06 Jul 09

Procalcitonin as a prognostic and diagnostic tool for septic complications after major trauma

Posted in Procalcitonin, Trauma at 16:18 by Laci

By G Castelli, C Pognani, M Cita, R Paladini

Critical Care Medicine 2009;37:1845-1849

The primary aim of this study was to investigate the diagnostic value of procalcitonin (PCT) and C-reactive protein (CRP) in septic complications after major trauma. A secondary aim was to determine whether there was a prognostic value of PCT for severity of injury, organ dysfunction, and sepsis.

Design
Prospective study.

Setting
Medical/surgical intensive care unit (ICU).

Patients
Ninety-four patients with consecutive trauma >=16 years who were admitted to the ICU for an expected stay of >24 hours.

Interventions
None.

Measurements
PCT and CRP were collected at admission and every day thereafter. The American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definition was used to identify sepsis criteria. The Sequential Organ Failure Assessment score was used to describe the severity of organ dysfunction. We retrospectively analyzed the occurrence of systemic inflammatory response syndrome and sepsis using the collected variables (criteria fulfilled at least during three continuous days).

Main results
Patients with trauma presented an early and significant increase in PCT at the moment of septic complications compared with concentrations measured 1 day before the diagnosis of sepsis: 0.85 vs. 3.32 ng/mL for PCT (p < 0.001) and 135 vs. 175 mg/L for CRP (p = not significant). The areas under the respective curve at admission in the diagnosis of sepsis were 0.787 (p < 0.001) and 0.489 for PCT and CRP, respectively.

Conclusion

PCT plasma reinduction marks possible septic complication during systemic inflammatory response syndrome after major trauma. In addition, high PCT concentration at admission after trauma in ICU patients indicates an increased risk of septic complications.

27 Jun 09

Procalcitonin to guide duration of antibiotic therapy in intensive care patients

Posted in Infection, Procalcitonin at 11:01 by Laci

By M Hochreiter, T Köhler, A Schweiger, F Sixtus Keck, B Bein, T von Spiegel and S Schroeder

Critical Care 2009, 13:R83

The development of resistance by bacterial species is a compelling issue to reconsider indications and administration of antibiotic treatment. Adequate indications and duration of therapy are particularly important for the use of highly potent substances in the intensive care setting. Until recently, no laboratory marker has been available to differentiate bacterial infection from viral or non-infectious inflammatory reaction; however, over the past years, procalcitonin (PCT) is the first among a large array of inflammatory variables that offers this possibility. The present study aimed to investigate the clinical usefulness of PCT for guiding antibiotic therapy in surgical intensive care patients.

Methods
All patients requiring antibiotic therapy based on confirmed or highly suspected bacterial infections and at least two concomitant systemic inflammatory response syndrome criteria were eligible. Patients were randomly assigned to either a PCT-guided (study group) or a standard (control group) antibiotic regimen. Antibiotic therapy in the PCT-guided group was discontinued, if clinical signs and symptoms of infection improved and PCT decreased to <1 ng/ml or the PCT value was >1 ng/ml, but had dropped to 25 to 35% of the initial value over three days. In the control group antibiotic treatment was applied as standard regimen over eight days.

Results

A total of 110 surgical intensive care patients receiving antibiotic therapy after confirmed or high-grade suspected infections were enrolled in this study. In 57 patients antibiotic therapy was guided by daily PCT and clinical assessment and adjusted accordingly. The control group comprised 53 patients with a standardized duration of antibiotic therapy over eight days. Demographic and clinical data were comparable in both groups. However, in the PCT group the duration of antibiotic therapy was significantly shorter than compared to controls (5.9 +/- 1.7 versus 7.9 +/- 0.5 days, P < 0.001) without negative effects on clinical outcome.

Conclusions
Monitoring of PCT is a helpful tool for guiding antibiotic treatment in surgical intensive care patients. This may contribute to an optimized antibiotic regimen with beneficial effects on microbial resistance and costs in intensive care medicine.

13 Jan 08

Induction of procalcitonin in liver transplant patients treated with anti-thymocyte globulin

Posted in Infection, Procalcitonin at 17:50 by Laci

By R Zazula, M Prucha, T Tyll and E Kieslichova

Critical Care 2007,11

The aim of this study was to compare the early postoperative kinetics of procalcitonin (PCT) and C-reactive protein (CRP) serum levels in patients undergoing orthotopic liver transplantation (OLTx) with different immunosuppressive regimens.

Methods
PCT and CRP serum concentrations were measured in a group of 28 OLTx recipients before induction of anesthesia, at 4 and 8 hours following graft reperfusion, and daily until postoperative day 4. The same parameters were determined in 12 patients undergoing liver resection without conjunctive immunosuppressive therapy. Summary data are expressed as medians and ranges. Two-tailed nonparametric tests were performed and considered significant at p values of less than 0.05.

Results
The highest serum levels of PCT (median 3.0 ng/mL, minimum 1.4 ng/mL, maximum 13.9 ng/mL) were found in patients after OLTx without ATG therapy, on postoperative day 1. In patients with ATG administration, PCT levels were highly increased on postoperative day 1 (median 53.0 ng/mL, minimum 7.9 ng/mL, maximum 249.1 ng/mL). Thereafter, PCT values continuously decreased independently of further ATG administration in both groups of patients. No evidence of infection was present in either group. In 12 patients undergoing liver resection, peak serum PCT levels did not exceed 3.6 ng/mL. CRP serum levels in a group of patients with and without ATG therapy increased significantly on postoperative day 1, followed by a decrease. The highest levels of CRP were found in patients after liver resection on postoperative day 2 and decreased thereafter.

Conclusion
ATG administration to patients with OLTx is associated with an increase in serum PCT levels, with peak values on postoperative day 1, and this was in the absence of any evidence of infection. The results of this study indicate that ATG immunosuppressive therapy is a stimulus for the synthesis of PCT.

21 Sep 07

Can procalcitonin guide therapy in newly admitted critically ill patients?

Posted in Critical Care, Procalcitonin at 14:00 by Laci

By JAH van Oers, JE Tulleken, JJM Ligtenberg, JHJM Meertens, JG Zijlstra

Neth J Crit Care 2007;11:81-86

Can plasma procalcitonin differentiate sepsis from systemic inflammatory response? Is plasma procalcitonin level a measure of severity of illness and can it be a prognostic factor in sepsis patients in an intensive care unit (ICU)?

Search strategy
Review of medical literature. Prospective studies published in the MEDLINE database that evaluated plasma procalcitonin as marker of sepsis in the intensive care unit were included. Positive and negative likelihood ratios were constructed for each study if possible.

Summary of findings
From the search of the MEDLINE database 11 prospective studies that evaluated plasma procalcitonin as a diagnostic marker in sepsis and systemic inflammatory response patients in the ICU were included. A further four articles were found by searching the bibliographies. Sepsis and systemic inflammatory response populations differed between studies. The total number sepsis patients was 688 and total number of systemic inflammatory response patients 507. PCT values were reported as mean +/- sd in sepsis and systemic inflammatory response patients in five studies, and as median with interquartile range in sepsis and SIRS in 10 studies. Cut-off points were established by using area under the curve in receiver operating characteristics curves. Median cut-off point 1.1 ng/ml; interquartile range 1.0-2.42. area under the curve in the receiver operating characteristics was between 0.66 and 0.97. Sensitivity was between 63% and 100% and for specificity 54% to 94%. Positive likelihood ratios (LR+) and negative likelihood ratios (LR-) could be calculated in 11 studies. The median LR+ was 3.31, interquartile range 2.17-6 and the median LR- was 0.11, interquartile range 0.06-0.16. Pre-test probability ranged from 32% to 83% and was modified by positive negative likelihood ratios to a range of 55%-96% and by negative likelihood ratios – to a range of 0-68%. Severity indexes (SOFA score, SAPS II score and APACHE II score) were used in 11 of the 14 studies. Correlation between plasma procalcitoninlevel and severity index was sporadically reported. In four studies plasma procalcitonin levels in survivors and non-survivors of the sepsis group were measured. Only in the surgical patients of one study there was no significant difference.

Conclusion
Although area under the curve , sensitivity and specificity are fairly good for a diagnostic test to differentiate sepsis from systemic inflammatory response , there is serious doubt whether this influences the decision to treat. The pre-test probability is too high to withhold antibiotics and perform diagnostics procedures. Positive test results will not lead to more prescription and negative test results will not lead to stopping of antibiotics. There are not enough data to draw conclusions about the power of plasma procalcitonin as a measure of severity or prognostic factor.

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