The clinical value of procalcitonin in the prediction of infected necrosis in acute pancreatitis

Case report: Ewing sarcoma with EWSR-ERG fusion elevates procalcitonin extremely in the long term without infection

Background

Ewing sarcoma (ES) represents a rare, aggressive bone and soft-tissue cancer. Unlike breast, liver, pancreatic, and prostate cancers, Ewing sarcoma has had no representative tumor marker until now. The use of procalcitonin (PCT) as a tumor marker is also rarely reported. PCT is a clinically recognized and widely used inflammatory marker in recent years. In rare cases, PCT may also be falsely positive due to non-infectious factors. In the few previously reported papers regarding the correlation between tumors and PCT, we learned that abnormalities of PCT level can also be impacted by individual cancers.

Case presentation

Here, we first reported a case of Ewing sarcoma with markedly elevated PCT without infection and carried out some literature review. The patient was a middle-aged man with extraskeletal Ewing sarcoma whose lesion was located in the distal abdominal ileum. He had a sudden and unprovoked onset of high fever during chemotherapy before surgery. After multiple examinations, the patient's blood routine, C-reactive protein, blood culture, and CT examination showed no signs of infection, and even the culture from the end of the central venous catheter showed no pathogen growth. Only PCT increased dramatically to more than 200 ng/ml. PCT remained at this level for several months until a single abdominal lumpectomy was performed before it dropped to near-normal levels.

Conclusion

In our report, PCT is significantly elevated in Ewing sarcoma in the absence of infection. Not only that, but we particularly highlighted the precipitous drop in PCT following tumor resection.

Association Between Procalcitonin and Post-hepatectomy Liver Failure in Hepatocellular Carcinoma Patients

Objectives: Procalcitonin (PCT) has long been proved as an early diagnostic signal for postoperative outcomes. The purpose of this study is to explore the value of serum procalcitonin levels in predicting post-hepatectomy liver failure (PHLF), and further to declarethe relationship between postoperative PCT and short-term prognosis in patients after hepatectomy.

Methods: Clinical data of patients with hepatocellular carcinoma (HCC) who underwent hepatectomy from June 1st, 2019 to September 31st, 2020 at Shanghai Eastern Hepatobiliary Surgery Hospital had been retrospectively analyzed. Logistic regression analysis was used to evaluate the risk factors related to PHLF. The Kaplan-Meier method was used to calculate the PHLF rate and 30-day survival after surgery.

Results: A total of 885 patients with complete data were finally included in analysis, 311 of them with elevated serum PCT (≥1 ng/ml). Results of the logistic regression analysis suggested a significant association between PCT and PHLF [HR, 95%CI; 3.801 (1.825, 7.917), p < 0.001]. Other significant risk factors for PHLF included portal hypertension, portal blocking time (>30 min) and blood transfusion (>200 ml). Kaplan-Meier analysis also suggested a higher PHLF rate in elevated PCT patients [9.0% (95% CI, 7.3 to 12.8 VS. 1.9% (95% CI, 1.1–4.3)); p < 0.001]. For secondary outcomes, elevated PCT was also highly associated with postoperative sepsis, ICU admission, 30-day mortality and 3-month mortality.

Conclusion: Elevated procalcitonin level in patients after hepatectomy is related to higher PHLF rate, with lower 30-day survival and poor short-term postoperative outcomes.

Diagnostic Challenges in Sepsis

Purpose of Review

Sepsis is a leading cause of death worldwide. Groundbreaking international collaborative efforts have culminated in the widely accepted surviving sepsis guidelines, with iterative improvements in management strategies and definitions providing important advances in care for patients. Key to the diagnosis of sepsis is identification of infection, and whilst the diagnostic criteria for sepsis is now clear, the diagnosis of infection remains a challenge and there is often discordance between clinician assessments for infection.

Recent Findings

We review the utility of common biochemical, microbiological and radiological tools employed by clinicians to diagnose infection and explore the difficulty of making a diagnosis of infection in severe inflammatory states through illustrative case reports. Finally, we discuss some of the novel and emerging approaches in diagnosis of infection and sepsis.

Summary

While prompt diagnosis and treatment of sepsis is essential to improve outcomes in sepsis, there remains no single tool to reliably identify or exclude infection. This contributes to unnecessary antimicrobial use that is harmful to individuals and populations. There is therefore a pressing need for novel solutions. Machine learning approaches using multiple diagnostic and clinical inputs may offer a potential solution but as yet these approaches remain experimental.

Serum procalcitonin as a biomarker for differentiating between infectious and non-infectious fever after pancreas transplantation

Laboratory biomarkers that can differentiate non-infectious fever from infectious fever after pancreas transplantation have yet to be discovered. Non-infectious fever was defined as the presence of fever (>38.3°C) in the absence of a documented clinical diagnosis of infection or a positive culture. Among 184 consecutive recipients, a total of 91 recipients developed fever within 1-month post-transplant, of whom 46 had infectious fever and 45 had non-infectious fever at our center between August 2014 and July 2019. The onset of fever was earlier in the non-infectious fever group (14.4 ± 3.7 post-transplant days) compared with the infectious fever group (16.5 ± 5.8 post-transplant days; p = .033). Multivariate analysis showed that serum procalcitonin at the peak of fever could significantly differentiate infectious fever from non-infectious fever (OR 53.378, 95% CI: 6.819-417.802, p < .001). The area under the curve for differentiating between the two groups was 0.853 (95% CI, 0.780-0.926) for procalcitonin and 0.667 (95% CI, 0.549-0.785) for CRP. The best cutoff values of serum procalcitonin and CRP were 0.405 ng/ml (sensitivity, 77.1%; specificity, 80.8%) and 7.355 mg/dl (sensitivity, 66.7%; specificity, 67.3%), respectively. Serum procalcitonin may be useful for differentiating non-infectious fever from infectious fever after pancreas transplantation.

A 2020 review on the role of procalcitonin in different clinical settings: an update conducted with the tools of the Evidence Based Laboratory Medicine

Biomarkers to guide antibiotic treatment decisions have been proposed as an effective way to enhancing a more appropriate use of antibiotics. As a biomarker, procalcitonin (PCT) has been found to have good specificity to distinguish bacterial from non-bacterial inflammations. Decisions regarding antibiotic use in an individual patient are complex and should be based on the pre-test probability for bacterial infection, the severity of presentation and the results of PCT serum concentration. In the context of a high pre-test probability for bacterial infections and/or a high-risk patient with sepsis, monitoring of PCT over time helps to track the resolution of infection and decisions regarding early stop of antibiotic treatment. As outlined by the Evidence Based Laboratory Medicine (EBLM), not only the pre-test probability but also the positive likelihood ratio influence the performance of a test do be really diagnostic. This aspect should be taken into account in the interpretation of the results of clinical trials evaluating the performance of PCT in guiding antibiotic therapy.

2019 WSES guidelines for the management of severe acute pancreatitis

Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.

Inflammatory mediators in the diagnosis and treatment of acute pancreatitis: pentraxin-3, procalcitonin and myeloperoxidase

INTRODUCTION

Acute pancreatitis (AP) is the third most common gastrointestinal disease at hospital admission. The etiology and pathogenesis of this disease are not completely clear. Our study was intended to determine the systemic levels of pentraxin-3 (PTX-3), myeloperoxidase (MPO), procalcitonin (PCT), and C-reactive protein (CRP) as prognostic parameters in early stages of AP. We also determined the effects of treatment on PTX-3, MPO, PCT and CRP levels in AP.

MATERIAL AND METHODS

The study group comprised 44 AP patients (22 male, 22 female; age: 49.3 ±16.9 years) referred to our outpatient clinic. Additionally, our investigation included a control group of 30 healthy volunteers (18 male, 12 female; age: 50.8 ±12.6 years).

RESULTS

Leukocytes, glucose, aspartate aminotransferase (AST (SGOT)), alanine aminotransferase (ALT (SGPT)), alkaline phosphatase (ALP), total and direct bilirubin levels were significantly higher in the AP group (p < 0.05, all). CRP, PTX-3, MPO and PCT were considerably higher in the AP group (p < 0.001, all), and after treatment, CRP, PTX-3, MPO and PCT levels were significantly lower (p < 0.001, all).

CONCLUSIONS

Our findings indicated that the CRP, PTX-3, MPO and PCT levels increase in patients with AP and hence these indicators can be used as diagnostic factors to predict inflammation severity in AP. It was revealed that after treatment, there were significant reductions in biomarker levels. However, further research is needed in order to understand how these biomarkers can help to monitor inflammatory responses in AP.

Comparison of multifactor scoring systems and single serum markers for the early prediction of the severity of acute pancreatitis

BACKGROUND

The purpose of this study was to clarify whether the current scoring systems and single serum markers used in pancreatitis remain applicable for the early prediction of infected pancreatic necrosis (IPN) and the severity and mortality of acute pancreatitis (AP) in accordance with the revised Atlanta and determinant-based classifications.

METHODS

Demographic, clinical, and laboratory data from 708 consecutive patients with AP were prospectively collected between January 2011 and December 2012. The severity was classified using the revised Atlanta and determinant-based classification systems. The predictive accuracies for moderately severe AP (MSAP), severe AP (SAP), critically severe AP (CAP), IPN, and mortality were measured using area under the receiver operating characteristic curves.

RESULTS

The receiver operating characteristic analysis showed that the multifactor scoring systems and single serum markers had a low predictive accuracy regarding moderately severe AP. The Acute Physiology and Chronic Health Evaluation (APACHE) II score had the highest accuracy in predicting SAP with area under the curve (AUC) values of 0.75 (95% CI = 0.71-0.79) and 0.77 (95% CI = 0.73-0.81) at 24 and 48 h after admission, respectively. Procalcitonin was the most accurate predictor for CAP and IPN, with respective AUCs of 0.86 (95% CI = 0.82-0.89) and 0.83 (95% CI = 0.78-0.87) at 48 h after admission. In predicting mortality, both the APACHE II score and blood urea nitrogen had the highest accuracy.

CONCLUSIONS

The APACHE II score had the highest predictive accuracy for SAP and mortality as defined by the revised Atlanta classification, whereas procalcitonin was the most accurate predictor for CAP and IPN.

Predictive value of procalcitonin for intestinal ischemia and/or necrosis in pediatric patients with adhesive small bowel obstruction (ASBO)

PURPOSE

Evaluate serum procalcitonin (PCT) level as a predictor of intestinal ischemia or necrosis (IN) in patients with postoperative adhesive small bowel obstruction (ASBO).

METHODS

Prospective cohort of consecutive patients with ASBO. Patients previously treated with antibiotics or septic were excluded. PCT was measured at the diagnosis of ASBO and every 24 h afterwards.

MAIN OUTCOME

intestinal ischemia or necrosis (IN).

RESULTS

Fifty-nine patients were included, 12 of whom were excluded; 47 patients remained in the study; male-to-female ratio = 1.9:1.

MANAGEMENT

medical in 15 cases (32%) and surgical in 32 (68%).

MAIN OUTCOME

Intestinal necrosis (IN) in 10 patients (21.3%). Mean PCT level was higher in patients with IN (15.11 ng/ml vs. 0.183 ng/ml, p=0.002), the proportion of patients with elevated PCT (>0.5 ng/dl) was higher in patients with IN (70% vs. 8.1%, p=<0.001, RR=26.4 with a 95% CI of 4.39-159.5). Elevated PCT levels at diagnosis had a 70% positive predictive value (PPV) and 91.8% negative predictive value (NPV) for prediction of IN. With a PCT value at diagnosis of >1.0 ng/dl, PPV was 87.5% and NPV, 92.3%.

CONCLUSIONS

PCT levels are closely related to the presence of intestinal ischemia and necrosis in children with ASBO.

LEVEL OF EVIDENCE

Study of Diagnostic Test, Level II.

The long-term quality of life in patients with persistent inflammation-immunosuppression and catabolism syndrome after severe acute pancreatitis: A retrospective cohort study

PURPOSE

To explore clinical characteristics and long-term quality of life (QOL) in severe acute pancreatitis (SAP) patients with persistent inflammation-immunosuppression and catabolism syndrome (PICS).

MATERIALS AND METHODS

SAP patients admitted to ICU were eligible for the retrospective cohort study if they needed prolonged intensive care (>14days). Post-ICU QOL was assessed by a questionnaire, including 36-item Short Form Health Survey (SF-36) and record of re-work in a long-term follow-up.

RESULTS

214 SAP patients were enrolled, in which 149 (69.6%) patients met the criteria of PICS. PICS patients had more complications and ICU days compared to non-PICS patients (P<0.001), and their post-ICU mortality was higher (P=0.046). When adjusted for confounders, PICS was independently associated with higher post-ICU mortality (hazard ratio 4.5; 95% CI, 1.2 to 16.3; P=0.024). The 36-item Short Form Health Survey (SF-36) score was lower for PICS group in six subscales (P<0.001). Only 28.8% patients in the PICS group returned to work compared to 60% patients in the non-PICS group (P=0.001) CONCLUSIONS: SAP patients with prolonged ICU stay had a high morbidity of PICS, which was a risk factor for the post-ICU mortality and poor long-term QOL.

Serum C-reactive protein, procalcitonin, and lactate dehydrogenase for the diagnosis of pancreatic necrosis

BACKGROUND

The treatment of people with pancreatic necrosis differs from that of people with oedematous pancreatitis. It is important to know the diagnostic accuracy of serum C-reactive protein (CRP), serum procalcitonin, and serum lactate dehydrogenase (LDH) as a triage test for the detection of pancreatic necrosis in people with acute pancreatitis, so that an informed decision can be made as to whether the person with pancreatic necrosis needs further investigations such as computed tomography (CT) scan or magnetic resonance imaging (MRI) scan and treatment for pancreatic necrosis started. There is currently no standard clinical practice, although CRP, particularly an increasing trend of CRP, is often used as a triage test to determine whether the person requires further imaging. There is also currently no systematic review of the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis.

OBJECTIVES

To compare the diagnostic accuracy of CRP, procalcitonin, or LDH (index test), either alone or in combination, in the diagnosis of necrotising pancreatitis in people with acute pancreatitis and without organ failure.

SEARCH METHODS

We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase.

SELECTION CRITERIA

We included all studies that evaluated the diagnostic test accuracy of CRP, procalcitonin, and LDH for the diagnosis of pancreatic necrosis in people with acute pancreatitis using the following reference standards, either alone or in combination: radiological features of pancreatic necrosis (contrast-enhanced CT or MRI), surgeon's judgement of pancreatic necrosis during surgery, or histological confirmation of pancreatic necrosis. Had we found case-control studies, we planned to exclude them because they are prone to bias; however, we did not locate any. Two review authors independently identified the relevant studies from the retrieved references.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, including methodological quality assessment, from the included studies. As the included studies reported CRP, procalcitonin, and LDH on different days of admission and measured at different cut-off levels, it was not possible to perform a meta-analysis using the bivariate model as planned. We have reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) on each of the different days of admission and measured at different cut-off levels.

MAIN RESULTS

A total of three studies including 242 participants met the inclusion criteria for this review. One study reported the diagnostic performance of CRP for two threshold levels (> 200 mg/L and > 279 mg/L) without stating the day on which the CRP was measured. One study reported the diagnostic performance of procalcitonin on day 1 (1 day after admission) using a threshold level of 0.5 ng/mL. One study reported the diagnostic performance of CRP on day 3 (3 days after admission) using a threshold level of 140 mg/L and LDH on day 5 (5 days after admission) using a threshold level of 290 U/L. The sensitivities and specificities varied: the point estimate of the sensitivities ranged from 0.72 to 0.88, while the point estimate of the specificities ranged from 0.75 to 1.00 for the different index tests on different days of hospital admission. However, the confidence intervals were wide: confidence intervals of sensitivities ranged from 0.51 to 0.97, while those of specificities ranged from 0.18 to 1.00 for the different tests on different days of hospital admission. Overall, none of the tests assessed in this review were sufficiently accurate to suggest that they could be useful in clinical practice.

AUTHORS' CONCLUSIONS

The paucity of data and methodological deficiencies in the studies meant that it was not possible to arrive at any conclusions regarding the diagnostic test accuracy of the index test because of the uncertainty of the results. Further well-designed diagnostic test accuracy studies with prespecified index test thresholds of CRP, procalcitonin, LDH; appropriate follow-up (for at least two weeks to ensure that the person does not have pancreatic necrosis, as early scans may not indicate pancreatic necrosis); and clearly defined reference standards (of surgical or radiological confirmation of pancreatic necrosis) are important to reliably determine the diagnostic accuracy of CRP, procalcitonin, and LDH.

Ileus is a predictor of local infection in patients with acute necrotizing pancreatitis

BACKGROUND & OBJECTIVES

Infected pancreatic necrosis (IPN) is associated with increased morbidity and mortality. Gut barrier dysfunction has been shown to increase the risk of bacterial translocation from the gut into the pancreatic bed. The primary aim of the study is to evaluate if ileus, a clinical marker of gut barrier dysfunction, can predict the development of IPN.

METHODS

A retrospective cohort study of patients with necrotizing pancreatitis (NP) was conducted from 2000 to 2014. Ileus was defined as ≥2 of the following criteria: nausea/vomiting; inability to tolerate a diet, absence of flatus, abdominal distension and features of ileus on imaging. Extensive necrosis was defined as >30% nonenhancing pancreatic parenchyma on contrast-enhanced CT. Multivariable cox proportional hazard analysis was used to evaluate known and potential predictors of IPN.

RESULTS

142 patients were identified with NP, 61 with IPN and 81 with sterile necrosis. In comparison to a diagnosis of ileus documented in the medical chart, the ileus criteria had a sensitivity, specificity and positive and negative predictive value of 100%, 93%, 78% and 100%, respectively. On multivariate cox proportional hazard analysis, ileus [HR:2.6; 95%CI:1.4-4.9] and extensive necrosis [HR:2.8; 95%CI:1.3-5.8] were independently associated with the development of IPN while there was no association with bacteremia [HR:1.09; 95%CI:0.6-2.1].

CONCLUSION

Ileus in NP can be accurately defined using surgical criteria. Ileus is independently associated with the future development of IPN. Further studies will be needed to determine if ileus can serve as a clinical marker to direct therapeutic interventions aimed at reducing the incidence of IPN.

Diagnostic Value of Procalcitonin Levels in Acute Mesenteric Ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is a potentially fatal disease. Difficulties in diagnosis make it essential to find early biomarkers.

AIMS

This study investigated the diagnostic value of procalcitonin (PCT) levels in AMI.

STUDY DESIGN

Animal experimentation.

METHODS

Rats were divided into six groups of six animals each. In the experimental group, an experimental ischemia model was established by clamping the superior mesenteric artery from the aortic outflow tract. Blood and tissue specimens were collected from rats in the experimental mesenteric ischemia model at 30 min and 2 and 6 h, and these were compared with specimens from the respective control groups. PCT levels were compared at 30 min and 2 and 6 h.

RESULTS

PCT levels were 185.3 pg/mL in the control group and 219.3 pg/mL in the study group, 199.6 pg/mL in the control group and 243.9 pg/mL in the study group, and 201.9 pg/mL in the control group and 286.9 pg/mL in the study group, respectively, at 30 minute, 2 and 6 hours. Significant differences were determined between 6-h control group and ischemia group PCT levels (p=0.005).

CONCLUSION

The absence of a significant increase in PCT levels in the early period, while a significant difference was detected in the later period (6 h), shows that PCT levels rise late in mesenteric ischemia and can be a marker in the late period.

Update on procalcitonin measurements

Procalcitonin (PCT) is used as a biomarker for the diagnosis of sepsis, severe sepsis and septic shock. At the same time, PCT has also been used to guide antibiotic therapy. This review outlines the main indications for PCT measurement and points out possible pitfalls. The classic indications for PCT measurement are: (i) confirmation or exclusion of diagnosis of sepsis, severe sepsis, or septic shock, (ii) severity assessment and follow up of systemic inflammation mainly induced by microbial infection, and (iii) individual, patient adapted guide of antibiotic therapy and focus treatment. Using serially monitored PCT levels, the duration and need of antibiotic therapy can be better adapted to the individual requirements of the patient. This individualized approach has been evaluated in various studies, and it is recommended to be a part of an antibiotic stewardship program.

Role of biomarkers in the management of antibiotic therapy: an expert panel review II: clinical use of biomarkers for initiation or discontinuation of antibiotic therapy

Biomarker-guided initiation of antibiotic therapy has been studied in four conditions: acute pancreatitis, lower respiratory tract infection (LRTI), meningitis, and sepsis in the ICU. In pancreatitis with suspected infected necrosis, initiating antibiotics best relies on fine-needle aspiration and demonstration of infected material. We suggest that PCT be measured to help predict infection; however, available data are insufficient to decide on initiating antibiotics based on PCT levels. In adult patients suspected of community-acquired LRTI, we suggest withholding antibiotic therapy when the serum PCT level is low (<0.25 ng/mL); in patients having nosocomial LRTI, data are insufficient to recommend initiating therapy based on a single PCT level or even repeated measurements. For children with suspected bacterial meningitis, we recommend using a decision rule as an aid to therapeutic decisions, such as the Bacterial Meningitis Score or the Meningitest®; a single PCT level ≥0.5 ng/mL also may be used, but false-negatives may occur. In adults with suspected bacterial meningitis, we suggest integrating serum PCT measurements in a clinical decision rule to help distinguish between viral and bacterial meningitis, using a 0.5 ng/mL threshold. For ICU patients suspected of community-acquired infection, we do not recommend using a threshold serum PCT value to help the decision to initiate antibiotic therapy; data are insufficient to recommend using PCT serum kinetics for the decision to initiate antibiotic therapy in patients suspected of ICU-acquired infection. In children, CRP can probably be used to help discontinue therapy, although the evidence is limited. In adults, antibiotic discontinuation can be based on an algorithm using repeated PCT measurements. In non-immunocompromised out- or in- patients treated for RTI, antibiotics can be discontinued if the PCT level at day 3 is < 0.25 ng/mL or has decreased by >80-90%, whether or not microbiological documentation has been obtained. For ICU patients who have nonbacteremic sepsis from a known site of infection, antibiotics can be stopped if the PCT level at day 3 is < 0.5 ng/mL or has decreased by >80% relative to the highest level recorded, irrespective of the severity of the infectious episode; in bacteremic patients, a minimal duration of therapy of 5 days is recommended.

Serum inter-cellular adhesion molecule 1 is an early marker of diagnosis and prediction of severe acute pancreatitis

AIM: To determine if serum inter-cellular adhesion molecule 1 (ICAM-1) is an early marker of the diagnosis and prediction of severe acute pancreatitis (SAP) within 24 h of onset of pain, and to compare the sensitivity, specificity and prognostic value of this test with those of acute physiology and chronic health evaluation (APACHE) II score and interleukin-6 (IL-6).

METHODS: Patients with acute pancreatitis (AP) were divided into two groups according to the Ranson’s criteria: mild acute pancreatitis (MAP) group and SAP group. Serum ICAM-1, APACHE IIand IL-6 levels were detected in all the patients. The sensitivity, specificity and prognostic value of the ICAM-1, APACHE IIscore and IL-6 were evaluated.

RESULTS: The ICAM-1 level in 36 patients with SAP within 24 h of onset of pain was increased and was significantly higher than that in the 50 patients with MAP and the 15 healthy volunteers (P < 0.01). The ICAM-1 level (25 ng/mL) was chosen as the optimum cutoff to distinguish SAP from MAP, and the sensitivity, specificity, positive predictive value, negative predictive value (NPV), positive likelihood ratio and negative likelihood ratio were 61.11%, 71.42%, 0.6111, 0.7142, 2.1382 and 0.5445, respectively. The area under the curve demonstrated that the prognostic accuracy of ICAM-1 (0.712) was similar to the APACHE-IIscoring system (0.770) and superior to IL-6 (0.508) in distinguishing SAP from MAP.

CONCLUSION: ICAM-1 test is a simple, rapid and reliable method in clinical practice. It is an early marker of diagnosis and prediction of SAP within the first 24 h after onset of pain or on admission. As it has a relatively low NPV and does not allow it to be a stand-alone test for the diagnosis of AP, other conventional diagnostic tests are required.

[Procalcitonin-based algorithm. Management of antibiotic therapy in critically ill patients]

Sepsis is one of the most cost-intensive conditions of critically ill patients in intensive care medicine. Furthermore, sepsis is known to be the leading cause of morbidity and of mortality in intensive care patients. Early initiation of antibiotic therapy can significantly reduce mortality. The development of resistance of bacterial species against antibiotics 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 distinguish bacterial infections from viral or non-infectious inflammatory responses. However, procalcitonin (PCT) appears to be the first among a large array of inflammatory markers that offers this possibility. Regular procalcitonin measurements can significantly shorten the length of antibiotic therapy, show positive influence on antibiotic costs and have no adverse affects on patient outcome.

Predictive value of procalcitonin for the diagnosis of bowel strangulation

Intestinal obstruction is responsible for 3% of admissions to hospital emergency surgical departments, but it is difficult to distinguish simple obstruction from strangulation. Simple criteria for this distinction are sought. In this experimental study, procalcitonin, a known marker of bacterial inflammation, was used to detect strangulation. The predictive value of procalcitonin for small bowel strangulation was evaluated. Thirty male New Zealand rabbits (mean weight: 3.0 kg) were divided into three groups. In the first (control) group, only laparatomy was performed. In the second group, simple obstruction was created by ligating a 10-cm distal ileum segment. In the third group, distal strangulation was created by ligating a 10-cm distal ileum segment with the mesentery. Blood (1 cc) was taken from the right auricular vein of each animal for measuring the procalcitonin level. In both the control group and the simple obstruction group the procalcitonin levels were normal. In the strangulation group, elevation of procalcitonin was detected after 30 minutes, and the elevation was statistically significant at 120th minute compared with the control and simple obstruction groups. In patients with small bowel obstruction, measurement of procalcitonin levels is easy to perform and can be used in the follow-up. A more extensive clinical study is needed to evaluate the accuracy of the test as a marker.

Procalcitonin: improved biochemical severity stratification and postoperative monitoring in severe abdominal inflammation and sepsis

BACKGROUND

Infections and sepsis are among the most devastating complications in abdominal surgery and significantly contribute to morbidity and mortality. Early and reliable diagnosis of septic complications is notoriously difficult, and the search for novel approaches to overcome this problem is still a compelling issue for clinicians. Among a large array of inflammatory parameters, procalcitonin (PCT), the 116-amino-acid pro-peptide of calcitonin, has gained considerable importance in identifying patients at risk of developing infection and sepsis in clinical practice.

METHODS

Along with the latest insights into pathophysiological aspects of this pro-hormone, the literature as well as our own experience on the usefulness of PCT determinations in patients with severe inflammatory abdominal disorders was reviewed.

RESULTS

Although the term "sepsis" does not embrace the integral properties of PCT, a remarkable number of clinical studies have demonstrated the pivotal role of this parameter in the host response to microbial and fungal infections. In acute pancreatitis PCT allows early severity stratification and closely correlates with the development of subsequent pancreatic infections. In patients with peritonitis PCT reflects overall disease severity and is an early and reliable indicator of overall prognosis. Postoperative monitoring of PCT is a helpful tool to identify patients with evolving or persisting septic complications after elective and emergency abdominal surgery.

CONCLUSIONS

Compared with established biochemical routine variables, PCT significantly contributes to earlier and better stratification of patients at risk of developing septic complications and provides excellent prognostic assessment in severe abdominal inflammation. The currently available test systems render PCT an applicable and readily available parameter under clinical routine and emergency conditions.