the registration ID: CRD42018081226

The Pathogenesis of Sepsis and Potential Therapeutic Targets

Sepsis is defined as “a life-threatening organ dysfunction caused by a host’s dysfunctional response to infection”. Although the treatment of sepsis has developed rapidly in the past few years, sepsis incidence and mortality in clinical treatment is still climbing. Moreover, because of the diverse manifestations of sepsis, clinicians continue to face severe challenges in the diagnosis, treatment, and management of patients with sepsis. Here, we review the recent development in our understanding regarding the cellular pathogenesis and the target of clinical diagnosis of sepsis, with the goal of enhancing the current understanding of sepsis. The present state of research on targeted therapeutic drugs is also elaborated upon to provide information for the treatment of sepsis.

Prognostic performance of pancreatic stone protein in critically ill patients with sepsis

Aim: To assess the prognostic value for 28-day mortality of PSP in critically ill patients with sepsis. Material & methods: 122 consecutive patients with sepsis were enrolled in this study. Blood samples were collected on admission and day 2. Results: On admission, the combination of PSP and lactate achieved an area under the receiver operating characteristic (AUC-ROC) of 0.796, similar to sequential organ failure assessment score alone (AUC-ROC: 0.826). On day 2, PSP was the biomarker with the highest performance (AUC-ROC: 0.844), although lower (p = 0.041) than sequential organ failure assessment score (AUC-ROC: 0.923). Conclusion: The combination of PSP and lactate and PSP alone, on day 2, have a good performance for prognosis of 28-day mortality and could help to identify patients who may benefit most from tailored intensive care unit management.

Procalcitonin as a prognostic marker for sepsis based on SEPSIS-3

BACKGROUND

The revised definition of sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (SEPSIS-3). The objective of this study was to evaluate procalcitonin (PCT) for the diagnosis and prognosis of sepsis using SEPSIS-3.

METHODS

We enrolled 248 patients, who were admitted to the emergency department with suspected bacterial infection from June 2016 to February 2017. Definite bacterial infection was defined by proven culture results, and probable bacterial infection was based on diagnostic modalities other than culture. The sequential organ failure assessment (SOFA) score of 2 points or more from the baseline was diagnosed as sepsis. PCT was measured by the AFIAS-6 immunoassay system (Boditech Med Inc.) using whole blood. White blood cell (WBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ERS) were evaluated.

RESULTS

The final diagnosis was sepsis in 185 patients with infection of respiratory and genitourinary tract constituted 84.6%. The area under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) was as follows: PCT, 0.682 (0.589-0.765); CRP, 0.583 (0.487-0.673); ESR, 0.540 (0.515-0.699); and WBC, 0.611 (0.455-0.633), respectively. In multivariate analysis, age, SOFA, and PCT (log scale) predicted non-survivors with an odds ratio with 95% confidence interval of 1.055 (1.008-1.105), 1.303 (1.142-1.486), and 2.004 (1.240-3.238), respectively. Among sepsis group, initial PCT was increased in non-survivor (23.2 ng/dL) compared to survivor group (8.1 ng/dL) with statistical significance (P = .005).

CONCLUSIONS

PCT could support and predict the unfavorable prognosis of sepsis based on SEPSIS-3, whereas diagnostic potential of PCT requires further evaluations.

Procalcitonin Clearance at 24, 48, 72, and 96 Hours and Mortality in Patients With Cancer and Sepsis: A Retrospective Cohort Study

INTRODUCTION

Previous studies have evaluated procalcitonin clearance (PCTc) as a marker of sepsis severity but at different time points and cutoffs. We aimed to assess the predictive performance of PCTc at different time points of sepsis management in patients with cancer.

METHODS

This retrospective cohort study included patients with cancer admitted to an intensive care unit between 2013 and 2016. We calculated PCTc at 24, 48, 72, and 96 hours after admission. Its predictive performance for hospital and 90-day mortality was analyzed with receiver operating characteristic curves and areas under the curves (AUCs). Sensitivity and specificity were calculated for different time points using different cutoffs.

RESULTS

We included 301 patients. Areas under the curves ranged from 0.62 for PCTc at 24 hours to 0.68 for PCTc at 72 and 96 hours for hospital mortality prediction, and from 0.61 for PCTc at 24 hours to 0.68 for PCTc at 72 hours for 90-day mortality prediction. For hospital mortality prediction, PCTc at 72 hours ≤80% showed the best sensitivity (96.0%; 95% confidence interval [CI]: 90.8%-98.7%), and PCTc at 96 hours ≤50% showed the best specificity (70.7%; 95% CI: 54.5%-83.9%).

CONCLUSIONS

Procalcitonin clearance at 24, 48, 72, and 96 hours poorly predicted hospital and 90-day mortality. Therefore, daily PCT measurement should not be used to predict mortality for patients with cancer and sepsis.

[Clinical value of blood lactate in predicting the prognosis of neonatal sepsis]

OBJECTIVE

To explore the clinical value of arterial blood lactate level in predicting the prognosis of neonatal sepsis.

METHODS

The clinical data of 301 cases of neonatal sepsis were collected, which mainly included biochemical indicators such as blood lactate on admission, C-reactive protein, and procalcitonin. ROC curves were plotted to evaluate the value of lactate level on admission in predicting the prognosis of neonatal sepsis.

RESULTS

The mortality rate was significantly higher for full-term infants in the severely-elevated lactate group than in the mildly-elevated lactate group and the normal lactate group (26.1% vs 3.1% and 0%; P<0.017). The poor prognosis group had a significantly increased lactate level on admission compared with the good prognosis group (6.5±5.1 mmol/L vs 3.6±1.7 mmol/L; P<0.05). The sensitivity and specificity of blood lactate level on admission (cutoff value: 6.15 mmol/L) were 0.545 and 0.919 respectively, in predicting the prognosis of neonatal sepsis.

CONCLUSIONS

Early blood lactate level can be used as a biochemical parameter to predict the prognosis of neonatal sepsis as it has a high specificity but a low sensitivity.

The accuracy assessment of presepsin (sCD14-ST) for mortality prediction in adult patients with sepsis and a head-to-head comparison to PCT: a meta-analysis

Objective: The soluble cluster of differentiation 14 subtype (sCD14-ST) or presepsin has recently been identified as a promising biomarker in sepsis. The present meta-analysis is performed to assess the prognostic value of presepsin in septic patients. Further, we compare the prognostic performance between presepsin and procalcitonin (PCT) in predicting all-cause mortality in these patients.

Methods: A systemic and comprehensive search was conducted in PubMed, Embase and Cochrane databases by using Exploded Medical Subject Headings and appropriate corresponding keywords. Studies were eligible if they assessed the prognostic value of presepsin in sepsis and provided sufficient information to construct a 2×2 contingency table. A bivariate meta-analysis model was used to calculate the pooled sensitivity, specificity, positive/negative likelihood ratios and diagnostic odds ratio. The Chi-square and I² index were used to assess the heterogeneity and inconsistency. The Deek’s funnel plot asymmetry test was used to assess the likelihood of publication bias.

Results: Nine publications, comprising 1,561 patients, were included in this study. The overall area under the receiver operating characteristic curve (AUROC) of presepsin was 0.77 (95% CI, 0.73–0.81) with a pooled prognostic sensitivity (SEN) and specificity (SPE) of 0.83 (95% CI, 0.72–0.90) and 0.69 (95% CI, 0.63–0.74), respectively. Additionally, the PLR, NLR and DOR of presepsin were 2.6 (95% CI, 2.1–3.3), 0.25 (95% CI, 0.15–0.44) and 10 (95% CI, 5–22), respectively. The AUROC of PCT was 0.81 (95% CI, 0.78–0.84) with a pooled SEN of 0.76 (95% CI, 0.55–0.89) and SPE of 0.74 (95% CI, 0.33–0.94). There is no statistically significant difference in the performance of pooled SEN and SPE between presepsin and PCT, with a p value of 0.39 and 0.71, respectively.

Conclusions: Based on the results of this meta-analysis, both presepsin and PCT are promising biomarkers for the prognosis of mortality in sepsis.

Procalcitonin: Between evidence and critical issues

Sepsis is a life-threatening organ dysfunction caused by a dysregulated response of the host to infection. It represents one of the major health care problems worldwide. Unfortunately, the diagnosis of sepsis is challenging for many reasons, including a lack of a sufficiently sensitive and specific diagnostic test. When procalcitonin (PCT) was discovered, it was thought that it could become the best test for identifying patients with sepsis. From the evidence sources in the available literature, it is now clear that the power of PCT in differentiating infectious from non-infectious forms of systemic inflammatory response syndrome in adults, and in stratifying morbidity and mortality risk, is limited. Nevertheless, PCT determination can be a useful tool for diagnosing late-onset neonatal sepsis, bacterial meningitis and other forms of organ-related bacterial infections and, above all, it can be used for guiding antibiotic stewardship in critical patients. The real impact of this application of PCT testing, however, still needs to be clearly defined. Laboratories should offer unrestricted PCT testing only to intensive care units (as an aid in decision for continuing or stopping antibiotics) and pediatric wards. For all other clinical wards, the laboratory should guide PCT requests and give them support towards the most appropriate approach to testing.

The usefulness of C-reactive protein and procalcitonin to predict prognosis in septic shock patients: A multicenter prospective registry-based observational study

The objective of this study was to evaluate the prognostic value of C-reactive protein (CRP), procalcitonin (PCT), and their combination for mortality in patients with septic shock. This multicenter, prospective, observational study was conducted between November 2015 and December 2017. A total of 1,772 septic shock patients were included, and the overall 28-day mortality was 20.7%. Although both CRP and PCT were elevated in the non-survivor group, only CRP had statistical significance (11.9 mg/dL vs. 14.7 mg/dL, p = 0.003, 6.4 ng/mL vs. 8.2 ng/mL, p = 0.508). Multivariate analysis showed that CRP and PCT were not independent prognostic markers. In the subgroup analysis of the CRP and PCT combination matrix using their optimal cut-off values (CRP 14.0 mg/dL, PCT 17.0 ng/dL), both CRP and PCT elevated showed significantly higher mortality (Odds ratio 1.552 [95% Confidence intervals 1.184-2.035]) than both CRP and PCT not elevated (p = 0.001) and only PCT elevated (p = 0.007). However, both CRP and PCT elevated was also not an independent predictor in multivariate analysis. Initial levels of CRP and PCT alone and their combinations in septic shock patients had a limitation to predict 28-day mortality. Future research is needed to determine new biomarkers for early prognostication in patients with septic shock.

Evaluation of a novel prognostic score based on thrombosis and inflammation in patients with sepsis: a retrospective cohort study

BACKGROUND

Inflammation and thrombosis are involved in the development and progression of sepsis. A novel thrombo-inflammatory prognostic score (TIPS), based on both an inflammatory and a thrombus biomarker, was assessed for its ability to predict adverse outcomes of sepsis patients in the emergency department (ED).

METHODS

This was a retrospective cohort study of sepsis patients. TIPS (range: 0-2) was predictive of adverse outcomes. Multivariable logistic regression analyses were performed to investigate the associations between TIPS and 28-day adverse outcomes. The study end points were mortality, mechanical ventilation (MV), consciousness disorder (CD) and admission to the intensive care unit (AICU).

RESULTS

In total, 821 sepsis patients were enrolled; 173 patients died within the 28-day follow-up period. Procalcitonin and D-dimer values were used to calculate TIPS because they had the best performance in the prediction of 28-day mortality by receiver operating characteristic curves. The 28-day mortality and the incidence of MV, CD and AICU were significantly higher in patients with higher TIPS. Multivariable logistic regression analysis indicated TIPS was an independent predictor of 28-day mortality, MV and AICU. TIPS performed better than other prognostic scores, including quick sequential organ failure assessment, Modified Early Warning Score and Mortality in Emergency Department Sepsis Score for predicting 28-day mortality, and similar to the Acute Physiology and Chronic Health Evaluation II, but inferior to sequential organ failure assessment.

CONCLUSIONS

TIPS is useful for stratifying the risk of adverse clinical outcomes in sepsis patients shortly after admission to the ED.

A Novel Combination of Biomarkers to Herald the Onset of Sepsis Prior to the Manifestation of Symptoms

Sepsis, which kills over 200,000 patients and costs over $20 billion in the United States alone, presents a constant but preventable challenge in the healthcare system. Among the more challenging problems that it presents is misdiagnosis due to conflation with other inflammatory processes, as its mechanisms are identical to those of other inflammatory states. Unfortunately, current biomarker tests can only assess the severity and mortality risk of each case, whereas no single test exists that can predict sepsis prior to the onset of symptoms for the purpose of pre-emptive care and monitoring. We propose that a single test utilizing three, rather than two, biomarkers that appear most quickly in the blood and are the most specific for sepsis rather than trauma, may improve diagnostic accuracy and lead to lessened patient morbidity and mortality. Such a test would vastly improve patient outcomes and quality of life, prevent complications for sepsis survivors, and prevent hospital readmissions, saving the American healthcare system money. This review summarizes the current use of sepsis biomarkers to prognosticate morbidity and mortality, and rejects the current single-biomarker and even combination biomarker tests as non-specific and inaccurate for current patient needs/pro-inflammatory cytokines, general markers of inflammation, and proteins specific to myeloid cells (and therefore to infection) are discussed. Ultimately, the review suggests a three-biomarker test of procalcitonin (PCT), interleukin-6 (IL-6), and soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) to diagnose sepsis before the onset of symptoms.

Sepsis: The evolution in definition, pathophysiology, and management

There has been a significant evolution in the definition and management of sepsis over the last three decades. This is driven in part due to the advances made in our understanding of its pathophysiology. There is evidence to show that the manifestations of sepsis can no longer be attributed only to the infectious agent and the immune response it engenders, but also to significant alterations in coagulation, immunosuppression, and organ dysfunction. A revolutionary change in the way we manage sepsis has been the adoption of early goal-directed therapy. This involves the early identification of at-risk patients and prompt treatment with antibiotics, hemodynamic optimization, and appropriate supportive care. This has contributed significantly to the overall improved outcomes with sepsis. Investigation into clinically relevant biomarkers of sepsis are ongoing and have yet to yield effective results. Scoring systems such as the sequential organ failure assessment and Acute Physiology and Chronic Health Evaluation help risk-stratify patients with sepsis. Advances in precision medicine techniques and the development of targeted therapy directed at limiting the excesses of the inflammatory and coagulatory cascades offer potentially viable avenues for future research. This review summarizes the progress made in the diagnosis and management of sepsis over the past two decades and examines promising avenues for future research.

Endotoxins and the importance of procalcitonin

Gram-negative bacilli and cocci bacteria produce and release endotoxins, which are lipopolysaccharides found in the outer membrane of the cell wall. These endotoxins are responsible for releasing a series of inflammatory mediators such as IL1, TNFα and proteases, as well as lipid mediators such as prostaglandins, leukotrienes, thromboxanes and platelet-activating factor, ultimately activitating immune response cells like leukocytes, macrophages and platelets. These cells amplify the response to shock, generate a procoagulant state and produce alterations at the cellular level, for example, damage to the endothelium, which in the end benefit and worsen the state of septic shock (Figure 1).

Matrix Metalloproteinase-9 and Tissue Inhibitor of Matrix Metalloproteinase-1 in Sepsis after Major Abdominal Surgery

Background

The role of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) in sepsis after major abdominal surgery and sepsis-associated organ dysfunction is unexplored.

Materials and Methods

Fifty-three patients with sepsis after major abdominal surgery were compared to 50 operated and 50 nonoperated controls. MMP-9, TIMP-1, biomarkers of inflammation, kidney and liver injury, coagulation, and metabolic disorders were measured daily during 96 h following diagnosis of sepsis and once in controls. MMP-9/TIMP-1 ratios and disease severity scores were calculated. Use of vasopressors/inotropes, mechanical ventilation, and survival were recorded.

Results

Septic patients had lower MMP-9 and MMP-9/TIMP-1 ratios but higher TIMP-1 levels compared to controls. AUC-ROC for diagnosis of sepsis was 0.940 and 0.854 for TIMP-1 and 0.924 and 0.788 for MMP-9/TIMP-1 ratio (sepsis versus nonoperated and sepsis versus operated controls, resp.). Lower MMP-9 and MMP-9/TIMP-1 ratio and higher TIMP-1 levels were associated with shorter survival. MMP-9, TIMP-1, and MMP-9/TIMP-1 ratio correlated with biomarkers of inflammation, kidney and liver injury, coagulation, metabolic disorders, and disease severity scores. Use of vasopressors/inotropes was associated with higher TIMP-1 levels.

Conclusions

MMP-9, TIMP-1, and MMP-9/TIMP ratio were good diagnostic or prognostic biomarkers of sepsis after major abdominal surgery and were linked to sepsis-associated organ dysfunction.

Prognostic value of presepsin in adult patients with sepsis: Systematic review and meta-analysis

Objective

Presepsin is a novel biomarker to diagnose sepsis but its prognostic value has not been comprehensively reviewed. We conducted this meta-analysis to evaluate the mortality prediction value of presepsin in sepsis.

Methods

We searched comprehensive electronic databases from PubMed, EMBASE, and Cochrane Library through September 2017 using the key words of (‘presepsin’ or ‘sCD14-ST’ or ‘soluble CD14 subtype’) and (‘sepsis’ or ‘septic shock’) and (‘prognosis’ or ‘prognostic value’ or ‘prognostic biomarker’ or ‘mortality’). We extracted the presepsin levels in survivors and non-survivors from each individual study and evaluated the standardized mean difference (SMD) using a web-based meta-analysis with the R statistical analysis program.

Results

A total of 10 studies and 1617 patients were included. Presepsin levels in the first sampling (within 24 hours) were significantly lower among survivors as compared with non-survivors: the pooled SMD between survivors and non-survivors was 0.92 (95% CI: 0.62–1.22) in the random effects model (I² = 79%, P< 0.01). In subgroups, divided by the sepsis severity or study site, pooled SMD was consistently noting higher presepsin levels in non-survivals (P< 0.05).

Conclusion

This meta-analysis demonstrates some mortality prediction value in presepsin in patients with sepsis. Further studies are needed to define the optimal cut-off point to predict mortality in sepsis.

Novel biomarkers for sepsis: A narrative review

BACKGROUND

Sepsis is a prevalent condition among hospitalized patients that carries a high risk of morbidity and mortality. Rapid recognition of sepsis as the cause of deterioration is desirable, so effective treatment can be initiated rapidly. Traditionally, diagnosis was based on presence of two or more positive SIRS criteria due to infection. However, recently published sepsis-3 criteria put more emphasis on organ dysfunction caused by infection in the definition of sepsis. Regardless of this, no gold standard for diagnosis exist, and clinicians still rely on a number of traditional and novel biomarkers to discriminate between patients with and without infection, as the cause of deterioration.

METHOD

Narrative review of current literature.

RESULTS

A number of the most promising biomarkers for diagnoses and prognostication of sepsis are presented.

CONCLUSION

Procalcitonin, presepsin, CD64, suPAR, and sTREM-1 are the best evaluated biomarkers for diagnosis and prognostication of sepsis to date. All have limitations in differentiation between infected and non-infected patients with SIRS, and their future role in diagnosis needs to be evaluated. It is important to test utility, performance, and validity of future biomarkers before implementing them in routine clinical care.