Procalcitonin as an adjunctive biomarker in sepsis

Diagnostic usefulness of serum procalcitonin in patients with bacterial sepsis

Background

The Sequential Organ Failure Assessment (SOFA) score is used for the diagnosis of sepsis and involves clinical and laboratory parameters that may not be readily and/or timely available in most resource-poor settings. Procalcitonin (PCT) has its level changed in response to bacterial sepsis and its measurement costs only a fraction of the total cost of investigations required to calculate SOFA score. This study aims to determine the diagnostic usefulness of PCT in bacterial sepsis.

Materials and Methods

Ninety-nine participants were studied, divided into three groups: apparently healthy volunteers, those with bacterial infection without sepsis (SOFA score <2), and patients with bacterial sepsis (positive culture and SOFA ≥2). PCT level of each participant was measured and median group levels compared. Pearson's correlation was used to determine the correlation between serum PCT levels and SOFA scores in the sepsis group using a significance level of 5 percent (P < 0.05). Diagnostic usefulness of PCT was assessed using receiver operating characteristic (ROC).

Result

Positive correlation was found between serum PCT levels and SOFA scores among patients with sepsis r = 0.42, P = 0.016. At a concentration of ≥4.25 ng/ml, serum PCT as a surrogate for SOFA score had a sensitivity and specificity of 57.60% and 84.80%, respectively, for indicating sepsis. The area under the ROC curve (AUC) was 0.74 (95% CI {0.62 to 0.86}, P = 0.001).

Conclusion

Serum PCT concentration was significantly higher in bacterial sepsis compared to bacterial infection without sepsis and healthy state. PCT concentration demonstrated positive correlation with SOFA score in bacterial sepsis and can be used as surrogate for sepsis screening/monitoring in resource-poor settings.

Optical method supported by machine learning for urinary tract infection detection and urosepsis risk assessment

The study presents an optical method supported by machine learning for discriminating urinary tract infections from an infection capable of causing urosepsis. The method comprises spectra of spectroscopy measurement of artificial urine samples with bacteria from solid cultures of clinical E. coli strains. To provide a reliable classification of results assistance of 27 algorithms was tested. We proved that is possible to obtain up to 97% accuracy of the measurement method with the use of use of machine learning. The method was validated on urine samples from 241 patients. The advantages of the proposed solution are the simplicity of the sensor, mobility, versatility, and low cost of the test.

C-reactive protein and procalcitonin use in adults in low- and middle-income countries: a narrative review

Objectives

C-reactive protein (CRP) and procalcitonin (PCT) are widely used biomarkers in high-income countries. However, evidence for their use in low- and middle-income countries (LMICs) is scant. Because many factors, including rates of endemic disease, comorbidities and genetics, may influence biomarkers' behaviour, we aimed to review available evidence generated in LMICs.

Methods

We searched the PubMed database for relevant studies within the last 20 years that originated in regions of interest (Africa, Latin America, Middle East, South Asia or South East Asia), and full-text articles involving diagnosis, prognostication and evaluation of therapeutic response with CRP and/or PCT in adults (n = 88) were reviewed and categorized in 12 predefined focus areas.

Results

Overall, results were highly heterogeneous, at times conflicting, and often lacking clinically useful cut-off values. However, most studies demonstrated higher levels of CRP/PCT in patients with bacterial versus other infections. HIV and TB patients had consistently higher levels of CRP/PCT versus controls. In addition, higher CRP/PCT levels at baseline and follow-up in HIV, TB, sepsis and respiratory tract infections were associated with poorer prognosis.

Conclusions

Evidence generated from LMIC cohorts suggests that CRP and PCT may have potential to become effective clinical guiding tools particularly in respiratory tract infections, sepsis and HIV/TB. However, more studies are needed to define potential scenarios for use and cost-effectiveness. Consensus across stakeholders regarding target conditions, laboratory standards and cut-off values would support the quality and applicability of future evidence.

Serum β-Defensin 2, A Novel Biomarker for the Diagnosis of Acute Infections

BACKGROUND

Defensins are natural antimicrobial peptides that the human body secretes to protect itself from an infection. Thus, they are ideal molecules to serve as biomarkers for infection. This study was conducted to evaluate the levels of human β-defensins in patients with inflammation.

METHODS

CRP, hBD2 and procalcitonin were measured in 423 sera of 114 patients with inflammation and healthy individuals using nephelometry and commercial ELISA assays.

RESULTS

Levels of hBD2 in the serum of patients with an infection were markedly elevated compared to those of hBD2 in patients with inflammation of non-infectious etiology (p < 0.0001, t = 10.17) and healthy individuals. ROC analysis demonstrated that hBD2 showed the highest detection performance for infection (AUC 0.897; p < 0.001) followed by PCT (AUC 0.576; p = ns) and CRP (AUC 0.517; p = ns). In addition, analysis of hBD2 and CRP in patients' sera collected at different time points showed that hBD2 levels could help differentiate inflammation of infectious and non-infectious etiology during the first 5 days of hospitalization, while CRP levels could not.

CONCLUSIONS

hBD2 has the potential to serve as a diagnostic biomarker for infection. In addition, the levels of hBD2 may reflect the efficacy of antibiotic treatment.

Predictive role of selected biomarkers in differentiating gram-positive from gram-negative sepsis in surgical patients: a retrospective study

INTRODUCTION

Patients after major surgery are at high risk of developing sepsis, which is accompanied by elevated serum levels of C-reactive protein (CRP) and procalcitonin (PCT). This study aimed to examine the differences in serum biomarker levels concerning the causative agent of sepsis in surgical patients.

MATERIAL AND METHODS

A retrospective study was carried out in the surgical intensive care unit (ICU) and included 81 septic patients admitted from January 2019 to May 2022, who had positive blood cultures (BC). Serum levels of PCT, CRP, white blood cells (WBC) and platelet counts were recorded on the day of the positive BC and over the following 3 days.

RESULTS

Patients with gram(-) sepsis had significantly higher PCT levels, and lower platelet count compared to patients with gram(+) sepsis. High PCT and low platelets levels in all measurements were a significant predictor of gram(-) isolate with the highest predictive value on the third day after BC sampling, with AUROC 0.821 (95% CI: 0.692-0.950), P = 0.001, and AUROC 0.676 (95% CI: 0.541-0.811), P = 0.02, respectively. In multivariate logistic regression, platelets the day after BC sampling and PCT on the third day made a significant contribution in distinguishing gam(+) from gram(-) BC. Age and high serum CRP levels were significant predictors of poor outcomes.

CONCLUSIONS

PCT and platelets may be useful biomarkers for predicting the causative agent of sepsis in surgical patients.

The effects of selenium supplementation on inflammatory markers in critically ill patients

Abstract

Low serum selenium (Se) levels have been shown in critical illness, which is associated with poor clinical outcomes and a higher mortality rate. Se plays an important role in inflammation and oxidative stress. Since the overproduction of inflammatory cytokines and increased oxidative stress is a major component of critical illnesses, its supplementation has been demonstrated to have promising effects on critically ill patients. This study aims to review the evidence regarding the effects of Se supplementation on inflammatory and oxidative markers in critically ill patients. The literature review highlights alterations of inflammatory markers, including procalcitonin, leukocyte count, albumin, prealbumin, C-reactive protein (CRP), inflammatory cytokines, and cholesterol following Se supplementation in critically ill patients. Besides, the antioxidant properties of Se due to its presence in the structure of several selenoenzymes have been reported.

Article highlights

Low serum Se level have been shown in critical illness, which is associated with poor clinical outcome and higher mortality rate.

Se plays an important role in inflammation and oxidative stress.

Se supplementation can have promising effects by alterations of inflammatory markers and its antioxidant properties for critically ill patients.

Procalcitonin as a Candidate Biomarker for Malarial Infection and Severe Malaria: A Meta-Analysis

Procalcitonin (PCT), as a marker of malaria severity, remains to be investigated. The present study collated and compared the levels of PCT between patients with severe malaria, uncomplicated malaria, and control participants to assess their role in predicting malaria infection and disease severity. The systematic review was registered at PROSPERO with registration number CRD42021297243. The search for relevant studies that reported PCT in patients with malaria was performed in PubMed, Scopus, and Web of Science. The following meta-analyses were conducted; (1) the pooled mean PCT levels in patients with severe and uncomplicated malaria, and (2) the pooled mean difference in PCT levels between patients with severe and uncomplicated malaria. Fifteen studies were included for qualitative and quantitative syntheses. The meta-analysis results show that the pooled mean PCT levels in patients with uncomplicated malaria were 3.92 ng/mL (95% CI: 2.26-5.58 ng/mL, I²: 96.5, five studies), whereas the pooled mean PCT levels in patients with severe malaria were 14.13 ng/mL (95% CI: 8.75-19.5 ng/mL, I²: 92.6, six studies). The meta-analysis showed that patients with severe malaria had an equal mean of PCT compared to those with uncomplicated malaria when the random-effects model was used (p: 0.055, weighted mean difference: 6.93, 95% CI: -0.16-14.02, I²: 84.6%, four studies). There were probable correlations between the level of parasitemia, immunity level, and possibly bacterial or other parasitic co-infection that could affect the PCT level among different clinical severities of malaria. Therefore, the PCT level alone does not seem to be a suitable biomarker to discriminate the severe/uncomplicated or infected/uninfected cases. Further studies should investigate the increased PCT levels in combination with other markers in association with malaria infection and severity.

Role of procalcitonin, Il-6 and C- reactive protein in suspected cases of sepsis

OBJECTIVES

To study the role of serum procalcitonin as a diagnostic biomarker in sepsis and to compare it with other sepsis markers (IL-6, CRP) in patients of suspected sepsis.

MATERIALS AND METHODS

A total of 80 patients were included in this study from ICU and each patient was investigated for serum Procalcitonin, Interleukin-6 and C-reactive protein levels by ELISA along with blood cultures by BacT/Alert system.

RESULT

Procalcitonin along with CRP is a better diagnostic tool for sepsis.

Novel applications for serum procalcitonin testing in clinical practice

INTRODUCTION

Procalcitonin has emerged as a reliable marker of acute bacterial infection in hospitalized patients and the assay has recently been incorporated into several clinical algorithms to reduce antimicrobial overuse, but its use in patients with end-organ dysfunction is controversial. Areas covered: In this review, the authors examine what is known about procalcitonin testing in patients with organ dysfunction, including those with end-stage renal disease, congestive heart failure, chronic obstructive pulmonary disease, and cirrhosis, and explore how the assay is now being used in the management of non-infectious diseases. Expert commentary: Procalcitonin holds tremendous promise to identify a diverse set of medical conditions beyond those associated with acute bacterial infection, including post-surgical anastomotic leaks, acute kidney injury, and complications after intracerebral hemorrhage. The authors review recent studies examining procalcitonin in these areas and explore how the assay might be used to guide diagnosis and prognosis of non-infectious diseases in the near future.

The Influence of Carbon Dioxide Pneumoperitoneum on Systemic Inflammatory Response Syndrome and Bacterial Translocation in Patients With Bacterial Peritonitis Caused by Acute Appendicitis

OBJECTIVE

To explore the influence of carbon dioxide pneumoperitoneum (CDP) on system inflammatory response syndrome (SIRS) and bacterial translocation (BT) in patients with bacterial peritonitis (BP) caused by acute appendicitis (AA).

METHODS

Eighty-six consecutive subjects were randomly divided into the laparoscopy and laparotomy groups (n = 44 and n = 42, respectively). The levels of white blood cells (WBC), C-reactive protein (CRP), tumor necrosis factor α (TNF-α), and interleukin 6 (IL-6) of the 2 groups were tested preoperatively and at days 1, 2, and 4 after surgery. Blood and secretion culture was performed to verify whether septicemia or incision infection occurred, respectively. And the abdominal ultrasound or computed tomography scanning was used to diagnose peritoneal abscess for the suspected patients. The essential risk factors related to the aggravation of SIRS were analyzed through analysis of variance and binary logistic regression.

RESULTS

The postoperative blood levels of WBC, CRP, TNF-α, and IL-6 on day 4 in the laparoscopy group were significantly lower than those in the control group (all Ps < .05). The differences in incidence rates of septicemia and peritoneal abscess between the CDP and control groups were not statistically significant ( P > .05). Nevertheless, the incision infection rate in the laparoscopy group was apparently lower than that in the control group (4.55% vs 19.04%, P = .047). Analysis of variance and binary logistic regression showed that the non-pneumoperitoneum, pathological type of appendicitis, and multidrug resistant infections were the 3 major risk factors for SIRS (the P values were .001, .019, and .012, respectively).

CONCLUSION

It was found that CDP is safe for BP and could be a potential protective factor to mitigate BP effectively, indicating that the performance of laparoscopy operation under CDP is feasible to control SIRS; at the same time, CDP would not raise the incidence rate of BT.

Procalcitonin level for prediction of postoperative infection in cardiac surgery

BACKGROUND

Diagnosing infection after cardiac surgery remains difficult due to the systemic inflammatory response induced by cardiopulmonary bypass. We compared procalcitonin levels with white blood cell counts as predictors of infection after cardiac surgery.

METHODS

We prospectively enrolled 100 consecutive adult cardiac patients. Postoperative white blood cell counts, serum procalcitonin levels, and blood cultures were examined.

RESULT

The sensitivity and specificity of white blood cell count and procalcitonin > 2 ng mL(-1) were 60% and 100%, 58.8% and 42.5%, respectively. Procalcitonin > 7 ng mL(-1) had 95% sensitivity and 80% specificity. Receiver-operating characteristic analysis showed a greater area under the curve for procalcitonin level (p < 0.0001) compared to white blood cell count (p = 0.31). Patients with positive blood cultures had significantly higher procalcitonin levels (51.97 ± 39.62 vs. 6.67 ± 10.73 ng mL(-1)), Acute Physiology and Chronic Health Evaluation-II scores (16.95 ± 3.24 vs. 13.60 ± 2.98), and intensive care unit stay (6.35 ± 3.42 vs. 4.6 ± 2.2 days). Non-survivors had significantly higher Acute Physiology and Chronic Health Evaluation-II scores (19.09 ± 1.30 vs. 13.67 ± 2.97) and procalcitonin levels (43.83 ± 52.15 vs. 12.26 ± 19.89 ng mL(-1)) but on logistic regression analysis, only Acute Physiology and Chronic Health Evaluation-II score was an independent risk factor for mortality.

CONCLUSION

The diagnostic accuracy of procalcitonin for bacterial infection is fairly high. Acute Physiology and Chronic Health Evaluation-II score is a better predictor of mortality and morbidity than absolute procalcitonin level. Procalcitonin > 7 ng mL(-1) can prognosticate and identify the high-risk group.

Role of C-reactive Protein and Tumor Necrosis Factor-Alpha in Differentiating between Ventilator-Associated Pneumonia and Systemic Inflammatory Response Syndrome without Infectious Etiology

BACKGROUND

Differential diagnosis of systemic inflammatory response syndrome (SIRS) with or without infectious cause is critically important in terms of initiating antimicrobial agents in case of infectious etiology such as ventilator-associated pneumonia (VAP). The aim of this study was to determine the diagnostic and prognostic roles of C-reactive protein (CRP) and tumor necrosis factor-alpha (TNF-α) in differentiating between ventilator-associated pneumonia and SIRS without infectious etiology.

MATERIALS AND METHODS

In this prospective observational study, 91 adult intensive care unit (ICU) patients were enrolled. According to established diagnostic criteria, they were classified into three groups of "non-SIRS non-VAP", "SIRS non-VAP" and "SIRS-VAP". Serum CRP and TNF-α were measured on days 1, 3 and 7 of the study and compared using repeated measures ANOVA.

RESULTS

With respect to diagnosis, there was no significant difference in the values of these biomarkers between groups (P>0.05). There was no statistically significant "time trend" for C-reactive protein and TNF-α (P>0.05). Considering both group effect and Time effect, the changes were not significantly different for CRP (P= 0.86) and TNF-α (P=0.69). In contrast, the clinical score and the clinical pulmonary infection score (CPIS) ≥ 6, had 100% specificity for diagnosing VAP. With respect to prognosis, only an unchanged or decreasing TNF-α from day 1 to day 3 was marginally associated with 28-day survival. However, day 1 and day 3 acute physiology and chronic health evaluation II (APACHE II) scores were highly associated with 28-day survival.

CONCLUSION

Unlike clinical scoring system including CPIS and APACHE II, TNF-α and CRP levels were not useful as diagnostic or prognostic biomarkers for differentiating between SIRS with VAP etiology and SIRS without infectious etiology.

Use of miRNAs as biomarkers in sepsis

Sepsis is one of the most common causes of death in critical patients. Severe generalized inflammation, infections, and severe physiological imbalances significantly decrease the survival rate with more than 50%. Moreover, monitoring, evaluation, and therapy management often become extremely difficult for the clinician in this type of patients. Current methods of diagnosing sepsis vary based especially on the determination of biochemical-humoral markers, such as cytokines, components of the complement, and proinflammatory and anti-inflammatory compounds. Recent studies highlight the use of new biomarkers for sepsis, namely, miRNAs. miRNAs belong to a class of small, noncoding RNAs with an approximate content of 19-23 nucleotides. Following biochemical and physiological imbalances, the expression of miRNAs in blood or other body fluids changes significantly. Moreover, its stability, specificity, and selectivity make miRNAs ideal candidates for sepsis biomarkers. In conclusion, we can affirm that stable species of circulating miRNAs represent potential biomarkers for monitoring the evolution of sepsis.

Procalcitonin and intestinal ischemia: A review of the literature

Intestinal ischemia is common after emergency gastrointestinal or cardiovascular surgery. At present, there are no diagnostic tools for the early diagnosis of intestinal ischemia. In the last decade, procalcitonin (PCT) has been suggested as a marker of this condition. Here, we review the use of PCT as a diagnostic tool for intestinal ischemia. Two reviewers independently searched the PubMed and EMBASE databases for articles on intestinal ischemia and PCT. They then considered (1) the criteria applicable to preclinical and clinical data; and (2) PCT’s predictive value in the diagnosis of intestinal ischemia. Article quality was rated according to the STAndards for Reporting of Diagnostic accuracy. Between 1993 and 2014, seven studies (including two preclinical studies and five clinical studies) dealt with the use of PCT to diagnose intestinal ischemia. Procalcitonin’s sensitivity, specificity, positive predictive value and negative predictive value ranged between 72% and 100%; 68% and 91%; 27% and 90% and 81% and 100%, respectively. The area under the receiver operating characteristic curve ranged from 0.77 to 0.92. In view of the preclinical and clinical data, we consider that PCT can be used in daily practice as a tool for diagnosing intestinal ischemia.

Biomarkers for sepsis: a review with special attention to India

Sepsis is a serious infection and still a common cause of morbidity and mortality in resource-limited settings such as India. Even when microbiologic diagnostics are available, bacteremia is only identified in a proportion of patients who present with sepsis and bloodstream infections. Biomarkers have been used in a variety of disease processes and can help aid in diagnosing bacterial infections. There have been numerous biomarkers investigated to aid with diagnosis and prognostication in sepsis with the majority suffering from lack of sensitivity or specificity. Procalcitonin has been heralded as the biomarker that holds the most promise for bloodstream infections. Data are emerging in India, and in this review, we focus on the current data of biomarkers in sepsis with particular attention to how biomarkers could be used to augment diagnosis and treatment in India.

Multifocal infections of the musculoskeletal system: description of a safe one-step procedure for eradication of associated spinal infections

BACKGROUND

The aim of this study was to evaluate the clinical outcome after radical surgical treatment of multifocal infections involving the spine.

METHODS

The study demonstrates a retrospective chart review of seven patients who had more than three different abscesses in the musculoskeletal system and at least one of them in the area of the spinal column. All patients had a sepsis.

RESULTS

Beside different musculoskeletal abscesses four patients had a spondylodiscitis in the cervical spine segments C4/5 or C5/6. Six patients had inflammatory processes in the lumbar spine with epidural abscesses, diffuse thoracolumbar paravertebral abscesses and a spondylodiscitis in different segments. In all cases we performed a radical surgical treatment of all related inflammatory focuses. Prompt radical surgical treatment of the spine included decompression, debridement and in the cases of spondylodiscitis a fusion of the involved segments. For more than one focus at the spine, a surgical one-step procedure was performed. An antibiotic therapy was administered for six to eight weeks. In follow up examinations no signs of ongoing inflammatory processes were seen in imaging studies or laboratory tests.

CONCLUSIONS

In the event of multiple abscesses of the musculoskeletal system involving the spine an early correct diagnosis and radical surgical treatment is recommended. We strongly favor a surgical single-stage procedure for treatment of multiple infections of the spine. In addition to a radical debridement and a sufficient decompression, the segmental fusion of affected areas in spondylodiscitis is essential. At the same time a surgical therapy of all other infected sites should be performed.

Proteomic characterization of the acute-phase response of yellow stingrays Urobatis jamaicensis after injection with a Vibrio anguillarum-ordalii bacterin

Systemic inflammatory responses of mammals and bony fish are primarily driven by coordinated up-regulation and down-regulation of plasma acute-phase proteins. Although this general principle is believed to be universal among vertebrates, it remains relatively unexplored in elasmobranchs. The objective of this study was to characterize acute changes in the plasma proteome of three yellow stingrays Urobatis jamaicensis following intraperitoneal injection with a commercial Vibrio bacterin. Changes in plasma protein levels were analyzed immediately prior to vaccination (time 0) and at 24 and 72 h post-injection by isobaric tags for relative and absolute quantitation (iTRAQ 4-plex) using shotgun-based nano liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis and de novo peptide sequencing. Pooled 2D-LC-MS/MS and de novo sequencing data revealed differential expression of 156 distinct plasma proteins between time 0 and at least one post-vaccination time point. Using 1.5-fold change in expression as physiologically significant, 14/156 (9.0%) proteins were upregulated in at least one stingray through at least one experimental timepoint. Upregulated proteins included complement factors, Mx-protein, hemopexin, factor X and prothrombin. Seventy-six of 156 (48.7%) proteins were downregulated in the acute-phase response, including transferrin, apolipoprotein B, heparin cofactor 2, alpha2-macroglobulin, and various growth factors. Other differentially upregulated or downregulated proteins included intracellular, cell binding and structural proteins, proteins involved in physiologic processes, and unknown/hypothetical proteins. Selected bioactive factors are discussed for their putative roles in the elasmobranchs acute-phase response. These findings contribute to our understanding of disease processes in elasmobranchs, immunologic phylogeny in vertebrates, and begin the search for potential biomarkers of disease in these ecologically important fish.

Serum procalcitonin levels in the postmortem diagnosis of sepsis

Procalcitonin is regarded as a valuable marker for sepsis in living persons and even in post-mortem investigations. At the Institute of Legal Medicine, 25 autopsy cases with suspected bacterial infectious diseases or sepsis were examined using the semi-quantitative PCT-Q(®)-test (B.R.A.H.M.S., Germany) in 2010 and 2011. As controls, 75 cadavers were used for which there was no suspicion of a bacterial infectious disease or sepsis. Femoral blood was cultured from the cases and from controls, and samples from the brain, heart, lungs, liver, spleen and kidneys were examined histologically for findings seen in sepsis. Twelve cases in the sepsis/infectious disease group (48%) were classifiable as sepsis following synopsis of PCT levels, autopsy results, and histopathological and microbiological findings. This study shows that the semi-quantitative PCT-Q(®)-test is a useful supplementary marker in routine autopsy investigations, capable of classifying death as due to sepsis.

Diagnostic Value of Simultaneous Measurement of Procalcitonin, Interleukin-6 and hs-CRP in Prediction of Early-Onset Neonatal Sepsis

Neonatal sepsis is a major cause of morbidities and mortalities mostly remarkable in the third world nations.We aimed to assess the value of simultaneous measurement of procalcitonin (PCT) and interleukin-6 (IL-6) in association with high sensitive- C reactive protein(hs-CRP) in prediction of early neonatal sepsis.A follow-up study was performed on 95 neonates who were below 12 hours (h) of age and had clinical signs of sepsis or maternal risk factors for sepsis. Neonates were assigned to 4 groups including "proven early-onset sepsis", "clinical early-onset sepsis", "negative infectious status", and "uncertain infectious status". Blood samples were obtained within the first 12 h of birth repeated between 24 hours and 36 hours of age for determination of serum levels of PCT, IL-6, hs-CRP, and white blood cell (WBC) count.On admission, neonates with sepsis had a higher WBC count, IL-6, PCT, and hs-CRP levels compared with those neonates without sepsis. This remained significant even after 12-24 hours of admission. Also, patients with clinical evidences of sepsis had a higher serum level of PCT and IL-6 within 12-24 hours after admission compared to the patients with uncertain sepsis.The combination of PCT and IL-6 yielded had a sensitivity of 88% and PCT and CRP (using the cutoff value of 8 mg/L) a sensitivity of 82%.The areas under the ROC curve for the two periods were 0.801, and 0.819 respectively.In final The combination of IL-6, hs-CRP, and PCT seems to be predictive in diagnosis of early onset neonatal sepsis.