Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis

Procalcitonin, brain natriuretic peptide and albumin as markers to predict prognosis in hospitalized older Japanese patients with a risk of infection

AIM

Whether serum concentration of procalcitonin (PCT), brain natriuretic peptide (BNP) and albumin (Alb) have an association with the outcome of hospitalized older patients is unclear. We investigated clinical outcomes and any predictive factors in hospitalized Japanese older patients with a risk of infection.

METHODS

In the retrospective study, 820 Japanese patients were followed up for 30 days or until death. During the observation period, 656 patients survived and 164 patients died. The predictive factors of death were analyzed according to demographic and clinical variables.

RESULTS

The survival rate was decreased as the serum PCT increased from <0.5 to ≥10 ng/mL, as was also the case with BNP from <300 to ≥300 pg./mL, whereas low Alb (<2.5 g/dL) showed a lower survival rate than high Alb (≥2.5 g/dL; P < 0.01). Using the Cox regression model, the multivariable-adjusted hazard ratios (95% confidence interval) were as follows: PCT 0.5-2 versus <0.5 ng/mL: 1.61(1.04-2.49), PCT 2-10 versus <0.5 ng/mL: 1.91(1.15-3.16), PCT ≥10 versus <0.5 ng/mL: 2.90(1.84-4.59), high BNP 1.26 (0.89-1.76) and low Alb 0.68 (0.52-0.87). The mortality rate increased as the number of scores (PCT + BNP + Alb) increased.

CONCLUSIONS

Concentration-dependent high PCT, high BNP and low Alb were positive risk factors associated with poor prognosis in hospitalized older patients with a risk of infection. Geriatr Gerontol Int 2024; 24: 571-576.

Association between the stress hyperglycemia ratio and 28-day all-cause mortality in critically ill patients with sepsis: a retrospective cohort study and predictive model establishment based on machine learning

BACKGROUND

Sepsis is a severe form of systemic inflammatory response syndrome that is caused by infection. Sepsis is characterized by a marked state of stress, which manifests as nonspecific physiological and metabolic changes in response to the disease. Previous studies have indicated that the stress hyperglycemia ratio (SHR) can serve as a reliable predictor of adverse outcomes in various cardiovascular and cerebrovascular diseases. However, there is limited research on the relationship between the SHR and adverse outcomes in patients with infectious diseases, particularly in critically ill patients with sepsis. Therefore, this study aimed to explore the association between the SHR and adverse outcomes in critically ill patients with sepsis.

METHODS

Clinical data from 2312 critically ill patients with sepsis were extracted from the MIMIC-IV (2.2) database. Based on the quartiles of the SHR, the study population was divided into four groups. The primary outcome was 28-day all-cause mortality, and the secondary outcome was in-hospital mortality. The relationship between the SHR and adverse outcomes was explored using restricted cubic splines, Cox proportional hazard regression, and Kaplan‒Meier curves. The predictive ability of the SHR was assessed using the Boruta algorithm, and a prediction model was established using machine learning algorithms.

RESULTS

Data from 2312 patients who were diagnosed with sepsis were analyzed. Restricted cubic splines demonstrated a "U-shaped" association between the SHR and survival rate, indicating that an increase in the SHR is related to an increased risk of adverse events. A higher SHR was significantly associated with an increased risk of 28-day mortality and in-hospital mortality in patients with sepsis (HR > 1, P < 0.05) compared to a lower SHR. Boruta feature selection showed that SHR had a higher Z score, and the model built using the rsf algorithm showed the best performance (AUC = 0.8322).

CONCLUSION

The SHR exhibited a U-shaped relationship with 28-day all-cause mortality and in-hospital mortality in critically ill patients with sepsis. A high SHR is significantly correlated with an increased risk of adverse events, thus indicating that is a potential predictor of adverse outcomes in patients with sepsis.

SIMPLIFIED IMMUNE-DYSREGULATION INDEX: A NOVEL MARKER PREDICTS 28-DAY MORTALITY OF INTENSIVE CARE PATIENTS WITH SEPSIS

ABSTRACT

Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. There is currently no simple immune-imbalance-driven indicator for patients with sepsis. Methods: This study was conducted in Peking Union Medical College Hospital. Patients with sepsis were identified according to Sepsis 3.0 after reviewing patient data from May 2018 through October 2022. Least absolute shrinkage and selection operator logistic regression was used for features selection. Receiver operating characteristic curves for 28-day mortality were used to compare the predictive performance of level of interleukin 6 (IL-6) and lymphocyte count (LY#) with that of the combined ratio, namely, the IL-6/LY# ratio. A Cox hazard model was also used to test the predictive performance of IL-6/LY# versus several other measurements. The dynamic trend of IL-6/LY# based on day 1 IL-6/LY# level was analyzed. Results: The mortality rate was 24.5% (220/898) in the study cohort. The LY#, IL-6 level, blood platelet count, Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Evaluation II score, heart rate, age and Fi o2 level were identified as key factors for predicting 28-day mortality. IL-6/LY# was identified as a core indicator according to Least absolute shrinkage and selection operator logistic regression analysis. IL-6/LY# was significantly higher in nonsurvivors than in survivors (348 [154.6-1371.7] vs. 42.3 [15.4-117.1]). IL-6/LY# yielded a higher area under the curve (0.852 [95% CI = 0.820-0.879]) than the level of IL-6 (0.776 [95% CI = 0.738-0.809]) and LY# (0.719 [95% CI = 0.677-0.755]) separately. Survival analysis of mortality risk versus the IL-6/LY# ratio suggested that IL-6/LY# was significantly more predictive of patient risk than the Sequential Organ Failure Assessment score or the other factors ( P = 1.5 × 10 -33 ). In trend analysis, as the trend of D1-D3-D7 IL-6/LY# decreases, the morality rate is lower than increase or fluctuate group (42.1% vs. 58.3%, 37.9% vs. 43.8%, 37.5% vs. 38.5% in high, moderate, and low D1 IL-6/LY# group separately). Conclusion: IL-6/LY# examined on first day in intensive care unit can be used as an immune-imbalance alert to identify sepsis patients with higher risk of 28-day mortality. Decreasing trend of IL-6/LY# suggests a lower 28-day mortality rate of sepsis patients.

Diagnostic and Prognostic Value of Pentraxin 3, Interleukin-6, CRP, and Procalcitonin Levels in Patients with Sepsis and Septic Shock

INTRODUCTION AND PURPOSE

In this prospective study, we aim to evaluate the effects of antibiotherapy on pentraxin-3 (PTX3), C-reactive protein (CRP), and interleukin-6 (IL-6) levels in patients with sepsis and septic shock.

MATERIALS AND METHODS

In our study, CRP, procalcitonin, IL-6, and PTX3 levels at initial and 48 hours of the antibiotherapy of patients who were admitted to the pediatric intensive care unit (PICU) with the diagnosis of sepsis and septic shock between June 2020 and March 2021 were compared. Patients were compared with the age-appropriate case-control group formed from the patients who received pre-operative routines to investigate the diagnostic value.

RESULTS

CRP, IL-6, and PTX3 levels of the patients were significantly higher compared to controls (P < 0.05). After the 48th hour of treatment compared to initial CRP, lactate and PCT levels were significantly lower (P < 0.05). The IL-6 and PCT levels were significantly higher in patients with mortality than in surviving patients. Surviving patients showed a significant decrease in CRP level at the 48th hour. IL-6 levels of patients with septic shock were significantly higher than those with sepsis (P = 0.010; P < 0.05). In the diagnosis of septic shock, the area under curve was 0.785 for IL-6 and the standard deviation was 0.09 (P = 0.002, cut-off value, >32 pg/mL, 88.9% sensitivity, 65.6% specifity).

CONCLUSION

The results of this study indicated that IL-6 level is an appropriate biomarker with high specificity in the diagnosis of sepsis and septic shock and in evaluating the response to treatment and determining the prognosis.

A biomarker panel of C-reactive protein, procalcitonin and serum amyloid A is a predictor of sepsis in severe trauma patients

Severe trauma could induce sepsis due to the loss of control of the infection, which may eventually lead to death. Accurate and timely diagnosis of sepsis with severe trauma remains challenging both for clinician and laboratory. Combinations of markers, as opposed to single ones, may improve diagnosis. We compared the diagnostic characteristics of routinely used biomarkers of sepsis alone and in combination, trying to define a biomarker panel to predict sepsis in severe patients. This prospective observational study included patients with severe trauma (Injury severity score, ISS = 16 or more) in the emergency intensive care unit (EICU) at a university hospital. Blood samples were collected and plasma levels of procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6) and serum amyloid A (SAA) were measured using commercial enzyme linked immunosorbent assay (ELISA) kits. A total of 100 patients were eligible for analysis. Of these, 52 were diagnosed with sepsis. CRP yielded the highest discriminative value followed by PCT. In multiple logistic regression, SAA, CRP, and PCT were found to be independent predictors of sepsis. Bioscore which was composed of SAA, CRP, and PCT was shown to be far superior to that of each individual biomarker taken individually. Therefore, compared with single markers, the biomarker panel of PCT, CRP, and SAA was more predictive of sepsis in severe polytrauma patients.

Low monocytic HLA-DR expression in critically ill patients of sepsis: An indicator for antimicrobial and/or immunomodulatory intervention

BACKGROUND

Sepsis is a result of suppressed host immune response which leads to fatal multi-organ dysfunctionality. Low frequency of active monocytes or reduced expression of human leukocyte antigen (HLA)-DR on monocytes shows the suppressed immune response in sepsis patients. One of the well-studied markers in patients with sepsis is procalcitonin (PCT). The role of monocytic (m) HLA-DR expression has been monitored in sepsis and is being considered a marker of the severity of interim immuno-depression in these patients. The study describes the impact of HLA-DR expression on monocytes quantitatively using flow cytometry.

METHODS

In this prospective study, we quantified monocytes and their HLA-DR expression in 20 patients of sepsis admitted to the Intensive Care Unit (ICU). Serum levels of PCT and interleukin (IL)-6 production were also measured in these patients, and the results were compared with those in healthy controls.

RESULTS

Monocyte frequency calculated was higher in sepsis patients as compared to healthy controls, however, HLA-DR expressing monocytes were significantly reduced as was the mean fluorescence intensity (MFI) of HLA-DR. Contrastingly, IL-6 and PCT levels were significantly high in sepsis than controls. The results suggest that low HLA-DR expression, combined with PCT, is a better prognostic parameter in the early phase of sepsis.

CONCLUSION

Poor recovery of mHLA-DR may serve as an early guide for clinicians to assess the prognosis of sepsis patients and consider immunomodulatory therapy in its management.

Identification of Clinically Significant Cytokine Signature Clusters in Patients With Septic Shock

OBJECTIVES

To identify cytokine signature clusters in patients with septic shock.

DESIGN

Prospective observational cohort study.

SETTING

Single academic center in the United States.

PATIENTS

Adult (≥ 18 yr old) patients admitted to the medical ICU with septic shock requiring vasoactive medication support.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred fourteen patients with septic shock completed cytokine measurement at time of enrollment (t 1 ) and 24 hours later (t 2 ). Unsupervised random forest analysis of the change in cytokines over time, defined as delta (t 2 -t 1 ), identified three clusters with distinct cytokine profiles. Patients in cluster 1 had the lowest initial levels of circulating cytokines that decreased over time. Patients in cluster 2 and cluster 3 had higher initial levels that decreased over time in cluster 2 and increased in cluster 3. Patients in clusters 2 and 3 had higher mortality compared with cluster 1 (clusters 1-3: 11% vs 31%; odds ratio [OR], 3.56 [1.10-14.23] vs 54% OR, 9.23 [2.89-37.22]). Cluster 3 was independently associated with in-hospital mortality (hazard ratio, 5.24; p = 0.005) in multivariable analysis. There were no significant differences in initial clinical severity scoring or steroid use between the clusters. Analysis of either t 1 or t 2 cytokine measurements alone or in combination did not reveal clusters with clear clinical significance.

CONCLUSIONS

Longitudinal measurement of cytokine profiles at initiation of vasoactive medications and 24 hours later revealed three distinct cytokine signature clusters that correlated with clinical outcomes.

Diagnostic Accuracy of Procalcitonin for Infection After Adult Liver Transplantation: A Meta-Analysis and Systematic Review

Background: Post-operative infection remains a major cause of morbidity and mortality in adults early after liver transplantation (LT). Procalcitonin (PCT) may be a good test method for early diagnosis of post-operative infection and determining its severity. This study was performed to assess the diagnostic accuracy of PCT as a biomarker for infection after LT. Patients and Methods: A meta-analysis and systematic review was conducted for studies reporting diagnostic performance of PCT for infection in adults after LT. Observational studies were evaluated for their reporting of diagnostic accuracy, relevance, and quality. Results: Ten eligible studies assessing 730 patients were included in this meta-analysis and systematic review summarizing the diagnostic value of PCT for post-operative infection in adult liver transplantation. Pooled sensitivity and specificity with corresponding 95% confidence interval were 69% (95% confidence interval [CI], 54-81; heterogeneity I2 = 82.4%) and 88% (95% CI, 82-92; I2 = 52.7%), respectively. The diagnostic odd ratio (DOR) was 16 (95% CI, 10-25; I2 = 76.4%). The summary receiver operator characteristic (SROC) of PCT for post-operative infection was 0.88. There was a wide range of variability in the cutoff values, ranging from 0.22 to 42.80 ng/mL. Heterogeneity was reduced by excluding studies that focused on pediatric LT recipients. Conclusions: Procalcitonin is a moderately accurate diagnostic marker for post-operative infection in adult LT. Additionally, the diagnostic performance can be improved by combining it with other inflammatory biomarkers. This article provides the research direction for post-operative infection control.

Detecting Diabetic Ketoacidosis with Infection: Combating a Life-Threatening Emergency with Practical Diagnostic Tools

BACKGROUND

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus and can lead to patient demise if not immediately treated. From the recent literature, the diabetic ketoacidosis mortality rate, depending on age, is 2-5%. Insulin discontinuation and infection remain the two most common triggers for diabetic ketoacidosis. About 50% of cases of ketoacidosis result from bacterial infections like urinary tract infections and pneumonia. It is also important to diagnose the presence of infection in diabetic ketoacidosis patients to prevent the excessive use of antibiotics, which may lead to antibiotic resistance. Although performing bacterial culture is confirmatory for the presence or absence of bacterial infection, the time required to obtain the result is long. At the same time, emergency treatment needs to be started as early as possible.

METHODS

This narrative review examines various septic markers to identify the appropriate tools for diagnosis and to distinguish between diabetic ketoacidosis with and without infection. Electronic databases were searched using the Google engine with the keywords "Diabetes Mellitus", "Diabetic Ketoacidosis", "Infection with Diabetic Ketoacidosis", "biomarkers for infection in Diabetic Ketoacidosis", "Procalcitonin", "Inflammatory cytokines in DKA", "Lactic acidosis in DKA", and "White blood cell in infection in DKA".

RESULTS

This narrative review article presents the options for diagnosis and also aims to create awareness regarding the gravity of diabetic ketoacidosis with infection and emphasizes the importance of early diagnosis for appropriate management. Diabetes mellitus is a clinical condition that may lead to several acute and chronic complications. Acute diabetic ketoacidosis is a life-threatening condition in which an excess production of ketone bodies results in acidosis and hypovolemia. Infection is one of the most common triggers of diabetic ketoacidosis. When bacterial infection is present along with diabetic ketoacidosis, the mortality rate is even higher than for patients with diabetic ketoacidosis without infection. The symptoms and biomarkers of diabetic ketoacidosis are similar to that of infection, like fever, C reactive protein, and white blood cell count, since both create an environment of systemic inflammation. It is also essential to distinguish between the presence and absence of bacterial infection to ensure the appropriate use of antibiotics and prevent antimicrobial resistance. A bacterial culture report is confirmatory for the existence of bacterial infection, but this may take up to 24 h. Diagnosis needs to be performed approximately in the emergency room upon admission since there is a need for immediate management. Therefore, researching the possible diagnostic tools for the presence of infection in diabetic ketoacidosis patients is of great importance. Several of such biomarkers have been discussed in this research work.

Anti-inflammatory Effect of Low-Intensity Ultrasound in Septic Rats

OBJECTIVE

Sepsis is a severe systemic inflammatory response caused by infection. Here, the spleen region of Sprague-Dawley (SD) rats with sepsis was irradiated with low-intensity ultrasound (LIUS) to explore the regulation of inflammation and its mechanism by LIUS.

METHODS

In this study, 30 rats used for survival analysis were randomly divided into the sham-operated group (Sham, n = 10), the group in which sepsis was induced by cecal ligation and puncture (CLP, n = 10) and the group treated with LIUS immediately after CLP (LIUS, n = 10). The other 120 rats were randomly divided into the aforementioned three groups for detection at each time point. The parameters used in the LIUS group were 200 mW/cm², 0.37 MHz, 20% duty cycle and 20 min, and no ultrasonic energy was produced in the Sham and CLP groups. Seven-day survival rate, histopathology and expression of inflammatory factors and proteins were evaluated in the three groups.

RESULTS

LIUS was able to improve the survival rate of septic SD rats (p < 0.05), significantly inhibit the expression of tumor necrosis factor α (TNF-α), interleukin 1β (IL-1β), interleukin 6 (IL-6) and nuclear factor-κB p65 (NF-κB p65) (p < 0.05) and restore the ultrastructure of the spleen.

CONCLUSION

Our study determined that LIUS can relieve spleen damage and alleviate severe cytokine storm to improve survival outcomes in septic SD rats, and its mechanism may be related to the inhibition of the NF-κB signaling pathway by downregulation of IL-1β.

Short treatment duration for community-acquired pneumonia

PURPOSE OF REVIEW

Lower respiratory tract infections are one of the most common indications for antibiotic use in community and hospital settings. Usual guidelines for adults with community-acquired pneumonia (CAP) recommend 5-7 days of antibiotic treatment. In daily practice, physicians often prescribe 9-10 days of antibiotic treatment. Among available strategies to decrease antibiotic use, possibly preventing the emergence of bacterial resistance, reducing treatment durations is the safest and the most acceptable to clinicians. We aim to review data evaluating the efficacy of short antibiotic duration in adult CAP and which criteria can help clinicians to reduce antibiotic treatment.

RECENT FINDINGS

Several studies and meta-analyses demonstrated that the treatment duration of 7 days or less was sufficient for CAP. Two trials found that 3-day treatments were effective, even in hospitalized CAP.To customize and shorten duration, clinical and biological criteria have been studied and reflect patient's response. Indeed, stability criteria were recently shown to be effective to discontinue antibiotic treatment. Procalcitonin was also studied but never compared with clinical criteria.

SUMMARY

Treatment duration for CAP is still under debate, but several studies support short durations. Clinical criteria could be possibly used to discontinue antibiotic treatment.

Diagnosis of bacterial infection in children with relapse of nephrotic syndrome: a personalized decision-analytic nomogram and decision curve analysis

BACKGROUND

Infections associated with nephrotic relapses (NR) are often managed according to physician preferences. A validated prediction tool will aid clinical decision-making and help in rationalizing antibiotic prescriptions. Our objective was to develop a biomarker-based prediction model and a regression nomogram for the prediction of the probability of infection in children with NR. We also aimed to perform a decision curve analysis (DCA).

METHODS

This cross-sectional study included children (1-18 years) with NR. The outcome of interest was the presence of bacterial infection as diagnosed using standard clinical definitions. Total leucocyte count (TLC), absolute neutrophil count (ANC), quantitative C-reactive protein (qCRP), and procalcitonin (PCT) were the biomarker predictors. Logistic regression was used to identify the best biomarker model, followed by discrimination and calibration testing. Subsequently, a probability nomogram was constructed and DCA was done to determine the clinical utility and net benefits.

RESULTS

We included 150 relapse episodes. A bacterial infection was diagnosed in 35%. Multivariate analysis showed the ANC + qCRP model to be the best predictive model. This model displayed excellent discrimination (AUC: 0.83), and calibration (optimism-adjusted intercept: 0.015, slope: 0.926). A prediction nomogram and web-application was developed. The superiority of the model was also confirmed by DCA in the probability threshold range of 15-60%.

CONCLUSIONS

An ANC-based and qCRP-based internally validated nomogram can be used for the prediction of probability of infection in non-critically ill children with NR. Decision curves from this study will aid in the decision-making of empirical antibiotic therapy, incorporating threshold probabilities as a surrogate of physician preference. A higher resolution version of the Graphical abstract is available as Supplementary information.

Developing a machine learning prediction algorithm for early differentiation of urosepsis from urinary tract infection

OBJECTIVES

Early recognition and timely intervention for urosepsis are key to reducing morbidity and mortality. Blood culture has low sensitivity, and a long turnaround time makes meeting the needs of clinical diagnosis difficult. This study aimed to use biomarkers to build a machine learning model for early prediction of urosepsis.

METHODS

Through retrospective analysis, we screened 157 patients with urosepsis and 417 patients with urinary tract infection. Laboratory data of the study participants were collected, including data on biomarkers, such as procalcitonin, D-dimer, and C-reactive protein. We split the data into training (80%) and validation datasets (20%) and determined the average model prediction accuracy through cross-validation.

RESULTS

In total, 26 variables were initially screened and 18 were statistically significant. The influence of the 18 variables was sorted using three ranking methods to further determine the best combination of variables. The Gini importance ranking method was found to be suitable for variable filtering. The accuracy rates of the six machine learning models in predicting urosepsis were all higher than 80%, and the performance of the artificial neural network (ANN) was the best among all. When the ANN included the eight biomarkers with the highest influence ranking, its model had the best prediction performance, with an accuracy rate of 92.9% and an area under the receiver operating characteristic curve of 0.946.

CONCLUSIONS

Urosepsis can be predicted using only the top eight biomarkers determined by the ranking method. This data-driven predictive model will enable clinicians to make quick and accurate diagnoses.

Procalcitonin detection in human plasma specimens using a fast version of proximity extension assay

An exciting trend in clinical diagnostics is the development of easy-to-use, minimally invasive assays for screening and prevention of disease at the point of care. Proximity Extension Assay (PEA), an homogeneous, dual-recognition immunoassay, has proven to be sensitive, specific and convenient for detection or quantitation of one or multiple analytes in human plasma. In this paper, the PEA principle was applied to the detection of procalcitonin (PCT), a widely used biomarker for the identification of bacterial infection. A simple, short PEA protocol, with an assay time suitable for point-of-care diagnostics, is presented here as a proof of concept. Pairs of oligonucleotides and monoclonal antibodies were selected to generate tools specifically adapted to the development of an efficient PEA for PCT detection. The assay time was reduced by more than 13-fold compared to published versions of PEA, without significantly affecting assay performance. It was also demonstrated that T4 DNA polymerase could advantageously be replaced by other polymerases having strong 3'>5' exonuclease activity. The sensitivity of this improved assay was determined to be about 0.1 ng/mL of PCT in plasma specimen. The potential use of such an assay in an integrated system for the low-plex detection of biomarkers in human specimen at the point of care was discussed.

Early immune system alterations in patients with septic shock

This study aims to investigate the early changes in the immune systems of patients with septic shock. A total of 243 patients with septic shock were included in this study. The patients were classified as survivors (n = 101) or nonsurvivors (n = 142). Clinical laboratories perform tests of the immune system's function. Each indicator was studied alongside healthy controls (n = 20) of the same age and gender as the patients. A comparative analysis of every two groups was conducted. Univariate and multivariate logistic regression analyses were performed to identify mortality risk factors that are independent of one another. In septic shock patients, neutrophil counts, infection biomarkers (C-reactive protein, ferritin, and procalcitonin levels), and cytokines (IL-1β, IL-2R, IL-6, IL-8, IL-10, and TNF-α) increased significantly. Lymphocyte and their subset counts (T, CD4+ T, CD8+ T, B, and natural killer cell counts), lymphocyte subset functions (the proportions of PMA/ionomycin-stimulated IFN-γ positive cells in CD4+ T cells), immunoglobulin levels (IgA, IgG, and IgM), and complement protein levels (C3 and C4) decreased significantly. Compared to survivors, nonsurvivors had higher levels of cytokines (IL-6, IL-8, and IL-10) but lower levels of IgM, complement C3 and C4, and lymphocyte, CD4+, and CD8+ T cell counts. Low IgM or C3 concentrations and low lymphocyte or CD4+ T cell counts were independent risk factors for mortality. These alterations should be considered in the future development of immunotherapies aimed at treating septic shock.

Pre-admission and In-Hospital Statin Use is Associated With Reduced Short-Term Mortality in Infective Endocarditis

OBJECTIVE

To investigate for potential protective effects of statin use among patients with infective endocarditis (IE) with consideration for underlying diseases and bacterial culture - variables which have prognostic implications and show considerable geographic variation yet are unappreciated in previous pharmacoepidemiological studies.

PATIENTS AND METHODS

Patients diagnosed with IE between January 1, 1996, and December 31, 2019, were identified. We estimated the effect on mortality of pre-admission statin use (≥90 cumulative days of use before index date) and in-hospital use (use beginning within 2 days of admission), compared with nonusers and discontinued users, respectively, through propensity score analytics.

RESULTS

Of 6700 IE patients (mean age, 58.0 years; 63.3% male [n=4251]), 776 patients had pre-admission statin use, with 626 continuing statin use following admission (in-hospital users). Pre-admission statin users had a 31% lower risk of 1-year mortality (HR, 0.69; 95% CI, 0.58 to 0.82) compared with nonusers. In-hospital users had a 48% lower risk of 1-year mortality (HR, 0.52; 95% CI, 0.34 to 0.78) compared with discontinued users. Subgroup analyses showed significant protective effects of statin use for patients with varying causative agents, underlying diseases, and with or without prosthetic valves. Results were consistent across different statins, and were dose-dependent.

CONCLUSION

In patients with IE, pre-admission and in-hospital use of statin, when compared with statin nonusers and discontinued users, respectively, were associated with a lower risk of 1-year mortality.

Diagnostic and therapeutic value of biomarkers in urosepsis

Urosepsis is sepsis caused by urogenital tract infection and is one of the most common critical illnesses in urology. If urosepsis is not diagnosed early, it can rapidly progress and worsen, leading to increased mortality. In recent years, with the increase of urinary tract surgery, the incidence of urosepsis continues to rise, posing a serious threat to patients. Early diagnosis of urosepsis, timely and effective treatment can greatly reduce the mortality of patients. Biomarkers such as WBC, NLR, PCT, IL-6, CRP, lactate, and LncRNA all play specific roles in the early diagnosis or prognosis of urosepsis. In addition to the abnormal increase of WBC, we should be more alert to the rapid decline of WBC. NLR values were superior to WBC counts alone in predicting infection severity. Compared with several other biomarkers, PCT values can differentiate between bacterial and non-bacterial sepsis. IL-6 always has high sensitivity and specificity for the diagnosis of sepsis, and CRP also has high sensitivity and specificity for the diagnosis of urosepsis. Lactic acid is closely related to the prognosis of patients with urosepsis. LncRNAs may be potential biomarkers of urosepsis. This article summarizes the main biomarkers, hoping to provide a reference for the timely diagnosis and evaluation of urosepsis.

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 Utility of Procalcitonin on Antibiotic Stewardship: A Narrative Review

Procalcitonin (PCT) was discovered as a useful marker for bacterial infection. Following its discovery, there have been a substantial number of clinical studies conducted to evaluate the presence of bacterial infections, and to guide antibiotic treatment by the stratified levels of PCT. Clinical evidence suggests that antibiotic treatment by PCT-guided antibiotic stewardship has been associated with a reduction in antibiotic usage without an increase in adverse outcomes. The use of PCT was approved by the Food and Drug Administration in the United States of America in 2017 to guide antibiotic treatment in sepsis and lower respiratory tract infections (LRTIs). In Korea, the use of PCT for sepsis and for pneumonia was approved in 2015 and 2022, respectively. This review will discuss the clinical utility of PCT on antibiotic stewardship in the management of sepsis and LRTIs including pneumonia.

Developing a new sepsis screening tool based on lymphocyte count, international normalized ratio and procalcitonin (LIP score)

Exploring an effective sepsis screening tool that can be widely implemented is important for improving the prognosis of sepsis worldwide. This study aimed to develop a new simple screening tool for sepsis (LIP scoring system) that includes the peripheral blood lymphocyte count, international normalized ratio, and procalcitonin level. In a single-center, prospective, observational study, 444 acute sepsis inpatients and 444 nonsepsis inpatients were ultimately included based on the Sepsis-3 and exclusion criteria. The differences in the Lym, INR, PCT level and other clinical biomarkers were compared between the two groups. Univariable and multivariable logistic regression analyses and receiver operating characteristic analysis were used to establish a LIP screening tool for sepsis with a combination of biomarkers. The Kappa and McNemar tests were used to evaluate the differences between the LIP screening results (LIP score ≥ 3) and Sepsis-3 criteria (SOFA score ≥ 2). Logistic regression analysis showed that the lymphocyte count, INR, PCT level, platelets, neutrophil/lymphocyte ratio (NLR) and prothrombin time (PT) were independent risk factors for the development of sepsis. The ROC analysis showed that the lymphocyte count, INR, and PCT level had high area under the ROC curve values (AUROC (95% CI): Lym 0.84 (0.810-0.860), INR 0.921 (0.902-0.938), PCT level 0.928 (0.909-0.944)). The LIP tool had satisfactory screening efficacy for sepsis (sensitivity, 92.8%; specificity, 94.1%), and a LIP score equal to or greater than 3 points had good agreement with Sepsis-3 criteria in the diagnosis of sepsis (Kappa = 0862 in the Kappa test and P = 0.512 in the McNemar test). The LIP tool has satisfactory sensitivity and specificity for sepsis screening, and it can be used for rapid screening of patients with sepsis in outpatient and emergency departments or in economically underdeveloped areas with limited resources.

Serum Procalcitonin Levels in Newly Diagnosed Hodgkin Lymphoma: Correlation with Other Inflammatory Biomarkers

Background and Objectives: Procalcitonin (PCT) is a useful biomarker for the diagnosis of sepsis. Inflammatory markers are elevated in patients with Hodgkin lymphoma (HL), and yet ongoing infection rarely coexists at diagnosis. PCT levels might be helpful in differentiating bacterial from disease-related inflammation. Materials and Methods: We evaluated serum PCT levels and other inflammation markers in newly diagnosed HL patients. Values < 0.50 ng/mL were considered normal (0.10−0.50 ng/mL: detectable, <0.10 ng/mL: undetectable), while values ≥ 0.50 ng/L were considered elevated. Results: Among 137 patients, 55 had B symptoms (40%), 77/130 (59%) had elevated Erythrocyte Sedimentation Rate (ESR) and 116 (85%) had elevated C-Reactive Protein (CRP) (median 38.1 mg/L (range; 2.97−328)). PCT levels were normal in most patients (undetectable 94/137 (68.5%) and detectable 41/137(30%)) with median value < 0.10 ng/mL (range; <0.10−15.90). Elevated PCT was recorded in only two patients (1.5%). Patients with PCT < 0.10 ng/mL had significantly lower median CRP (25.75; range (2.97−203.0)) compared to patients with PCT ≥ 0.1 ng/mL (median CRP 92.50 mg/L; range (3.34−328.0)). Almost all patients (40/41, 97.6%) with detectable PCT had elevated CRP. Conclusions: This is the first study showing that the inflammation characterizing HL is not associated with PCT elevations, although CRP levels are elevated in 85% of the patients. Normal PCT levels may rule out the possibility of occult infection, thus preventing extensive evaluation, which may delay treatment initiation.

Construction and efficacy evaluation of an early warning scoring system for septic shock in patients with digestive tract perforation: A retrospective cohort study

Objective

To establish an early warning scoring system for septic shock in patients with digestive tract perforation (DTP) and evaluate its diagnostic efficacy.

Methods

Patients with surgically confirmed or clinically diagnosed DTP admitted to the Department of Intensive Care Medicine of Fujian Provincial Hospital from June 2012 to October 2021 were retrospectively analyzed. General demographic characteristics, perforation-related information, vital signs, common laboratory indicators, and common ICU scores (Glasgow Coma Scale score, Acute Physiology and Chronic Health Evaluation-II score,Sequential Organ Failure Assessment score) were collected. The patients were divided into shock group and non-shock group according to whether the patients had septic shock during hospitalization. The risk factors of septic shock were screened by basic statistical analysis and multivariate Logistic regression analysis. The receiver operating characteristic curve was drawn to determine the cut-off value of the continuous indicators and discretized with reference to clinic, and the corresponding score was set according to the β regression coefficient of each variable.

Results

A total of 176 patients with DTP were included. The average age of the patients was 64.13 ± 14.67 years old, and 74.40% were males. The incidence of septic shock was 30.11% (53/176). Multivariate Logistic regression analysis showed that the highest heart rate≥105 beats/min, Glasgow Coma Scale score≤14 points, lactic acid≥5.75 mmol/L, procalcitonin≥41.47 ug/L, C-reactive protein≥222.5 mg/L were independent risk factors for septic shock in patients with DTP. The total score of clinical diagnostic scoring system of septic shock in patients with DTP was 6 points, including the highest heart rate≥105 beats/min (1 point), lactic acid≥5.75 mmol/L (two points), procalcitonin≥41.47 ug/L (one point), C-reactive protein≥222.5 mg/L (1 point), and Glasgow Coma Scale score≤14 points (1 point). The area under ROC curve (AUC) of this scoring system was 0.789 and the 95% confidence interval was 0.717–0.860 (P &lt; 0.001); when the optimal cut-off value was 2.5, the sensitivity and specificity were 54.70 and 87.80%, respectively.

Conclusion

This new score system has its certain clinical value and has important guiding significance for clinicians to judge the prognosis of patients with DTP in time.

Diagnostic accuracy of procalcitonin and interleukin-6 for postoperative infection in major gastrointestinal surgery: a systematic review and meta-analysis

BACKGROUND

We aim to assess the diagnostic accuracy of procalcitonin (PCT) and interleukin-6 (IL-6) as diagnostic biomarkers for postoperative infection/sepsis following major abdominal surgery. Postoperative infection is an important cause for morbidity and mortality in major surgery. Early diagnosis and antimicrobial treatment improves outcomes, and high-performing biomarkers could guide clinical decision making.

METHODS

A systematic database search was conducted for studies reporting diagnostic performance of biomarkers (including PCT and IL-6) for infection/sepsis following major abdominal surgery. Studies were assessed for reporting of diagnostic accuracy, relevance and quality. Data were extracted for meta-analysis.

RESULTS

Ten studies with 1,611 participants reported the diagnostic accuracy of PCT, with pooled sensitivity, specificity and summary receiver operator curve of 72% (95% CI 66-78), 62% (95% CI 59-64) and 0.766, respectively. Four studies with 175 participants reported the diagnostic accuracy of IL-6, with pooled sensitivity, specificity and summary receiver operator curve of 84% (95% CI 72-92), 76% (95% CI 68-84) and 0.878, respectively There was variability in the timing of sampling and cut-off values and significant heterogeneity and inconsistency between studies (I2 diagnostic odds ratio (DOR)= 43.2% for PCT, I2 DOR=0% for IL-6).

CONCLUSIONS

PCT performs only moderately well as a diagnostic test for postoperative infection/sepsis in major abdominal surgery, demonstrating limited sensitivity and specificity. Heterogeneity between studies is a limitation of the meta-analysis. There is an ongoing need for a rapid, accurate biomarker for postoperative infection or sepsis.

Usefulness of Procalcitonin in the Diagnosis of Bacterial Infection in Immunocompetent Children

Bacterial infections (BIs) need to be differentiated from non-BIs (NBIs) to enable prompt administration of antibiotics. Therefore, inflammatory biomarkers are needed as they can accurately identify BIs. This study evaluated the usefulness of procalcitonin (PCT) in the diagnosis of BI in immunocompetent children. We retrospectively reviewed the medical records of patients <18 years who underwent PCT measurements between July 2012 and June 2019. In total, 474 patients were enrolled and divided into the BI (n = 205) and NBI groups (n = 269). The BI group was subcategorized into the invasive BI (IBI; n = 94), mucosal BI (MBI; n = 31), toxigenic BI (TBI; n = 23), and localized BI (LBI; n = 57) subgroups. The NBI group was further subcategorized into the viral infection (VI; n = 118) and inflammatory disease groups (ID; n = 151). PCT was compared with the levels of C-reactive protein (CRP), white blood cell (WBC), and erythrocyte sedimentation rate (ESR). Between the BI and NBI groups, PCT (4.2 ± 16.9 vs. 1.1 ± 2.5 ng/mL; p = 0.008) and ESR (39.1 ± 32.4 vs. 54.8 ± 28.2 mm/h; p < 0.001) were significantly different. Between the IBI and other groups, WBC (14,797 ± 7148 vs. 12,622 ± 5770 × 106/L; p = 0.007), ESR (35.3 ± 30.3 vs. 51.5 ± 30.3 mm/h; p < 0.001), and PCT (8.1 ± 23.8 vs. 1.0 ± 3.4 ng/mL; p = 0.005) were significantly different. However, none of the biomarkers were useful in differentiating BI from NBI. While WBC (area under curve (AUC) = 0.615, p = 0.003) and PCT (AUC = 0.640, p < 0.001) were useful, they fared poorly in differentiating IBI from other groups. Thus, additional studies are needed to identify more accurate biomarkers capable of differentiating BIs, especially IBIs.

Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin for post-operative sepsis/infection in liver transplantation

BACKGROUND

Post-operative infection is a major cause of morbidity and mortality in Liver Transplantation (LT). Early diagnosis and antimicrobial treatment improves outcomes and ruling out sepsis aids immunosuppression decisions. Procalcitonin (PCT) has recently become part of such decision making in COVID-19 pneumonia but its role in LT is not established. We assessed the diagnostic accuracy of PCT as a diagnostic biomarker for infection or sepsis following LT.

METHODS

A systematic search was conducted for studies reporting diagnostic performance of PCT for infection/sepsis following LT. Studies were assessed for reporting of diagnostic accuracy, relevance and quality.

RESULTS

Eight studies with 363 participants reported data on the diagnostic accuracy of PCT, with pooled sensitivity, specificity, diagnostic odds ratio and summary receiver operator curve of 70% (95% CI 62-78), 77% (95% CI 73-83), 15.82 (95% CI 5.82-43.12) and 0.871 respectively. There was variability in the timing of sampling (post-operative day 1-8) and range of cut-off values (0.48 to 42.8 ng/mL). Heterogeneity was reduced when only studies with adult LT recipients were considered.

CONCLUSIONS

PCT performs moderately well as a diagnostic test for postoperative infection/sepsis following LT. This marker is more suited for use in adult LT populations.

Acute Respiratory Failure

Respiratory failure is one of the most common reasons for hospitalization and intensive care unit (ICU) admissions, and a diverse range of etiologies can precipitate it. Respiratory failure can result from various mechanisms such as hypoventilation, diffusion impairment, shunting, ventilation-perfusion mismatch, or a combination of those mentioned earlier. Hence, an accurate understanding of different pathophysiologic mechanisms is required for appropriate patient care. Prompt identification and treatment of various respiratory emergencies such as tension pneumothorax, massive hemoptysis, and high-risk pulmonary embolism lead to fewer complications, shorter ICU and hospital stay, and improved survival. This review article entails common respiratory failure pathologies encountered in the ICU and addresses their epidemiology, pathophysiology, clinical presentation, and management.

The ability of inflammatory markers to recognize infection in cancer patients with fever at admission

Infection is one of the main causes of death in cancer patients. Accurate identification of fever caused by infection could avoid unnecessary antibiotic treatment and hospitalization. This study evaluated the diagnostic value of procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-10 (IL-10), and other commonly used inflammatory markers in suspected infected adult cancer patients with fever, for better use of antibiotics. This research retrospective analyzed the clinical data of 102 adult cancer patients with fever and compared the serum levels of commonly used inflammatory markers for different fever reasons. Receiver-operating characteristic (ROC) curve and logistic regression analyses were performed. In adult cancer patients with fever, the serum PCT, CRP, IL-6, and IL-10 levels of infected patients were significantly higher than uninfected patients (median 1.19 ng/ml vs 0.14 ng/ml, 93.11 mg/l vs 56.55 mg/l, 123.74 pg/ml vs 47.35 pg/ml, 8.74 pg/ml vs 3.22 pg/ml; Mann-Whitney p = 0.000, p = 0.009, p = 0.004, p = 0.000, respectively). The ROC area under the curve(AUC) was 0.769 (95% confidence interval (CI) 0.681-0.857; p = 0.000) for PCT, 0.664 (95% CI 0.554-0.775; p = 0.009) for CRP, 0.681(95% CI 0.576-0.785; p = 0.004) for IL-6, and 0.731(95% CI 0.627-0.834; p = 0.000) for IL-10. PCT had specificity of 96.67% and positive predictive value (PPV) of 97.6%, when the cut-off value is set as 0.69 ng/ml. The serum IL-6 and IL-10 levels also had significant differences between the infected and uninfected cancer patients with advanced disease (median 128.92 pg/ml vs 36.40 pg/ml, 8.05 pg/ml vs 2.92 pg/ml; Mann-Whitney p = 0.003, p = 0.001, respectively). For the patients with neutropenia, IL-6 and IL-10 had higher AUC of 0.811 and 0.928, respectively. With a cut-off of 9.10 pg/ml, IL-10 had the highest sensitivity 83.33% and specificity 100%. In adult cancer patients, PCT had the best performance compared to CRP, IL-6, and IL-10 in differentiating infected from uninfected causes of fever, with high specificity and PPV. IL-6 and IL-10 might be useful in cancer patients with severe bloodstream infections and advanced disease. However, for patients with neutropenia, IL-10 might be more valuable than PCT in diagnosing infection.

Targeting Procalcitonin Protects Vascular Barrier Integrity

RATIONALE

Capillary leakage frequently occurs during sepsis and after major surgery and is associated with microvascular dysfunction and adverse outcome. Procalcitonin is a well-established biomarker in inflammation without known impact on vascular integrity.

OBJECTIVE

We determined how procalcitonin induces endothelial hyperpermeability and how targeting procalcitonin protects vascular barrier integrity.

METHODS

In a prospective observational clinical study, procalcitonin levels were assessed in 50 cardiac surgery patients and correlated to postoperative fluid and vasopressor requirements along with sublingual microvascular functionality. Effects of the procalcitonin signaling pathway on endothelial barrier and adherens junctional integrity were characterized in vitro and verified in mice. Inhibition of procalcitonin activation by dipeptidyl-peptidase 4 (DPP4) was evaluated in murine polymicrobial sepsis and clinically verified in cardiac surgery patients chronically taking the DPP4 inhibitor sitagliptin.

MEASUREMENTS AND MAIN RESULTS

Elevated postoperative procalcitonin levels identified patients with 2-fold increased fluid requirements (P<0.01), 1.8-fold higher vasopressor demand (P<0.05) and compromised microcirculation (reduction to 63.5±2.8% of perfused vessels, P<0.05). Procalcitonin induced 1.4-fold endothelial and 2.3-fold pulmonary capillary permeability (both P<0.001) by destabilizing VE-cadherin. Procalcitonin effects were dependent on activation by DPP4 and targeting the procalcitonin receptor or DPP4 during sepsis-induced hyperprocalcitonemia reduced capillary leakage by 54±10.1% and 60.4±6.9% (both P<0.01), respectively. Sitagliptin prior to cardiac surgery was associated with augmented microcirculation (74.1±1.7% vs. 68.6±1.9% perfused vessels in sitagliptin non-medicated patients, P<0.05) and 2.3-fold decreased fluid (P<0.05) and 1.8-fold reduced vasopressor demand postoperatively (P<0.05).

CONCLUSION

Targeting procalcitonin's action on the endothelium is a feasible means to preserve vascular integrity during systemic inflammation associated with hyperprocalcitonemia.

Combination of C-reactive protein, procalcitonin, IL-6, IL-8, and IL-10 for early diagnosis of hyperinflammatory state and organ dysfunction in pediatric sepsis

Background

Although early diagnosis and management are critical for prognosis of pediatric sepsis, there are no specific diagnostic biomarkers for the hyperinflammatory state and organ dysfunction, important stages of sepsis.

Methods

We enrolled 129 children with infection into three groups: non‐sepsis infection (33), Sepsis 1.0 (hyperinflammatory state, 67), and Sepsis 3.0 (organ dysfunction, 29). Another 32 children with no infections were included as controls. Serum C‐reactive protein (CRP), procalcitonin (PCT), interleukin (IL)‐1β, IL‐2, IL‐4, IL‐5, IL‐6, IL‐8, IL‐10, IL‐12p70, IL‐17, tumor necrosis factor (TNF)‐α, interferon (IFN)‐α, and IFN‐γ were assessed to diagnose the two stages, and their diagnostic capacities were evaluated using receiver operating characteristic (ROC) curves. We also examined whether combining biomarkers improved diagnostic efficiency.

Results

Significantly higher CRP, PCT, and IL‐6 levels were detected in the Sepsis 1.0 than the non‐sepsis infection group (p < 0.001). The areas under the curve (AUCs) for diagnosing Sepsis 1.0 were 0.974 (CRP), 0.913 (PCT) and 0.919 (IL‐6). A combination of any two biomarkers increased diagnostic sensitivity to ≥92.54% and specificity to 100.00%. Significantly higher PCT, IL‐8, and IL‐10 levels were found in the Sepsis 3.0 than the Sepsis 1.0 group (p ≤ 0.01), with AUCs for diagnosing Sepsis 3.0 0.807 (PCT), 0.711 (IL‐8), and 0.860 (IL‐10). Combining these three biomarkers increased diagnostic sensitivity to 96.55% and specificity to 94.03%.

Conclusion

In pediatric sepsis, combining any two of CRP, PCT, and IL‐6 can accurately diagnose the hyperinflammatory state and increase diagnostic specificity. Early diagnosis of organ dysfunction requires a combination of PCT, IL‐8, and IL‐10.

Optimization of flow path parameters for enhanced sensitivity lateral flow devices

Lateral flow devices (LFDs) or lateral flow tests (LFTs) are one of the most widely used biosensor platforms for point-of-care (POC) diagnostics. The basic LFD design has remained largely unchanged since its first appearance, and this has limited LFD use in clinical applications due to a general lack of analytical sensitivity. We report here a comprehensive study of the use of laser-patterned geometric control barriers that influence the flow dynamics within an LFD, with the specific aim of enhancing LFD sensitivity and lowering the limit of detection (LOD). This control of sample flow produces an increase in the time available for optimizing the binding kinetics of the implemented assay. The geometric modification to the flow path is in the form of a constriction that is produced by depositing a photo-sensitive polymer onto the nitrocellulose membrane which when polymerized, creates impermeable barrier walls through the depth of the membrane. Both the position of the constriction within the flow path and the number of constrictions allow for an increase in the sensitivity because of a slower overall flow rate within the test and a larger volume of sample per unit width of the test line. For these high sensitivity LFDs (HS-LFD), through optimization of the constriction position and addition of a second constriction we attained a 62% increase in test line color intensity for the detection of procalcitonin (PCT) and were also able to lower the LOD from 10 ng/mL to 1 ng/mL. In addition, of relevance for future commercial exploitation, this also significantly decreases the antibody consumption per device leading to reduced costs for test production. We have further tested our HS-LFD with contrived human samples, validating its application for future clinical use.

[Urosepsis-targeted diagnostics and effective therapy]

Urinary tract infections (UTIs) are characterized by a broad clinical presentation ranging from uncomplicated cystitis to septic shock. 9-31% of all septicemias have a urogenital focus and are referred to as urosepsis. Urosepsis often occurs in the context of health system-associated infections. Obstructive uropathy (e.g., urolithiasis, tumors, strictures) is a major risk factor. The severity and course of urosepsis depend not only on the pathogenicity of the pathogen but also on the type and extent of the individual immune response. Therapy is divided into causal (antimicrobial therapy and focal sanitation), supportive (hemodynamic and pulmonal stabilization), and adjunctive (glucocorticoid and insulin therapy) therapy and should be initiated without delay. Due to demographic change, a further increase in urosepsis is expected in the future, so every urologist should be familiar with targeted diagnostics and effective therapy.

Elevated Procalcitonin Levels in a Patient With Diabetic Ketoacidosis in the Absence of Infection

Bacterial infections are one of the major precipitating factors in diabetic ketoacidosis (DKA). Procalcitonin (PCT) is highly specific in identifying bacteria sepsis, but PCT may be elevated in patients who do not have sepsis. Here, we report a 25-year-old patient admitted to the ICU for DKA. Initial laboratory investigation showed elevated PCT of 0.87 ng/ml and reached a concentration of 15.88 ng/ml on the second day of admission. PCT levels trended down to 4.7 ng/ml by the third day of admission. This case report shows PCT levels can be increased in patients with DKA even in the absence of infection and PCT levels decrease with clinical improvement of DKA without administration of antibiotics.

Procalcitonin is a prognosis biomarker in very preterm neonates with late onset sepsis: a pilot study

Neonatal sepsis contributes substantially to neonatal morbidity and mortality. Procalcitonin (PCT) is a recognized biomarker for the diagnosis of late-onset neonatal sepsis (LONS); however, little is known about the prognosis value of PCT in LONS. This study aims at assessing PCT value as a prognosis biomarker in preterm infants with LONS. Retrospective single center observational cohort study. All premature infants (less than 32 weeks of gestational age) with LONS admitted in a tertiary neonatal intensive care unit. Among the 59 preterm infants included in the analysis, 48 survived (81.4%, 48/59). Deceased patients had a significantly lower postmenstrual age (30 [29-32] vs. 28 [27-30], p = 0.025) and weight (1072 [850-1320] vs. 820 [730-1065], p = 0.016) at the time of LONS diagnosis. Although PCT values were not different between both groups at the time of LONS diagnosis, it was more elevated during the first 24 h in deceased patients (12 [1.1-20.3] vs. 1.57 [0.6-4.1], p = 0.041). Accuracy of PCT for predicting 60-day mortality in preterm neonates with LONS ranged from 0.70 to 0.82 of area under the curve on receiver operating characteristic curves. Optimal PCT cut-off values at LONS diagnosis was 8.92 µg/L, 15.75 µg/L for PCT values during the first 24 h, and 6.74 µg/L between 24 and 48 h after diagnosis. The estimated survival probability at day 60 was above 95% for patient with a PCT value at sepsis diagnosis under 8.92 µg/L and less than 45% if higher (p < 0.0001).

CONCLUSION

A PCT value > 8.92 µg/L obtained at LONS diagnosis suspicion seems to be a good prognosis biomarker.

WHAT IS KNOWN

•Procalcitonin (PCT) is a recognized biomarker of 28-day mortality in critically ill adults with septic shock and trauma. •Failure to have decreased in PCT in the first days of critical care is associated with increased mortality.

WHAT IS NEW

•Hereby, we show that PCT has a prognosis value in premature infants with late-onset neonatal sepsis. •Procalcitonin value > 8.92 µg/L at LONS diagnosis is associated with an increase at 60-day mortality.

Antimicrobial Stewardship Programs: A Review of Strategies to Avoid Polymyxins and Carbapenems Misuse in Low Middle-Income Countries

Antibiotics misuse and overuse are concerning issues worldwide, especially in low middle-income countries. These practices contribute to the increasing rates of antimicrobial resistance. One efficient strategy to avoid them is antimicrobial stewardship programs. In this review, we focus on the possible approaches to spare the prescription of polymyxins and carbapenems for the treatment of Acinetobacter baumannii, carbapenem-resistant Enterobacterales, and Pseudomonas aeruginosas infections. Additionally, we highlight how to implement cumulative antibiograms and biomarkers to a sooner de-escalation of antibiotics.

Diagnostic Value of the Triple Combination of Serum Heparin-Binding Protein, Procalcitonin, and C-Reactive Protein in Children with Acute Bacterial Upper Respiratory Tract Infection

To investigate the role of the triple combination serum heparin-binding protein (HBP), procalcitonin (PCT), and C-reactive protein (CRP) in children with acute bacterial upper respiratory tract infection (ABURTI). A total of 130 children with upper respiratory tract infection admitted to the Department of Pediatrics of Fujian Maternity and Child Health Hospital from September 2019 to January 2021 were selected as the research group. According to the results of pathogenic analysis, children were further subdivided into a bacterial infection group (n = 67) and a viral infection group (n = 63). Additionally, 65 children who underwent physical examinations in our hospital during the same period were collected and included into the control group (n = 65). All patients selected were treated with cefixime granules orally for 5 days. Serum HBP level, serum PCT level, and serum CRP level were measured by double antibody Sandwich Enzyme Linked Immunosorbent Assay (ELISA), fluorescence method, and immunoturbidimetric assay, respectively. The expression levels of the three indicators in the serum of all subjects were compared, and the receiver operating characteristic (ROC) curve was used to analyze their diagnostic value in children with ABURTI. Furthermore, according to clinical efficacy of children with bacterial infections, they were divided into a good efficacy group (markedly effective) and a poor efficacy group (effective + ineffective) to compare serum HBP, PCT, and CRP levels between the two groups. The ROC curve was drawn to analyze the value of the three indicators in predicting the curative effect in children with ABURTI. Pearson test was used to analyze the correlation among the expression of HBP, PCT, and CRP. Results showed that the expression levels of HBP, PCT, and CRP in the serum of children in the bacterial infection group were significantly higher than those in the other two groups. The positive rates of HBP, PCT, and CRP in children in the bacterial infection group were also significantly higher than those of the other two groups. The area under the curve (AUC) of the combined diagnosis of HBP, PCT, and CRP was 0.973, which was significantly higher than that of the single detection by any of the three indicators, which were 0.849, 0.819, and 0.854, respectively. The expression levels of HBP, PCT, and CRP in the serum of children in the good efficacy group were significantly lower than those in the poor efficacy group, and the AUC of the triple combination for predicting treatment efficacy was 0.959. Pearson test showed that there was a positive correlation between the serum expression of HBP, PCT, and CRP in children. HBP, PCT, and CRP were highly correlated in children with ABURTI, and their combined detection was of high diagnostic value among ABURTI patients, indicating that the three were expected to become potential indicators for efficacy prediction.

Candidate High-Resolution Mass Spectrometry-Based Reference Method for the Quantification of Procalcitonin in Human Serum Using a Characterized Recombinant Protein as a Primary Calibrator

Procalcitonin (PCT) is a widely used biomarker for rapid sepsis diagnosis and antibiotic stewardship. Variability of results in commercial assays has highlighted the need for standardization of PCT measurements. An antibody-free candidate reference measurement procedure (RMP) based on the isotope dilution mass spectrometry and protein calibration approach was developed and validated to quantify PCT in human serum. The method allows quantification of PCT from 0.25 to 13.74 μg/L (R > 0.998) with extension up to 132 μg/L after dilution of samples with PCT concentration above 13.74 μg/L. Intraday bias was between −3.3 and +5.7%, and interday bias was between −3.0 and −0.7%. Intraday precision was below 5.1%, and interday precision was below 4.0%. The candidate RMP was successfully applied to the absolute quantification of PCT in five frozen human serum pools. A recombinant PCT used as a primary calibrator was characterized by high-resolution mass spectrometry and amino acid analysis to establish traceability of the results to the SI units. This candidate RMP is fit to assign target values to secondary certified reference materials (CRMs) for further use in external quality assessment schemes to monitor the accuracy and comparability of the commercially available immunoassay results and to confirm the need for improving the harmonization of PCT assays. The candidate RMP will also be used to evaluate whether the correlation between the candidate RMP and immunoassays is sufficiently high. Overall, this candidate RMP will support reliable sepsis diagnosis and guide treatment decisions, patient monitoring, and outcomes.

Buried-Gate MWCNT FET-Based Nanobiosensing Device for Real-Time Detection of CRP

C-reactive protein (CRP), an acute-phase protein synthesized in the liver in response to inflammation, is one of the biomarkers used for the detection of several diseases. Sepsis and cardiovascular diseases are two of the most important diseases for which detection of CRP at very early stages in the clinical range can help avert serious consequences. Here, a CNT-based nanobiosensing system, which is portable and reproducible, is used for label-free, online detection of CRP. The system consists of an aptameric CNT-based field-effect transistor benefiting from a buried gate geometry with Al₂O₃ as a high dielectric layer and can reflect the pro-cytokine concentration. Test results show that the device responds to CRP changes within 8 min, with a limit of detection as low as 150 pM (0.017 mg L^-1). The device was found to have a linear behavior in the range of 0.43-42.86 nM (0.05-5 mg L^-1). The selectivity of the device was tested with TNF-α, IL-6, and BSA, to which the nanosensing system showed no significant response compared with CRP. The device showed good stability for 14 days and was completely reproducible during this period. These findings indicate that the proposed portable system is a potential candidate for CRP measurements in the clinical range.

Predictors of COVID-19 Hospital Treatment Outcome

Background

There are more than 228,394,572 confirmed cases and 4,690,186 confirmed deaths caused by COVID-19 worldwide. The magnitude of the COOVID-19 pandemic has stimulated research on the treatment and diagnosis of COVID-19 patients.

Objective

In this report, a battery of specific parameters was used to develop a model that allows prediction of the outcome of the COVID-19 treatment. These parameters are C-reactive protein, procalcitonin, fibrinogen, D-dimers, immature granulocytes, and interleukin-6.

Methods

The study was carried out on a sample of N = 49 survivors (22 men, 27 women) and 83 deceased patients (62 men, 21 women). The distribution of means and differences in means of the parameters studied between survivors and deceased patients were evaluated using the bootstrap method.

Results

A mathematical model that allows for the prediction of hospitalization outcome was obtained using the Naive Bayes model. The results demonstrated a statistically significant difference between survivors and deceased patients in all parameters studied. A mathematical model employing a battery of parameters provided a 97% precision in predicting the outcome of hospitalization.

Conclusion

This study showed that the cross-correlation of survivability with absolute levels of C-reactive protein, procalcitonin, fibrinogen, D-dimers, immature granulocytes, and interleukin-6 could be used successfully in the hospital setting as a diagnostic tool.

High Interleukin-8 Levels Associated With Decreased Survival in Patients With Cirrhosis Following Transjugular Intrahepatic Portosystemic Shunt

Background

Serum cytokines—reflecting systemic inflammation has been associated with the risk of decompensation and mortality in patients with cirrhosis. However, the role of systemic inflammation in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt procedure remains unknown.

Patients and Methods

Patients with cirrhosis who received transjugular intrahepatic portosystemic shunt between June 2015 and September 2017 were included. Portal and hepatic venous blood samples were obtained intraoperatively; serum cytokine levels (IL-10, IL-17A, IL-1RA, IL-8, and CXCL10) were measured in 105 patients. Associations with survival and other outcomes during long-term follow-up (median: 1,564 days) were assessed using logistic regression.

Results

IL-17A and CXCL10 levels were higher in the portal than in the hepatic veins, whereas IL-1RA levels were higher in the hepatic than in the portal veins. However, IL-8 or IL-10 levels between hepatic and portal veins showed no differences. Multivariate analysis demonstrated that Child–Pugh scores (P = 0.017, HR: 1.484, 95% CI: 1.072–2.055) and IL-8 level in hepatic veins (P < 0.001, HR: 1.043, 95% CI: 1.019–1.068) were independent predictors for mortality during long-term follow-up, with an optimal cut-off of 5.87 pg/ml for IL-8 in hepatic veins. Patients with hepatic IL-8 levels < 5.87 pg/ml had significantly higher cumulative survival rates (98.4 vs. 72.9% at 1 year, 98.4 vs. 65.3% at 2 years, 96.7 vs. 60.3% at 3 years, 94.2 vs. 60.3% at 4 years; P < 0.0001).

Conclusions

IL-8 levels in hepatic veins may reflect liver cirrhosis severity. Elevated IL-8 levels suggest shorter survival in patients receiving TIPS.

Comparison of Two Predictive Models of Sepsis in Critically Ill Patients Based on the Combined Use of Inflammatory Markers

Background

Sepsis is a systemic inflammatory response due to infection, resulting in organ dysfunction. Timely targeted interventions can improve prognosis. Inflammation plays a crucial role in the process of sepsis. To identify potential sepsis early, we developed and validated a nomogram model and a simple risk scoring model for predicting sepsis in critically ill patients.

Methods

The medical records of adult patients admitted to our intensive care unit (ICU) from August 2017 to December 2020 were analyzed. Patients were randomly divided into a training cohort (70%) and a validation cohort (30%). A nomogram model was developed through multivariate logistic regression analysis. The continuous variables included in nomogram model were transformed into dichotomous variables. Then, a multivariable logistic regression analysis was performed based on these dichotomous variables, and the odds ratio (OR) for each variable was used to construct a simple risk scoring model. The receiver operating characteristic curves (ROC) were constructed, and the area under the curve (AUC) was calculated.

Results

A total of 2074 patients were enrolled. Finally, white blood cell (WBC), C-reactive protein (CRP), interleukin-6 (IL-6), procalcitonin (PCT) and neutrophil-to-lymphocyte ratio (NLR) were included in our models. The AUC of the nomogram model and the simple risk scoring model were 0.854 and 0.842, respectively. The prediction performance of the two models on sepsis is comparable (p = 0.1298).

Conclusion

This study combining five commonly available inflammatory markers (WBC, CRP, IL-6, PCT and NLR) developed a nomogram model and a simple risk scoring model to predict sepsis in critically ill patients. Although the prediction performance of the two models is comparable, the simple risk scoring model may be simpler and more practical for clinicians to identify potential sepsis in critically ill patients at an early stage and strategize treatments.

Retrospective Cohort Analysis of the Effect of Antimicrobial Stewardship on Postoperative Antibiotic Therapy in Complicated Intra-Abdominal Infections: Short-Course Therapy Does Not Compromise Patients’ Safety

Background: Recent evidence suggests that short-course postoperative antibiotic therapy (PAT) of intra-abdominal infections is non-inferior considering clinical outcomes. The aim of this study was to compare the outcome of short vs. long PAT in complicated intra-abdominal infections (cIAIs) without sepsis. Methods: We performed a single center-quality improvement study at a 1500 bed sized university hospital in Bavaria, Germany, with evaluation of the length of antibiotic therapy after emergency surgery on cIAIs with adequate source control during 2016 to 2018. We reviewed a total of 260 cases (160 short duration vs. 100 long duration). The antibiotic prescribing quality was assessed by our in-house antimicrobial stewardship team (AMS). Results: No significant differences of patient characteristics were observed between short and long PAT. The frequency of long PAT declined during the observation period from 48.1% to 26.3%. Prolongation of PAT was not linked with any clinical benefits, on the contrary clinical outcome of patients receiving longer regimes were associated with higher postoperative morbidity. AMS identified additional educational targets to improve antibiotic prescribing quality on general wards like unnecessary postoperative switches of antibiotic regimes, e.g., unrequired switches to oral antibiotics as well as prolongation of PAT due to elevated CRP. Conclusion: Short-course antibiotic therapy after successful surgical source control in cIAIs is safe, and long-duration PAT has no beneficial effects.

Semi-quantitative detection of inflammatory biomarkers using a laser-patterned multiplexed lateral flow device

Inflammatory markers including C-reactive protein (CRP) and procalcitonin (PCT) have been shown to be useful biomarkers to improve triage speed and prevent the inappropriate use of antibiotics for infections such as pneumonia. Here, we present a novel and exciting solution to guide the administration of antibiotic treatment via rapid, semi-quantitative and multiplexed detection of CRP and PCT using an advanced lateral flow device (LFD) designed to have multiple parallel flow-paths, produced via the precise laser-based partitioning of the single flow-path of a standard LFD. Each flow-path within this multiplexed LFD has a unique detection capability which permits tailored detection of CRP within a predefined cut-off range (20 μg/mL - 100 μg/mL) and PCT above a pre-defined threshold (0.5 ng/mL). We demonstrate the use of this LFD in the successful detection of CRP and PCT semi-quantitatively within spiked human serum samples. This multiplexed near-patient assay has potential for development into a rapid triage and treatment of patients with suspected pneumonia.

MicroRNA as an Early Biomarker of Neonatal Sepsis

Sepsis is a major cause of lethality in neonatal intensive care units. Despite significant advances in neonatal care and growing scientific knowledge about the disease, 4 of every 10 infants born in developed countries and suffering from sepsis die or experience considerable disability, including substantial and permanent neurodevelopmental impairment. Pharmacological treatment strategies for neonatal sepsis remain limited and mainly based upon early initiation of antibiotics and supportive treatment. In this context, numerous clinical and serum-based markers have been evaluated for diagnosing sepsis and evaluating its severity and etiology. MicroRNAs (miRNAs) do not encode for proteins but regulate gene expression by inhibiting the translation or transcription of their target mRNAs. Recently, it was demonstrated in adult patients that miRNAs are released into the circulation and that the spectrum of circulating miRNAs is altered during various pathologic conditions, such as inflammation, infection, and sepsis. Here, we summarize current findings on the role of circulating miRNAs in the diagnosis and staging of neonatal sepsis. The conclusions point to substantial diagnostic potential, and several miRNAs have been validated independently by different teams, namely miR-16a, miR-16, miR-96-5p, miR-141, miR-181a, and miR-1184.

Procalcitonin metabolomics in the critically ill reveal relationships between inflammation intensity and energy utilization pathways

Procalcitonin is a biomarker of systemic inflammation and may have importance in the immune response. The metabolic response to elevated procalcitonin in critical illness is not known. The response to inflammation is vitally important to understanding metabolism alterations during extreme stress. Our aim was to determine if patients with elevated procalcitonin have differences in the metabolomic response to early critical illness. We performed a metabolomics study of the VITdAL-ICU trial where subjects received high dose vitamin D3 or placebo. Mixed-effects modeling was used to study changes in metabolites over time relative to procalcitonin levels adjusted for age, Simplified Acute Physiology Score II, admission diagnosis, day 0 25-hydroxyvitamin D level, and the 25-hydroxyvitamin D response to intervention. With elevated procalcitonin, multiple members of the short and medium chain acylcarnitine, dicarboxylate fatty acid, branched-chain amino acid, and pentose phosphate pathway metabolite classes had significantly positive false discovery rate corrected associations. Further, multiple long chain acylcarnitines and lysophosphatidylcholines had significantly negative false discovery rate corrected associations with elevated procalcitonin. Gaussian graphical model analysis revealed functional modules specific to elevated procalcitonin. Our findings show that metabolite differences exist with increased procalcitonin indicating activation of branched chain amino acid dehydrogenase and a metabolic shift.

Procalcitonin Increase Is Associated with the Development of Critical Care-Acquired Infections in COVID-19 ARDS

Secondary bacterial infection in COVID-19 patients is associated with increased mortality and disproportionately affects critically ill patients. This single-centre retrospective observational study investigates the comparative efficacy of change in procalcitonin (PCT) and other commonly available biomarkers in revealing or predicting microbiologically proven secondary infection in critical COVID-19 patients. Adult patients admitted to an intensive care unit (ICU) with confirmed SARS-CoV-2 infection between 9 March 2020 and 5 June 2020 were recruited to the study. For daily biomarker and secondary infection, laboratory-confirmed bloodstream infection (LCBI) and ventilator-associated pneumonia/tracheobronchitis (VAP/VAT) data were collected. We observed a PCT rise in 53 (81.5%) of the patients, a C-reactive protein (CRP) rise in 55 (84.6%) and a white blood cell count (WBC) rise in 61 (93.8%). Secondary infection was confirmed in 33 (50.8%) of the patients. A PCT rise was present in 97.0% of patients with at least one confirmed VAP/VAT and/or LCBI event. CRP and WBC rises occurred in 93.9% and 97.0% of patients with confirmed VAP/VAT and/or LCBI, respectively. Logistic regression analysis found that, when including all biomarkers in the same model, there was a significant association between PCT rise and the occurrence of LCBI and/or VAP/VAT (OR = 14.86 95%CI: 2.20, 342.53; p = 0.021). Conversely, no statistically significant relationship was found between either a CRP rise (p = 0.167) or a WBC rise (p = 0.855) and the occurrence of VAP/VAT and/or LCBI. These findings provide a promising insight into the usefulness of PCT measurement in predicting the emergence of secondary bacterial infection in ICU.

Impact of a Procalcitonin-Based Protocol on Antibiotic Exposure and Costs in Critically Ill Patients

Supplemental Digital Content is available in the text.

To examine the impact before and after adoption of a procalcitonin-based protocol to guide sepsis management has on antibiotic use, care costs, and outcomes of critically ill patients.

Risk prediction of biomarkers for early multiple organ dysfunction in critically ill patients

Background

Shock and organ damage occur in critically ill patients in the emergency department because of biological responses to invasion, and cytokines play an important role in their development. It is important to predict early multiple organ dysfunction (MOD) because it is useful in predicting patient outcomes and selecting treatment strategies. This study examined the accuracy of biomarkers, including interleukin (IL)-6, in predicting early MOD in critically ill patients compared with that of quick sequential organ failure assessment (qSOFA).

Methods

This was a multicenter observational sub-study. Five universities from 2016 to 2018. Data of adult patients with systemic inflammatory response syndrome who presented to the emergency department or were admitted to the intensive care unit were prospectively evaluated. qSOFA score and each biomarker (IL-6, IL-8, IL-10, tumor necrosis factor-α, C-reactive protein, and procalcitonin [PCT]) level were assessed on Days 0, 1, and 2. The primary outcome was set as MOD on Day 2, and the area under the curve (AUC) was analyzed to evaluate qSOFA scores and biomarker levels.

Results

Of 199 patients, 38 were excluded and 161 were included. Patients with MOD on Day 2 had significantly higher qSOFA, SOFA, and Acute Physiology and Chronic Health Evaluation II scores and a trend toward worse prognosis, including mortality. The AUC for qSOFA score (Day 0) that predicted MOD (Day 2) was 0.728 (95% confidence interval [CI]: 0.651–0.794). IL-6 (Day 1) showed the highest AUC among all biomarkers (0.790 [95% CI: 0.711–852]). The combination of qSOFA (Day 0) and IL-6 (Day 1) showed improved prediction accuracy (0.842 [95% CI: 0.771–0.893]). The combination model using qSOFA (Day 1) and IL-6 (Day 1) also showed a higher AUC (0.868 [95% CI: 0.799–0.915]). The combination model of IL-8 and PCT also showed a significant improvement in AUC.

Conclusions

The addition of IL-6, IL-8 and PCT to qSOFA scores improved the accuracy of early MOD prediction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00534-z.

The role of procalcitonin in identifying high-risk cancer patients with febrile neutropenia: A useful alternative to the multinational association for supportive care in cancer score

Background

The Multinational Association for Supportive Care in Cancer (MASCC) risk index has been utilized to determine the risk for poor clinical outcomes in patients with febrile neutropenia (FN) in an emergency center (EC). However, this index comprises subjective elements and elaborated metrics limiting its use in ECs. We sought to determine whether procalcitonin (PCT) level (biomarker of bacterial infection) with or without lactate level (marker of inadequate tissue perfusion) offers a potential alternative to MASSC score in predicting the outcomes of patients with FN presenting to an EC.

Methods

We retrospectively identified 550 cancer patients with FN who presented to our EC between April 2018, and April 2019, and had serum PCT and lactate levels measured.

Results

Compared with patients with PCT levels <0.25 ng/ml, those with levels ≥0.25 ng/ml had a significantly higher 14‐day mortality rate (5.2% vs. 0.7%; p = 0.002), a higher bloodstream infection (BSI) rate, and a longer hospital length of stay (LOS). Logistic regression analysis showed that patients with PCT levels ≥0.25 ng/ml and lactate levels >2.2 mmol/L were more likely to be admitted and have an LOS >7 days, BSI, and 14‐day mortality than patients with lower levels. PCT level was a significantly better predictor of BSI than MASSC score (p = 0.003) or lactate level (p < 0.0001).

Conclusions

Procalcitonin level is superior to MASCC index in predicting BSI. The combination of PCT and lactate levels is a good predictor of BSI, hospital admission, and 14‐day mortality and could be useful in identifying high‐risk FN patients who require hospital admission.