Procalcitonin to Reduce Long-Term Infection-associated Adverse Events in Sepsis. A Randomized Trial

Risk factors for peripancreatic and pancreatic infection of acute pancreatitis and the development of a clinical prediction model

Infected necrotizing pancreatitis (INP) is a serious complication that can increase the length of hospital stay and the cost of treatment, and is the leading cause of death in patients with acute pancreatitis (AP). This article aimed to predict the possibility of pancreatic and peripancreatic infections by early clinical indicators of AP and construct a clinical prediction model. We retrospectively studied consecutive patients admitted to the Nankai Hospital for moderate severe AP and severe AP, which developed within 2 weeks. Logistic regression was used to evaluate potential factors that could lead to INP and to develop clinical prediction model. Persistent organ failure, pancreatic necrosis area, and procalcitonin account were risk factors for INP. A prediction model was constructed based on the risk factors. The results showed that the model had good predictive performance. We developed a clinical prediction model with good predictive results that can be helpful for clinicians to identify and prevent the development of INP at an early stage.

Severe Pneumonia

Severe pneumonia is a leading cause of mortality and morbidity worldwide. Being a complex condition caused by a variety of microorganisms including bacteria, viruses, and fungi, it requires intensive care. A combination of early initiation of antimicrobial therapy and adjunctive nonantimicrobial interventions improve patient outcomes. This article reviews the most recent data on the epidemiology, microbiology, diagnosis, and management of severe pneumonia.

Comparative efficacy of two hemopurification filters for treating intra-abdominal sepsis: A retrospective study

PURPOSE

To compare the efficacy of continuous renal replacement therapy (CRRT) using either oXiris or conventional hemopurification filters in the treatment of intra-abdominal sepsis.

METHODS

We conducted a retrospective analysis of septic patients with severe intra-abdominal infections admitted to our hospital from October 2019 to August 2023. Patients who meet the criteria for intra-abdominal sepsis based on medical history, symptoms, physical examination, and laboratory/imaging findings were included.

EXCLUSION CRITERIA

pregnancy, terminal malignancy, prior CRRT before intensive care unit admission, pre-existing liver or renal failure. Heart rate (HR), mean arterial pressure, oxygenation index, lactic acid level (Lac), platelet count (PLT), neutrophil percentage, serum levels of procalcitonin, C-reactive protein, interleukin (IL)-6, norepinephrine dosage, acute physiology and chronic health evaluation II (APACHE II), and sequential organ failure assessment (SOFA) scores before and after 24 h and 72 h of treatment, as well as ventilator use time, hemopurification treatment time, intensive care unit and hospital lengths of stay, and 14-day and 28-day mortality were compared between patients receiving CRRT using either oXiris or conventional hemofiltration. Statistical analysis was performed using SPSS Statistics 26.0 software, including the construction of predictive models via logistic regression equations and repeated measures ANOVA.

RESULTS

Baseline values including time to antibiotic administration, time to source control, and time to initiation of CRRT were similar between the 2 groups (all p>0.05). Patients receiving conventional CRRT exhibited significant changes in HR but of none of the other indexes at the 24 h and 72 h time points (p=0.041, p=0.026, respectively). The oXiris group showed significant improvements in HR, Lac, IL-6, and APACHE II score 24 h after treatment (p<0.05); after 72 h, all indexes were improved except PLT (all p<0.05). Intergroup comparison disclosed significant differences in HR, Lac, norepinephrine dose, APACHE II, SOFA, neutrophil percentage, and IL-6 after 24 h of treatment (p<0.05). Mean arterial pressure, serum levels of procalcitonin, C-reactive protein, SOFA score, and norepinephrine dosage were similar between the 2 groups at 24h (p>0.05). Except for HR, oxygenation index, and PLT, post-treatment change rates of △ (%) were significantly greater in the oXiris group (p < 0.05). Duration of ventilator use, CRRT time, and intensive care unit and hospital lengths of stay were similar between the 2 groups (p>0.05). The 14-day mortality rates of the 2 groups were similar (p=0.091). After excluding patients whose CRRT was interrupted, 28-day mortality was significantly lower in the oXiris than in the conventional group (25.0% vs. 54.2%; p=0.050). The 28-day mortality rate increased by 9.6% for each additional hour required for source control and by 21.3% for each 1-point increase in APACHE II score.

CONCLUSIONS

In severe abdominal infections, the oXiris filter may have advantages over conventional CRRT, which may provide an alternative to clinical treatment. Meanwhile, early active infection source control may reduce the case mortality rate of patients with severe abdominal infections.

Procalcitonin and interleukin- 6 in predicting prognosis of sepsis patients with cancer

OBJECTIVE

To evaluate the ability of infection indicators to predict the prognosis of sepsis patients with tumor.

METHODS

A total of 317 patients admitted to ICU from January 1, 2021 to June 30, 2021 were enrolled. Among them, 163 patients were infected during peri-operative period, and 98 patients were ultimately diagnosed with sepsis. The infection indicators were analyzed for prediction of sepsis prognosis.

RESULTS

Comparison of infection indicators between sepsis and non-sepsis patients showed that procalcitonin (PCT) and interleukin-6 (IL-6) showed significant changes in sepsis patients (p < 0.05), and PCT combined with IL-6 significantly improved the specificity of early screening for sepsis with the highest positivity predictive value for sepsis. A combination of PCT > 5.965 ng/mL and IL-6 > 2808 pg/mL was associated with poor prognosis. Peak value combinations of PCT and IL-6 for prediction specificity, positive predictive value, and negative predictive value were 0.935, 0.692, and 0.682, respectively.

CONCLUSION

Abnormal increase of PCT and IL-6 has a good early warning effect on sepsis in cancer patients, and the combination of PCT and IL-6 can improve predictive specificity and increase positive predictive ability of sepsis diagnosis. PCT combined with IL-6 shows the value in predicting the prognosis of sepsis patients with cancer.

Antimicrobial stewardship interventions in hospitalized adults with community-acquired pneumonia: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis evaluate the effectiveness of ASPs in managing community-acquired pneumonia (CAP), focusing on antibiotic optimization and resistance mitigation.

METHODS

Comprehensive literature searches were conducted in PubMed, Scopus, and Web of Science using PICOS criteria. Studies involving adults with CAP exposed to ASPs were included. Data on clinical, economic, diagnostic, and treatment outcomes were extracted. Random-effects meta-analysis using R software pooled effect sizes. Outcomes reported in at least three studies were analyzed for robustness.

RESULTS

ASPs did not significantly impact in-hospital mortality, length of stay, 30-day readmissions, sample collection rates, or intravenous antibiotic duration. However, notable improvements included shorter time to clinical stability and a 31% reduction in 30-day mortality. Legionella urinary antigen testing frequency increased nearly threefold, and the time from admission to antibiotic initiation was reduced. Enhanced adherence to timely antibiotic administration and recommended regimens was observed, though outcome variability persisted.

CONCLUSION

ASPs significantly improve CAP management by enhancing clinical stability and accelerating antibiotic initiation. Multifaceted strategies, including rapid diagnostics and clinician education, yield clinical benefits. However, outcome variability suggests a need for tailored interventions. Future research should isolate specific ASP components influencing prescriber behavior. Ongoing investment in education, diagnostics, and interdisciplinary collaboration is vital to optimize CAP treatment and combat antibiotic resistance.

Procalcitonin-guided early cessation of antibiotics prevents gut inflammation and preserves gut microbiome: Data from the PROGRESS controlled trial

The PROGRESS randomised trial (ClinicalTrials.gov: NCT03333304) showed that early stopof antibiotics guided by procalcitonin (PCT) decreased the incidence of infections by multidrug-resistant organisms and/or Clostridioides difficile and was associated with survival benefit. This study was conducted to investigate whether this survival benefit is associated with microbiome dysbiosis. Patients with sepsis due to lung infection, acute pyelonephritis or primary bacteraemia were randomised to standard-of-care (SoC) duration of antibiotics or early stop using PCT. Faecal samples were collected before, and 7 and 28 days after randomisation and analysed using 16S rRNA Nanopore sequencing. Calprotectin was measured using an enzyme immunoassay. Median (Q1-Q3) antimicrobial duration was 5 (5-7.5) days in the PCT arm and 11 (8-15) days in the SoC arm (P < 0.001). Faecal calprotectin levels were similar in the two treatment arms at baseline. By day 7, the levels of faecal calprotectin were significantly increased in the SoC arm (P = 0.002) but were unchanged in the PCT arm. Microbiome α- and β-diversity was similar at baseline in the PCT (n=81) and SoC (n=76) treatment arms. Shannon's index was significantly lower in the SoC arm on day 7 compared with baseline (median [Q1-Q3], 2.88 [2.37-3.39] at day 1 vs. 2.24 [1.52-3.08] at day 7; Pt-test = 0.0013). This was not the case for the PCT arm (median [Q1-Q3], 2.73 [2.26-3.4] at day 1 vs. 2.43 [1.81-3.21] at day 7; Pt-test = 0.037, Bonferroni corrected α = 0.0125). The relative abundance of Actinomycetota and Pseudomonadota was decreased in the PCT arm by day 7 and that of Bacillota was increased. Early PCT-guided stop of antibiotics contributes to decreased microbiome dysbiosis by day 7.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Predictive value of procalcitonin for the therapeutic response of patients with uroseptic shock: a retrospective case-control study

OBJECTIVES

To evaluate the predictive value of procalcitonin (PCT) in assessing the therapeutic response of patients with uroseptic shock.

METHODS

This retrospective case-control study included 220 patients treated for uroseptic shock at Liyang People's Hospital between January 2018 and December 2023. Patients were classified into high-risk (HR) (n = 116) and low-risk (LR) (n = 104) groups based on their Sepsis-related Organ Failure Assessment (SOFA) scores after 14 days of treatment. Demographic, clinical, and laboratory data were collected, and PCT levels were measured using chemiluminescence. Correlation analysis and receiver operating characteristic (ROC) curve analysis were used to assess the predictive value of PCT.

RESULTS

The HR group had significantly higher PCT levels (25.33 ± 5.32 ng/mL) compared to the LR group (18.47 ± 2.88 ng/mL, P < 0.001). Elevated PCT levels were strongly correlated with poor therapeutic response (rho = -0.635, P < 0.001). Other markers, including hypertension (rho = -0.207, P = 0.002), CRP (rho = -0.224, P < 0.001), IL-6 (rho = -0.200, P = 0.003), TNF-α (rho = -0.151, P = 0.025), NEUT% (rho = -0.208, P = 0.002), GGT (rho = -0.160, P = 0.017), and BUN (rho = -0.198, P = 0.003), also showed significant negative correlations with treatment outcome. Conversely, PLT (rho = 0.156, P = 0.021) and the CD4+/CD8+ ratio (rho = 0.242, P < 0.001) were positively correlated with better treatment outcome. ROC analysis revealed an area under the curve (AUC) of 0.867 for PCT, indicating its strong predictive value.

CONCLUSIONS

PCT level is a robust predictor of therapeutic response in uroseptic shock patients and may be integrated into clinical protocols for sepsis management.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Comparison of the accuracy of procalcitonin, neutrophil CD64, and C-reactive protein for the diagnosis and prognosis of septic patients after antibiotic therapy

Background

The performance of the inflammatory biomarkers in the management of septic patients who received antimicrobial therapies is largely neglected. This study aimed to compare the accuracy of procalcitonin (PCT), neutrophil CD64 (CD64), and C-reactive protein (CRP) for the diagnosis and prognosis of septic patients after antimicrobial therapy.

Methods

This study prospectively recruited consecutive patients without infection and those diagnosed with infection but had received initial antimicrobial therapies. Sepsis was diagnosed according to sepsis-3 criteria. Serum PCT, CD64 and CRP levels were measured upon entry to the ICU. We also collected each patient's baseline characteristics. The diagnostic and prognostic performance of these parameters was evaluated from the area under the receiver operator characteristic curve (AUC).

Results

A total of 635 consecutive ICU patients were screened for eligible and 289 (45.5 %) patients were diagnosed with sepsis upon entry to the ICU. The area under the curve (AUC) for PCT, CD64 and CRP in the identification of sepsis is 0.726, 0.692 and 0.719, respectively. Neither PCT (p = 0.587) nor CD64 (p = 0.373) is superior to CRP in the diagnosis of septic patients who received antimicrobial therapies. The AUC for PCT, CD64 and CRP in the prediction of ICU mortality in these sepsis patients is 0.702, 0.637 and 0.593, respectively. The prognostic performance of PCT (p = 0.006) rather than CD64 (p = 0.509) is better than CRP.

Conclusions

Both PCT and CD64 are not superior to CRP in the identification of septic patients who received antimicrobial therapies. However, PCT instead of CD64 has a better prognostic accuracy than CRP for the prediction of ICU mortality of these septic patients.

Therapy of Aspiration: Out-of-Hospital and In-Hospital-Acquired

Therapeutic considerations for aspiration pneumonia prioritize the risk of multidrug-resistant organisms. This involves integrating microbiological insights with each patient's unique risk profile, including the location at the time of aspiration, and whether it occurred in or out of the hospital. Our understanding of the microbiology of aspiration pneumonia has also evolved, leading to a reassessment of anaerobic bacteria as the primary pathogens. Emerging research shows a predominance of aerobic pathogens, in both community and hospital-acquired cases. This shift challenges the routine use of broad-spectrum antibiotics targeting anaerobes, which can contribute to antibiotic resistance and complications such as Clostridium difficile infections-concerns that are especially relevant given the growing issue of antimicrobial resistance. Adopting a comprehensive, patient-specific approach that incorporates these insights can optimize antibiotic selection, improve treatment outcomes, and reduce the risk of resistance and adverse effects.

Dual-Fluorescent Quantum Dot Nanobead-Based Lateral Flow Immunoassay for Simultaneous Detection of C-Reactive Protein and Procalcitonin

Simultaneous detection of C-reactive protein (CRP) and procalcitonin (PCT) at the point of care is crucial for the management of infections in patients with inflammation and in critical care settings. The challenge of detecting high concentrations of CRP alongside low concentrations of PCT in plasma from inflammatory patients has limited the clinical application of multiplexed immunoassays. Herein, we developed a lateral flow immunoassay (LFIA) that employs quantum dot nanobeads (QDNBs) of varying sizes and colors to enable the simultaneous quantification of PCT and CRP in human plasma. To extend the dynamic range of CRP detection, we combined QDNBs with smaller particle sizes with the CRP detection antibodies, thereby increasing the assay's dynamic range and reducing the hook effect. At the same time, the stronger fluorescence emitted by these larger QDNBs, in conjugation with the PCT detection antibodies, allows for the detection of PCT at the nanogram level, meeting the demand for high sensitivity. The results show that this method can detect CRP concentrations from 0.1 to 3 mg/L and PCT with a detection limit of 0.09 ng/mL, which is on par with clinically used methods. By employing this dual-color and dual-size QDNB labeling strategy, we successfully achieved simultaneous detection of CRP with a broad dynamic range and PCT with high sensitivity in a one-step point-of-care rapid test.

Procalcitonin Guided Antibiotic Stewardship

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

Benefits and Harms of Procalcitonin- or C-Reactive Protein-Guided Antimicrobial Discontinuation in Critically Ill Adults With Sepsis: A Systematic Review and Network Meta-Analysis

OBJECTIVES

In sepsis treatment, antibiotics are crucial, but overuse risks development of antibiotic resistance. Recent guidelines recommended the use of procalcitonin to guide antibiotic cessation, but solid evidence is insufficient. Recently, concerns were raised that this strategy would increase recurrence. Additionally, optimal protocol or difference from the commonly used C-reactive protein (CRP) are uncertain. We aimed to compare the effectiveness and safety of procalcitonin- or CRP-guided antibiotic cessation strategies with standard of care in sepsis.

DATA SOURCES

A systematic search of PubMed, Embase, CENTRAL, Igaku Chuo Zasshi, ClinicalTrials.gov , and World Health Organization International Clinical Trials Platform.

STUDY SELECTION

Randomized controlled trials involving adults with sepsis in intensive care.

DATA EXTRACTION

A systematic review with network meta-analyses was performed. The Grading of Recommendations, Assessments, Developments, and Evaluation method was used to assess certainty.

DATA SYNTHESIS

Eighteen studies involving 5023 participants were included. Procalcitonin-guided and CRP-guided strategies shortened antibiotic treatment (-1.89 days [95% CI, -2.30 to -1.47], -2.56 days [95% CI, -4.21 to -0.91]) with low- to moderate-certainty evidence. In procalcitonin-guided strategies, this benefit was consistent even in subsets with shorter baseline antimicrobial duration (7-10 d) or in Sepsis-3, and more pronounced in procalcitonin cutoff of "0.5 μg/L and 80% reduction." No benefit was observed when monitoring frequency was less than half of the initial 10 days. Procalcitonin-guided strategies lowered mortality (-27 per 1000 participants [95% CI, -45 to -7]) and this was pronounced in Sepsis-3, but CRP-guided strategies led to no difference in mortality. Recurrence did not increase significantly with either strategy (very low to low certainty).

CONCLUSIONS

In sepsis, procalcitonin- or CRP-guided antibiotic discontinuation strategies may be beneficial and safe. In particular, the usefulness of procalcitonin guidance for current Sepsis-3, where antimicrobials are used for more than 7 days, was supported. Well-designed studies are needed focusing on monitoring protocol and recurrence.

Towards improved point-of-care (POC) testing for patients with suspected sepsis: POC tests for host biomarkers and possible microbial pathogens

INTRODUCTION

Sepsis is a heterogeneous syndrome often misdiagnosed. Point-of-care (POC) diagnostic tests are commonly used to guide decision and include host biomarkers and molecular diagnostics.

AREAS COVERED

The diagnostic and prognostic accuracy of established and emerging biomarkers for sepsis, including procalcitonin (PCT) soluble urokinase plasminogen activator receptor (suPAR), presepsin, TRAIL/IP-10/CRP, MxA, and MxA-CRP, are analyzed in this review. The clinical utility of the two prevalent molecular techniques for pathogens identification using polymerase chain reaction (PCR) assays is also presented: FILMARRAY and QIAstat-Dx RP.

EXPERT OPINION

The rising benefits of the combined use of POC biomarkers with molecular diagnostics in daily clinical routine appear to outperform conventional practices in terms of reduced turnaround time, timely diagnosis, and prompt administration of the appropriate treatment. Yet, this must be further demonstrated in future investigations. However, the cost-effectiveness of POC tests and the high rate of false positive and negative results, indicate the need for a comprehensive clinical evaluation.

[Short antibiotic therapy in hospitalized pneumonia: A cohort study]

INTRODUCTION

Pneumonia is one of the most common indications for antibiotic. Shortening the duration of antibiotic therapy should help reduce bacterial resistance. To date, three randomized control trials have shown non-inferiority of short courses of antibiotic therapy (3 days) compared with 7 days in non-severe pneumonia. The aim of this study was to assess this strategy in real life.

METHOD

This retrospective observational cohort study included all patients with pneumonia hospitalized in an internal medical ward from 11/01/2022 to 05/31/2023. We implemented the strategy based on early discontinuation of antibiotic therapy in patients with pneumonia who were clinically stable after 3 days of β-lactam treatment.

RESULTS

Among 49 patients included, median age was 72, median antibiotic duration was 4 days (IQR 3-6), and cure rate at D30 was 88 %. At day 30, we observed one death (2 %), four new antibiotic therapy (9 %), and two new hospitalisation (5 %), among five immunosuppressed patients. Among immunosuppressed patients (n=17; 35 %), failure rate was three times higher in case of short antibiotic courses (3/8; 38 %) than long antibiotic courses (1/7; 14 %).

CONCLUSION

Strategy based on early discontinuation of antibiotic therapy in immunocompetent patients with pneumonia who were clinically stable after 3 days of β-lactam treatment is safe, and easy to implement in a medical ward.

Early Diagnosis of Sepsis: The Role of Biomarkers and Rapid Microbiological Tests

Sepsis is a medical emergency resulting from a dysregulated response to an infection, causing preventable deaths and a high burden of morbidity. Protocolized and accurate interventions in sepsis are time-critical. Therefore, earlier recognition of cases allows for preventive interventions, early treatment, and improved outcomes. Clinical diagnosis of sepsis by clinical scores cannot be considered an early diagnosis, given that underlying molecular pathophysiological mechanisms have been activated in the preceding hour or days. There is a lack of a widely available tool enhancing preclinical diagnosis of sepsis. Sophisticated technologies for sepsis prediction have several limitations, including high costs. Novel technologies for fast molecular and microbiological diagnosis are focusing on bedside point-of-care combined testing to reach most settings where sepsis represents a challenge.

Development and validation of a machine learning-based interpretable model for predicting sepsis by complete blood cell parameters

Background

Sepsis, a severe infectious disease, carries a high mortality rate. Early detection and prompt treatment are crucial for reducing mortality and improving prognosis. The aim of this research is to develop a clinical prediction model using machine learning algorithms, leveraging complete blood cell (CBC) parameters, to detect sepsis at an early stage.

Methods

The study involved 572 patients admitted to West China Hospital of Sichuan University between July 2020 and September 2021. Among them, 215 were diagnosed with sepsis, while 357 had local infections. Demographic information was collected, and 57 CBC parameters were analyzed to identify potential predictors using techniques such as the Least Absolute Shrinkage and Selection Operator (LASSO), Random Forest (RF), Support Vector Machine (SVM), and eXtreme Gradient Boosting (XGBoost). The prediction model was built using Logistic Regression and evaluated for diagnostic specificity, discrimination, and clinical applicability including metrics such as the area under the curve (AUC), calibration curve, clinical impact curve, and clinical decision curve. Additionally, the model's diagnostic performance was assessed on a separate validation cohort. Shapley's additive explanations (SHAP), and breakdown (BD) profiles were used to explain the contribution of each variable in predicting the outcome.

Results

Among all the machine learning methods' prediction models, the LASSO-based model (λ = min) demonstrated the highest diagnostic performance in both the discovery cohort (AUC = 0.9446, P < 0.001) and the validation cohort (AUC = 0.9001, P < 0.001). Furthermore, upon local analysis and interpretation of the model, we demonstrated that LY-Z, MO-Z, and PLT-I had the most significant impact on the outcome.

Conclusions

The predictive model based on CBC parameters can be utilized as an effective approach for the early detection of sepsis.

Rapid identification of early infections in febrile patients after CD19 target CAR-T cell therapy for B-cell malignancies

BACKGROUND

CD19-targeted chimeric antigen receptor T (CAR-T) cell therapy stands out as a revolutionary intervention, exhibiting remarkable remission rates in patients with refractory/relapsed (R/R) B-cell malignancies. However, the potential side effects of therapy, particularly cytokine release syndrome (CRS) and infections, pose significant challenges due to their overlapping clinical features. Promptly distinguishing between CRS and infection post CD19 target CAR-T cell infusion (CTI) remains a clinical dilemma. Our study aimed to analyze the incidence of infections and identify key indicators for early infection detection in febrile patients within 30 days post-CTI for B-cell malignancies.

METHODS

In this retrospective cohort study, a cohort of 104 consecutive patients with R/R B-cell malignancies who underwent CAR-T therapy was reviewed. Clinical data including age, gender, CRS, ICANS, treatment history, infection incidence, and treatment responses were collected. Serum biomarkers procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) levels were analyzed using chemiluminescent assays. Statistical analyses employed Pearson's Chi-square test, t-test, Mann-Whitney U-test, Kaplan-Meier survival analysis, Cox proportional hazards regression model, Spearman rank correlation, and receiver operating characteristic (ROC) curve analysis to evaluate diagnostic accuracy and develop predictive models through multivariate logistic regression.

RESULTS

In this study, 38 patients (36.5%) experienced infections (30 bacterial, 5 fungal, and 3 viral) within the first 30 days of CAR T-cell infusion. In general, bacterial, fungal, and viral infections were detected at a median of 7, 8, and 9 days, respectively, after CAR T-cell infusion. Prior allogeneic hematopoietic cell transplantation (HCT) was an independent risk factor for infection (Hazard Ratio [HR]: 4.432 [1.262-15.565], P = 0.020). Furthermore, CRS was an independent risk factor for both infection ((HR: 2.903 [1.577-5.345], P < 0.001) and severe infection (9.040 [2.256-36.232], P < 0.001). Serum PCT, IL-6, and CRP were valuable in early infection prediction post-CAR-T therapy, particularly PCT with the highest area under the ROC curve (AUC) of 0.897. A diagnostic model incorporating PCT and CRP demonstrated an AUC of 0.903 with sensitivity and specificity above 83%. For severe infections, a model including CRS severity and PCT showed an exceptional AUC of 0.991 with perfect sensitivity and high specificity. Based on the aforementioned analysis, we proposed a workflow for the rapid identification of early infection during CAR-T cell therapy.

CONCLUSIONS

CRS and prior allogeneic HCT are independent infection risk factors post-CTI in febrile B-cell malignancy patients. Our identification of novel models using PCT and CRP for predicting infection, and PCT and CRS for predicting severe infection, offers potential to guide therapeutic decisions and enhance the efficacy of CAR-T cell therapy in the future.

Utilizing procalcitonin, C-reactive protein, and serum amyloid A in combination for diagnosing sepsis due to urinary tract infection

OBJECTIVE

In this study, we aimed to evaluate the combined diagnostic value of procalcitonin (PCT), C-reactive protein (CRP), and serum amyloid A (SAA) in sepsis caused by urinary tract infection.

METHOD

A total of 80 patients with urosepsis who were hospitalized were included in the study group, and 80 patients with urinary tract infection without sepsis were included in the control group. We collected the PCT, SAA, and CRP levels of patients following admission. Subsequently, we conducted a comparative analysis to assess the specificity, accuracy, and sensitivity of combined diagnostic approaches in contrast to individual diagnostic methods for blood PCT, SAA, and CRP.

RESULTS

The levels of PCT, SAA, and CRP in the study group were significantly higher than those in the control group, and the differences were statistically significant (P < 0.01). Multi-factor logistic regression analysis revealed that the levels of PCT (P = 0.003) and SAA (P = 0.014) were associated with urosepsis. The sensitivity of PCT was 87.133% and the specificity was 93.066%, which were higher than that of SAA and CRP. The specificity of the combined detection of the three was 95.670%, which was higher than that of PCT, SAA, and CRP alone. Correlation analysis revealed that PCT had a significant positive correlation with CRP and SAA (P < 0.01), and a weak correlation with white blood cell count (WBC) and fibrinogen (FIB) (P = 0.03 for WBC, P = 0.04 for FIB).

CONCLUSION

PCT, SAA, and CRP indicators in patients with urosepsis are significantly elevated, and all three are valuable in the diagnosis of urosepsis. PCT alone has good diagnostic efficiency for urosepsis, and a certain correlation with other inflammatory factors. The diagnostic efficacy of the three indicators in combination is better than that of any one of the three, and is worthy of widespread clinical application.

The value of IL-6, PCT, qSOFA, NEWS, and SIRS to predict septic shock after Percutaneous nephrolithotomy

BACKGROUND

There are numerous methods available for predicting sepsis following Percutaneous Nephrolithotomy. This study aims to compare the predictive value of Quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SISR), National Early Warning Score (NEWS), interleukin-6 (IL-6), and procalcitonin (PCT) for septicemia.

METHODS

Patients who underwent percutaneous nephrolithotomy were included in the study and divided into a control group and a septic shock group. The effectiveness of qSOFA, SIRS, NEWS, Interleukin-6, and Procalcitonin was assessed, with Receiver Operating Characteristic curves and Area Under the Curve used to compare the predictive accuracy of these four indicators.

RESULTS

Among the 401 patients, 16 cases (3.99%) developed septic shock. Females, elderly individuals, and patients with positive urine culture and positive nitrite in urine were found to be more susceptible to septic shock. PCT, IL-6, SIRS, NEWS, qSOFA, and surgical time were identified as independent risk factors for septic shock. The cutoff values are as follows: qSOFA score > 0.50, SIRS score > 2.50, NEWS score > 2.50, and IL-6 > 264.00 pg/ml. Among the 29 patients identified by IL-6 as having sepsis, 16 were confirmed to have developed sepsis. The qSOFA identified 63 septicemia cases, with 16 confirmed to have developed septicemia; NEWS identified 122 septicemia cases, of which 14 cases actually developed septicemia; SIRS identified 128 septicemia patients, with 16 confirmed to have developed septicemia. In terms of predictive ability, IL-6 (AUC 0.993, 95% CI 0.985 ~ 1) demonstrated a higher predictive accuracy compared to qSOFA (AUC 0.952, 95% CI 0.928 ~ 0.977), NEWS (AUC 0.824, 95% CI 0.720 ~ 0.929) and SIRS (AUC 0.928, 95% CI 0.888 ~ 0.969).

CONCLUSIONS

IL-6 has higher accuracy in predicting septic shock after PCNL compared to qSOFA, SIRS, and NEWS.

Review of the Predictive Value of Biomarkers in Sepsis Mortality

Sepsis is a leading cause of mortality among severely ill individuals, primarily due to its potential to induce fatal organ dysfunction. For clinicians, it is vital to have appropriate indicators, including the physiological status and personal experiences of patients with sepsis, to monitor the condition and assess prognosis. This approach aids in preventing the worsening of the illness and reduces mortality. Recent guidelines for sepsis focus on improving patient outcomes through early detection and timely treatment. Nonetheless, identifying severe cases and predicting their prognoses remain challenging. In recent years, there has been considerable interest in utilising the C-reactive protein (CRP)/albumin ratio (CAR) to evaluate the condition and forecast the prognosis of patients with sepsis. This research concentrates on the significance of CAR in the pathological process of sepsis, its association with prognosis, and the latest developments in employing procalcitonin, lactic acid, CRP, and other potential biomarkers. The CAR, with its predictive value for sepsis prognosis and mortality, is increasingly used as a clinical biochemical marker in diagnosing and monitoring patients with sepsis.

Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis

Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium. It is characterized by acute onset, rapid progress and high risk of death. Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm. According to China's practical experience, the adoption of the "life support-based comprehensive treatment regimen" (with mechanical circulation support and immunomodulation therapy as the core) can significantly improve the survival rate and long-term prognosis. Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.

Role of biomarkers in antimicrobial stewardship: physicians' perspectives

Biomarkers are playing an increasingly important role in antimicrobial stewardship. Their applications have included use in algorithms that evaluate suspected bacterial infections or provide guidance on when to start or stop antibiotic therapy, or when therapy should be repeated over a short period (6-12 h). Diseases in which biomarkers are used as complementary tools to determine the initiation of antibiotics include sepsis, lower respiratory tract infection (LRTI), COVID-19, acute heart failure, infectious endocarditis, acute coronary syndrome, and acute pancreatitis. In addition, cut-off values of biomarkers have been used to inform the decision to discontinue antibiotics for diseases such as sepsis, LRTI, and febrile neutropenia. The biomarkers used in antimicrobial stewardship include procalcitonin (PCT), C-reactive protein (CRP), presepsin, and interleukin (IL)-1β/IL-8. The cut-off values vary depending on the disease and study, with a range of 0.25-1.0 ng/mL for PCT and 8-50 mg/L for CRP. Biomarkers can complement clinical diagnosis, but further studies of microbiological biomarkers are needed to ensure appropriate antibiotic selection.

Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study

OBJECTIVE

To evaluate the association of biomarkers with successful ventilatory weaning in COVID-19 patients.

METHODS

An observational, retrospective, and single-center study was conducted between March 2020 and April 2021. C-reactive protein, total lymphocytes, and the neutrophil/lymphocyte ratio were evaluated during attrition and extubation, and the variation in these biomarker values was measured. The primary outcome was successful extubation. ROC curves were drawn to find the best cutoff points for the biomarkers based on sensitivity and specificity. Statistical analysis was performed using logistic regression.

RESULTS

Of the 2,377 patients admitted to the intensive care unit, 458 were included in the analysis, 356 in the Successful Weaning Group and 102 in the Failure Group. The cutoff points found from the ROC curves were -62.4% for C-reactive protein, +45.7% for total lymphocytes, and -32.9% for neutrophil/lymphocyte ratio. These points were significantly associated with greater extubation success. In the multivariate analysis, only C-reactive protein variation remained statistically significant (OR 2.6; 95%CI 1.51 - 4.5; p < 0.001).

CONCLUSION

In this study, a decrease in C-reactive protein levels was associated with successful extubation in COVID-19 patients. Total lymphocytes and the neutrophil/lymphocyte ratio did not maintain the association after multivariate analysis. However, a decrease in C-reactive protein levels should not be used as a sole variable to identify COVID-19 patients suitable for weaning; as in our study, the area under the ROC curve demonstrated poor accuracy in discriminating extubation outcomes, with low sensitivity and specificity.

Clarithromycin for early anti-inflammatory responses in community-acquired pneumonia in Greece (ACCESS): a randomised, double-blind, placebo-controlled trial

BACKGROUND

Addition of macrolide antibiotics to β-lactam antibiotics for the treatment of patients in hospital with community-acquired pneumonia is based on results from observational studies and meta-analyses rather than randomised clinical trials. We investigated if addition of the macrolide clarithromycin to treatment with a β-lactam antibiotic in this population could improve early clinical response-the new regulatory endpoint for community-acquired pneumonia-and explored the possible contribution of modulation of the inflammatory host response to that outcome.

METHODS

The ACCESS trial was a phase 3 prospective, double-blind, randomised controlled trial, in which adults in hospital with community-acquired pneumonia who had systemic inflammatory response syndrome, Sequential Organ Failure Assessment (SOFA) score of 2 or more, and procalcitonin 0·25 ng/mL or more were enrolled in 18 internal medicine departments of public Greek hospitals. Patients were randomly assigned (1:1) by computer-generated block randomisation to standard of care medication (including intravenous administration of a third-generation cephalosporin or intravenous administration of β-lactam plus β-lactamase inhibitor combination) plus either oral placebo or oral clarithromycin 500 mg twice daily for 7 days. Investigators, staff, and patients were masked to group allocation. The primary composite endpoint required that patients fulfilled both of the following conditions after 72 hours (ie, day 4 of treatment): (1) decrease in respiratory symptom severity score of 50% or more as an indicator of early clinical response and (2) decrease in SOFA score of at least 30% or favourable procalcitonin kinetics (defined as ≥80% decrease from baseline or procalcitonin <0·25 ng/mL), or both, as an indicator of early inflammatory response. Participants who were randomly assigned and received allocated treatment were included in the primary analysis population. This trial is complete and is registered with the EU Clinical Trials Register (2020-004452-15) and ClinicalTrials.gov (NCT04724044).

FINDINGS

Patients were enrolled between Jan 25, 2021, and April 11, 2023, and 278 individuals were randomly allocated to receive standard of care in combination with either clarithromycin (n=139) or placebo (n=139). 134 patients in the clarithromycin group (five withdrew consent) and 133 patients in the placebo group (six withdrew consent) were included in the analysis of the primary endpoint. The primary endpoint was met in 91 (68%) patients in the clarithromycin group and 51 (38%) patients in the placebo group (difference 29·6% [95% CI 17·7-40·3]; odds ratio [OR] 3·40 [95% CI 2·06-5·63]; p<0·0001). Serious treatment-emergent adverse events (TEAEs) occurred in 58 (43%) patients in the clarithromycin group and 70 (53%) patients in the placebo group (difference 9·4% [95% CI -2·6 to 20·9]; OR 0·67 [95% CI 0·42 to 1·11]; p=0·14). None of the serious TEAEs was judged to be related to treatment assignment.

INTERPRETATION

Addition of clarithromycin to standard of care enhances early clinical response and attenuates the inflammatory burden of community-acquired pneumonia. The mechanism of benefit is associated with changes in the immune response. These findings suggest the importance of adding clarithromycin to β-lactams for treatment of patients in hospital with community-acquired pneumonia to achieve early clinical response and early decrease of the inflammatory burden.

FUNDING

Hellenic Institute for the Study of Sepsis and Abbott Products Operations.

Aspiration Pneumonia

Aspiration pneumonia is a lower respiratory tract infection that results from inhalation of foreign material, often gastric and oropharyngeal contents. It is important to distinguish this from a similar entity, aspiration with chemical pneumonitis, as treatment approaches may differ. An evolving understanding of the human microbiome has shed light on the pathogenesis of aspiration pneumonia, suggesting that dysbiosis, repetitive injury, and inflammatory responses play a role in its development. Risk factors for aspiration events involve a complex interplay of anatomical and physiological dysfunctions in the nervous, gastrointestinal, and pulmonary systems. Current treatment strategies have shifted away from anaerobic organisms as leading pathogens. Prevention of aspiration pneumonia primarily involves addressing oropharyngeal dysphagia, a significant risk factor for aspiration pneumonia, particularly among elderly individuals and those with cognitive and neurodegenerative disorders.

Beyond the Surviving Sepsis Campaign Guidelines: a systematic review of interventions affecting mortality in sepsis

INTRODUCTION

Sepsis-related mortality is decreasing over time after the introduction of "Surviving Sepsis Campaign" Guidelines in 2004. The last Guidelines version collects 93 recommendations, but several interventions supported by randomized evidence of mortality reduction are not included.

EVIDENCE ACQUISITION

We performed a systematic review of all randomized controlled trials reporting a statistically significant mortality reduction in septic patients and compared the identified studies to the Surviving Sepsis Campaign Guidelines 2021 to highlight discrepancies.

EVIDENCE SYNTHESIS

We identified 83 randomized controlled trials (58 interventions) influencing mortality in sepsis. Only 9/58 of these interventions were included in the Guidelines: lactate measurement and lactate-guided hemodynamic management, procalcitonin-guided antibiotics discontinuation, balanced crystalloids as first choice fluids, albumin infusion, avoidance of starches, noradrenaline as first line vasopressor, vasopressin as an adjunctive vasopressor to noradrenaline, neuromuscular blocking agents in moderate-severe sepsis-associated acute respiratory distress syndrome, and corticosteroids use. Only 11/93 Guidelines recommendations were supported by randomized evidence with mortality difference. Five of the interventions with survival benefit in literature (vitamin C, terlipressin, polymyxin B, liberal transfusion strategy and immunoglobulins) were recommended to avoid in the Guidelines, while 44 interventions were not mentioned, including three interventions (esmolol, omega 3, and external warming) with at least two randomized controlled trials with a documented survival benefit.

CONCLUSIONS

Several discrepancies exist between the randomized controlled trials with mortality difference in septic patients and the latest Surviving Sepsis Campaign Guidelines. This systematic review can be of help for improving future guidelines and may guide research on specific promising topics.

Practical Lessons on Antimicrobial Therapy for Critically Ill Patients

Sepsis stands as a formidable global health challenge, with persistently elevated mortality rates in recent decades. Each year, sepsis not only contributes to heightened morbidity but also imposes substantial healthcare costs on survivors. This narrative review aims to highlight the targeted measures that can be instituted to alleviate the incidence and impact of sepsis in intensive care. Here we discuss measures to reduce nosocomial infections and the prevention of equipment and patient colonisation by resilient pathogens. The overarching global crisis of bacterial resistance to newly developed antimicrobial agents intensifies the imperative for antimicrobial stewardship and de-escalation. This urgency has been accentuated in recent years, notably during the COVID-19 pandemic, as high-dose steroids and opportunistic infections presented escalating challenges. Ongoing research into airway colonisation's role in influencing disease outcomes among critically ill patients underscores the importance of tailoring treatments to disease endotypes within heterogeneous populations, which are important lessons for intensivists in training. Looking ahead, the significance of novel antimicrobial delivery systems and drug monitoring is poised to increase. This narrative review delves into the multifaceted barriers and facilitators inherent in effectively treating critically ill patients vulnerable to nosocomial infections. The future trajectory of intensive care medicine hinges on the meticulous implementation of vigilant stewardship programs, robust infection control measures, and the continued exploration of innovative and efficient technological solutions within this demanding healthcare landscape.

Clinical utility of procalcitonin in implementation of procalcitonin-guided antibiotic stewardship in the South-East Asia and India: evidence and consensus-based recommendations

INTRODUCTION

The South-East Asian (SEA) region and India are highly susceptible to antibiotic resistance, which is caused due to lack of antimicrobial stewardship (AMS) knowledge, uncontrolled use of antibiotics, and poor infection control. Nonadherence to national/local guidelines, developed to combat antimicrobial resistance, is a major concern. A virtual advisory board was conducted to understand the current AMS standards and challenges in its implementation in these regions.

AREAS COVERED

Procalcitonin (PCT)-guided antibiotic use was discussed in various clinical conditions across initiation, management, and discontinuation stages. Most experts strongly recommended using PCT-driven antibiotic therapy among patients with lower respiratory tract infections, sepsis, and COVID-19. However, additional research is required to understand the optimal use of PCT in patients with organ transplantation and cancer patients with febrile neutropenia. Implementation of the solutions discussed in this review can help improve PCT utilization in guiding AMS in these regions and reducing challenges.

EXPERT OPINION

Experts strongly support the inclusion of PCT in AMS. They believe that PCT in combination with other clinical data to guide antibiotic therapy may result in more personalized and precise targeted antibiotic treatment. The future of PCT in antibiotic treatment is promising and may result in effective utilization of this biomarker.

Diagnostic value of inflammatory indicators for surgical site infection in patients with breast cancer

Background

Breast cancer is the most commonly diagnostic cancer in women worldwide. The main treatment for these patients is surgery. However, there is a high incidence of surgical site infection (SSI) in breast cancer patients. The aim of this study was to identify effective infection-related diagnostic markers for timely diagnosis and treatment of SSI.

Methods

This retrospective study included 263 breast cancer patients who were treated between July 2018 and March 2023 at the Shandong Cancer Hospital and Institute. We analyzed differences between the SSI group and control group and differences before and during infection in the SSI group. Finally, we tested the distribution of pathogenic microorganisms and their susceptibility to antibiotics.

Results

Compared with preoperative inflammatory indicators, white blood cells (WBC), neutrophils (NEU), absolute neutrophil count to the absolute lymphocyte count (NLR), D2 polymers (D-Dimer) and fibrinogen (FIB) were significantly increased, while lymphocytes (LYM), albumin (ALB) and prealbumin (PA) were significantly decreased in the SSI group. Compared with uninfected patients, WBC, NEU, NLR and FIB were significantly increased, ALB and PA were significantly decreased in SSI patients, while LYM and D-Dimer did not differ significantly. The distribution of infection bacteria in SSI patients showed that the proportion of patients with Staphylococcus aureus infection was as high as 70.41%; of those patients, 19.33% had methicillin-resistant Staphylococcus aureus (MRSA) infection. The area under the curves (AUCs) of the receiver operating curves (ROCs) for WBC, NEU, NLR, FIB, ALB and PA were 0.807, 0.811, 0.730, 0.705, 0.663 and 0.796, respectively. The AUCs for other inflammatory indicators were not statistically significant. There was no significant difference in antibiotic resistance for Staphylococcus aureus when compared to that of gram-positive bacteria. The resistance of gram-positive bacteria to ceftriaxone (CRO), cefoxitin (FOX), chloramphenicol (CHL), minocycline (MNO) and tetracycline (TCY) was lower than that of gram-negative bacteria, while the resistance to gentamicin (GEN) was higher.

Conclusion

This study demonstrated that WBC, NEU, NLR, FIB and PA have good predictive value for identifying patients at risk of SSI. The cut-off values of inflammatory indicators can be helpful in the prevention and diagnosis of SSI.

Clinical value of neutrophil-to-lymphocyte ratio and prognostic nutritional index on prediction of occurrence and development of diabetic foot-induced sepsis

Background

Diabetic foot-induced sepsis is a serious complication associated with increased disability and mortality in hospitalized patients. Early prediction of admission and detection effectively improve treatment options and prevent further deterioration. This study aims to evaluate the clinical value of the neutrophil-to-lymphocyte ratio (NLR) and prognostic nutritional index (PNI) to predict the risk of sepsis in patients with diabetic foot ulcers (DFU).

Methods

Retrospective analysis was performed on 216 patients who were admitted to the Fujian Medical University Union Hospital between January 2015 and December 2022. Patients with DFU were divided into the non-sepsis (n = 166) and the DFU-induced sepsis (n = 50) groups. The independent factors of DFU-induced sepsis were determined by univariate and multivariate logistic regression analyses. A receiver operating characteristic (ROC) curve was performed to compare the area under the curves (AUC) of PNI and NLR.

Results

Multivariate logistic regression analysis revealed that the PNI, NLR, international normalized ratio (INR), thrombin time (PT), and C-reactive protein (CRP) were independent prognostic factors for DFU-induced sepsis. After adjusting for potential confounders, the adjusted odds ratios of NLR for DFU-induced sepsis were 1.121 (1.072-1.172), 1.132 (1.077-1.189), and 1.080 (1.022-1.142), while those of PNI were 0.912 (0.873-0.953), 0.902 (0.856-0.950), and 1.004 (1.001-1.006). Moreover, the AUC of NLR was significantly greater than that of CRP (0.790, 95% CI: 0.689-0.891, p < 0.001 vs. 0.780, 95% CI: 0.686-0.873, p < 0.001).

Conclusion

NLR and PNI have been regarded as readily and independently predictive markers in patients with DFU-induced sepsis. NLR is critical for the early detection and effective treatment of DFU-induced sepsis and is superior to CRP.

Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis

BACKGROUND

Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients.

METHODS

We searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes.

RESULTS

We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79 days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95% CI: - 3.13, 0.67, respectively).

CONCLUSIONS

PCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.

Detection of Inflammatory Biomarkers Among Patients with Sepsis of Gram-Negative Bacteria: A Cross-Sectional Study

Background

Sepsis is a highly mixed ailment that affects patients with numerous conditions of infectious sources and can lead to multi-organ failure with dysregulated host immune response.

Objective

To determine inflammatory biomarkers in patients with sepsis caused by Gram-negative bacteria and compare their role in the early detection of sepsis.

Methods

This cross-sectional study was conducted on patients with sepsis admitted to the intensive care unit at different hospitals in Sulaimaniyah, Iraq, from May to December 2021. Patients (n=147) were enrolled in this study according to the primary diagnosis of sepsis by Sequential Organ Failure Assessment scores. Blood samples were taken from patients to investigate white blood cells, inflammatory biomarkers (pentraxin-3, procalcitonin, adrenomedullin, lipopolysaccharide binding protein, interleukin-17A, lactate dehydrogenase, and C-creative protein), blood culture, antibiotic susceptibility test, and coagulation biomarkers (Prothrombin time, activated partial thromboplastin time, and international normalized ratio). Then, isolated Gram-negative bacteria were tested for extended-spectrum β-lactamase enzymes production by screening and combined disc tests.

Results

A total of 51.7% samples were blood culture positive for different Gram-negative bacteria, and P. aeruginosa (51.95%) was a more isolated bacterium. Both males and females were affected by sepsis in a ratio of 1.23:1 with different age groups. Extended-spectrum β-lactamase was estimated to be 77.2% by antibiotic profile, and the rate decreased using two double-disc synergy tests. This was confirmed by combined disc test at a rate of 41.35%. The most prevalent biomarkers were procalcitonin (88.16%), adrenomedullin (84.21%), pentraxin-3 (22.37%), and lipopolysaccharide binding protein (11.84%).

Conclusion

Sepsis is a life-threatening condition that can be diagnosed early by several blood biomarkers such as procalcitonin, adrenomedullin, and pentraxin-3 combined with a standard blood culture technique to improve the patient outcome.

Prognostic value of platelet combined with serum procalcitonin in patients with sepsis

Sepsis, a common and life-threatening condition in critically ill patients, is a leading cause of death in intensive care units. Over the past few decades, there has been significant improvement in the understanding and management of sepsis. However, the mortality rate remains unacceptably high, posing a prominent challenge in modern medicine and a significant global disease burden. A total of 295 patients with sepsis admitted to the hospital from January 2021 to December 2022 were collected and divided into survival group and death group according to their 28-day survival status. The differences in general clinical data and laboratory indicators between the 2 groups were compared. Receiver operating characteristic curve analysis was used to evaluate the predictive value of platelet (PLT) and procalcitonin (PCT) for the prognosis of sepsis patients within 28 days. A total of 295 patients were diagnosed with sepsis, and 79 died, with a mortality rate of 26.78%. The PLT level in the death group was lower than that in the survival group; the PCT level in the death group was higher than that in the survival group. The receiver operating characteristic curve showed that the area under the curve of PCT and PLT for evaluating the prognosis of sepsis patients were 0.808 and 0.804, respectively. Kaplan-Meier survival analysis showed that the 28-day survival rate of the low PLT level group was 19.0% and that of the high PLT level group was 93.1% at the node of 214.97 × 109/L, and the difference between the 2 groups was statistically significant (χ2 = 216.538, P < .001). The 28-day survival rate of the low PCT level group was 93.4% and that of the high PCT level group was 51.7% at the node of 2.85 ng/mL, and the difference between the 2 groups was statistically significant (χ2 = 63.437, P < .001). There was a negative correlation between PCT level and PLT level (r = -0.412, P < .001). Platelet combined with serum procalcitonin detection has high predictive value for judging the 28-day prognosis of sepsis, and it can be used as an index for evaluating the patient's condition and prognosis, and is worthy of clinical promotion and application.

Antimicrobial stewardship in the intensive care unit

High resistance rates to antimicrobials continue to be a global health threat. The incidence of multidrug-resistant (MDR) microorganisms in intensive care units (ICUs) is quite high compared to in the community and other units in the hospital because ICU patients are generally older, have higher numbers of co-morbidities and immune-suppressed; moreover, the typically high rates of invasive procedures performed in the ICU increase the risk of infection by MDR microorganisms. Antimicrobial stewardship (AMS) refers to the implementation of coordinated interventions to improve and track the appropriate use of antibiotics while offering the best possible antibiotic prescription (according to dose, duration, and route of administration). Broad-spectrum antibiotics are frequently preferred in ICUs because of greater infection severity and colonization and infection by MDR microorganisms. For this reason, a number of studies on AMS in ICUs have increased in recent years. Reducing the use of broad-spectrum antibiotics forms the basis of AMS. For this purpose, parameters such as establishing an AMS team, limiting the use of broad-spectrum antimicrobials, terminating treatments early, using early warning systems, pursuing infection control, and providing education and feedback are used. In this review, current AMS practices in ICUs are discussed.

Utility of Procalcitonin in Clinical Practice

The rise of multi-resistant infections and complications associated with the overuse of antibiotics has led to the implementation of antibiotic stewardship strategies as a marker of patient safety and quality. Using biomarkers that can accurately predict the presence or absence of bacterial infection, thus signaling the need for antibiotic use, or supporting appropriate and safe discontinuation, has become an increasingly relevant strategy for antibiotic stewardship. Evidence supporting procalcitonin for antimicrobial stewardship has focused mostly on lower respiratory tract infections and sepsis. This review discusses the most relevant evidence to support the use of procalcitonin in clinical practice.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Procalcitonin as a biomarker to guide treatments for patients with lower respiratory tract infections

INTRODUCTION

Lower respiratory tract infections are amongst the main causes for hospital/intensive care unit admissions and antimicrobial prescriptions. In order to reduce antimicrobial pressure, antibiotic administration could be optimized through procalcitonin-based algorithms.

AREAS COVERED

In this review, we discuss the performances of procalcitonin for the diagnosis and the management of community-acquired and ventilator-associated pneumonia. We provide up-to-date evidence and deliver clear messages regarding the purpose of procalcitonin to reduce unnecessary antimicrobial exposure.

EXPERT OPINION

Antimicrobial pressure and resulting antimicrobial resistances are a major public health issue as well as a daily struggle in the management of patients with severe infectious diseases, especially in intensive care units where antibiotic exposure is high. Procalcitonin-guided antibiotic administration has proven its efficacy in reducing unnecessary antibiotic use in lower respiratory tract infections without excess in mortality, hospital length of stay or disease relapse. Procalcitonin-guided algorithms should be implemented in wards taking care of patients with severe infections. However, procalcitonin performances are different regarding the setting of the infection (community versus hospital-acquired infections) the antibiotic management (start or termination of antibiotic) as well as patient's condition (immunosuppressed or in shock) and we encourage the physicians to be aware of these limitations.

Diagnostic and Prognostic Roles of Procalcitonin and Other Tools in Community-Acquired Pneumonia: A Narrative Review

Community-acquired pneumonia (CAP) is among the most common causes of death and one of the leading healthcare concerns worldwide. It can evolve into sepsis and septic shock, which have a high mortality rate, especially in critical patients and comorbidities. The definitions of sepsis were revised in the last decade as "life-threatening organ dysfunction caused by a dysregulated host response to infection". Procalcitonin (PCT), C-reactive protein (CRP), and complete blood count, including white blood cells, are among the most commonly analyzed sepsis-specific biomarkers also used in pneumonia in a broad range of studies. It appears to be a reliable diagnostic tool to expedite care of these patients with severe infections in the acute setting. PCT was found to be superior to most other acute phase reactants and indicators, including CRP as a predictor of pneumonia, bacteremia, sepsis, and poor outcome, although conflicting results exist. In addition, PCT use is beneficial to judge timing for the cessation of antibiotic treatment in most severe infectious states. The clinicians should be aware of strengths and weaknesses of known and potential biomarkers in expedient recognition and management of severe infections. This manuscript is intended to present an overview of the definitions, complications, and outcomes of CAP and sepsis in adults, with special regard to PCT and other important markers.

Central role of laboratory medicine in public health and patient care

Clinical laboratories play a vital role in the healthcare system. Objective medical data provided by clinical laboratories supports approximately 60-70% of clinical decisions, however, evidence supporting this claim is poorly documented and laboratories still lack visibility, despite their indisputable impact on patient care and public health. The International Federation for Clinical Chemistry and Laboratory Medicine (IFCC) Task Force on Outcome Studies in Laboratory Medicine (TF-OSLM) was recently developed to support directed research evaluating the role of laboratory medicine on clinical outcomes. Establishing and documenting this evidence is key to enhance visibility of the field in the eye of the public and other healthcare professionals together with optimizing patient outcomes and health care system operations. In this review, we discuss four areas that exemplify the contribution of laboratory medicine directly to patient care. This includes high-sensitivity cardiac troponin (hs-cTn) and N-terminal pro-B-type natriuretic peptide/B-type natriuretic peptides (NT-proBNP/BNP) for the diagnosis and prognosis of myocardial infarction and heart failure, respectively, and procalcitonin for the management of sepsis and antibiotic stewardship. Emerging markers of traumatic brain injury and the role of laboratory medicine in the fight against the COVID-19 pandemic are discussed along with an introduction to plans of IFCC TF-OSLM.

BIOMARKERS: CAN THEY REALLY GUIDE OUR DAILY PRACTICE?

ABSTRACT

Optimal management of septic patients requires accurate assessment of both current severity status and prognosis. Since the 1990s, substantial advances have been made in the use of circulating biomarkers for such assessments. This summary of the session on "Biomarkers: can they really use guide our daily practice?" presented at the 2021 WEB-CONFERENCE OF THE EUROPEAN SHOCK SOCIETY, 6 November 2021. These biomarkers include ultrasensitive detection of bacteremia, circulating soluble urokina-type plasminogen activator receptor (suPAR), C-reactive protein (CRP) and ferritin and procalcitonin. In addition, the potential application of novel multiwavelength optical biosensor technology allows noninvasive monitoring of multiple metabolites that can be used to assess severity and prognosis in septic patients. The application these biomarkers and improved technologies provide the potential for improved personalized management of septic patients.

Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial

Background

In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients.

Materials and methods

Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients.

Results

In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively (p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively (p = 0.82). The time courses for MDR/HRMO development were also similar for both groups (p = 0.33).

Conclusions

In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences.

Diagnostic value of procalcitonin, hypersensitive C-reactive protein and neutrophil-to-lymphocyte ratio for bloodstream infections in pediatric tumor patients

OBJECTIVES

Bloodstream infection (BSI) is one of the major causes of death in pediatric tumor patients. Blood samples are relatively easy to obtain and thus provide a ready source of infection-related biological markers for the prompt evaluation of infection risk.

METHODS

A total of 259 pediatric tumor patients were included from May 2019 to March 2022. Patients were divided into BSI group (n=70) and control group (n=189). Clinical and biological data were collected using electronic medical records. Differences in biological markers between BSI group and control group and differences before and during infection in BSI group were analyzed.

RESULTS

The infected group showed higher levels of procalcitonin (PCT) and hypersensitive C-reactive-protein (hsCRP), and lower prealbumin (PA) than the uninfected group. Area under the receiver-operating curve (ROC) curves (AUC) of PCT, hsCRP and NLR (absolute neutrophil count to the absolute lymphocyte count) were 0.756, 0.617 and 0.612. The AUC of other biomarkers was ≤0.6. In addition, PCT, hsCRP, NLR and fibrinogen (Fg) were significantly increased during infection, while PA and lymphocyte (LYM) were significantly decreased. Antibiotic resistant of Gram-positive bacteria to CHL, SXT, OXA and PEN was lower than that of Coagulase-negative Staphylococcus. Resistant of Gram-positive bacteria to CHL was lower, while to SXT was higher than that of Gram-negative bacteria.

CONCLUSIONS

This study explored the utility of biomarkers to assist in diagnosis and found that the PCT had the greatest predictive value for infection in pediatric tumor patients with BSI. Additionally, the PCT, hsCRP, NLR, PA, LYM and Fg were changed by BSI.

Consider this tool to reduce antibiotic-associated adverse events in patients with sepsis

Predictive biomarker procalcitonin can aid clinical decision-making on continued antibiotic treatment in this patient population.

Severe community-acquired pneumonia

Severe community-acquired pneumonia is the most life-threatening form of community-acquired pneumonia, characterised by intensive care unit admission and high morbidity and mortality. In this review article, we cover in depth six aspects of severe community-acquired pneumonia that are still controversial: use of PCR molecular techniques for microbial diagnosis; the role of biomarkers for initial management; duration of treatment, macrolides or quinolones in the initial empirical antibiotic therapy; the use of prediction scores for drug-resistant pathogens to modify initial empiric therapy; the use of noninvasive mechanical ventilation and high-flow nasal oxygen; and the use of corticosteroids as adjunctive therapy in severe community-acquired pneumonia.

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.

An automated DNA computing platform for rapid etiological diagnostics

Rapid and accurate classification of the etiology for acute respiratory illness not only helps establish timely therapeutic plans but also prevents inappropriate use of antibiotics. Host gene expression patterns in peripheral blood can discriminate bacterial from viral causes of acute respiratory infection (ARI) but suffer from long turnaround time, as well as high cost resulting from the measurement methods of microarrays and next-generation sequencing. Here, we developed an automated DNA computing-based platform that can implement an in silico trained classification model at the molecular level with seven different mRNA expression patterns for accurate diagnosis of ARI etiology in 4 hours. By integrating sample loading, marker amplification, classifier implementation, and results reporting into one platform, we obtained a diagnostic accuracy of 87% in 80 clinical samples without the aid of computer and laboratory technicians. This platform creates opportunities toward an accurate, rapid, low-cost, and automated diagnosis of disease etiology in emergency departments or point-of-care clinics.

Nutritional risk factors for all-cause mortality of critically ill patients: a retrospective cohort study

OBJECTIVES

This study aimed to explore the predictive value of single and multiple risk factors for the clinical outcomes of critically ill patients receiving enteral nutrition and to establish an effective evaluation model.

DESIGN

Retrospective cohort study.

SETTING

Data from the 2020-2021 period were collected from the electronic records of the First Affiliated Hospital, Nanjing Medical University.

PARTICIPANTS

459 critically ill patients with enteral nutrition in the geriatric intensive care unit were included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was 28-day mortality. The secondary outcomes were 28-day invasive mechanical ventilation time, intensive care unit stay, Nutrition Risk Screening 2002 (NRS2002) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score.

RESULTS

Independent prognostic factors, including prealbumin/procalcitonin (PCT) ratio and APACHE II score, were identified using a logistic regression model and used in the nomogram. The area under the receiver operating characteristic curve and concordance index indicated that the predictive capacity of the model was 0.753. Moreover, both the prealbumin/PCT ratio and the combination model of PCT, prealbumin and NRS2002 had a higher predictive value for clinical outcomes. Subgroup analysis also identified that a higher inflammatory state (PCT >0.5 ng/mL) and major nutritional risk (NRS2002 >3) led to worse clinical outcomes. In addition, patients on whole protein formulae bore less nutritional risk than those on short peptide formulae.

CONCLUSIONS

This nomogram had a good predictive value for 28-day mortality in critically ill patients receiving enteral nutrition. Both the prealbumin/PCT ratio and the combination model (PCT, prealbumin and NRS2002), as composite models of inflammation and nutrition, could better predict the prognosis of critically ill patients.