Procalcitonin in preoperative diagnosis of abdominal sepsis

The Role of Biomarkers and Scores in Describing Urosepsis

Background and Objectives: Patients with urinary tract obstruction (UTO) and systemic inflammatory response syndrome (SIRS) are at risk of developing urosepsis, whose evolution involves increased morbidity, mortality and cost. The aim of this study is to evaluate the ability of already existing scores and biomarkers to diagnose, describe the clinical status, and predict the evolution of patients with complicated urinary tract infection (UTI) and their risk of progressing to urosepsis. Materials and Methods: We conducted a retrospective study including patients diagnosed with UTI hospitalized in the urology department of” Sfântul Apostol Andrei” County Emergency Clinical Hospital (GCH) in Galati, Romania, from September 2019 to May 2022. The inclusion criteria were: UTI proven by urine culture or diagnosed clinically complicated with UTO, fever or shaking chills, and purulent collections, such as psoas abscess, Fournier Syndrome, renal abscess, and paraurethral abscess, showing SIRS. The exclusion criteria were: patients age < 18 years, pregnancy, history of kidney transplantation, hemodialysis or peritoneal dialysis, and patients with missing data. We used the Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) and qSOFA (quick SOFA) scores, and procalcitonin (PCT) to describe the clinical status of the patients. The Charlson Comorbidity Index (CCI) was used to assesses pre-existing morbidities. The hospitalization days and costs and the days of intensive care were considered. Depending on the diagnosis at admission, we divided the patients into three groups: SIRS, sepsis and septic shock. The fourth group was represented by patients who died during hospitalization. Results: A total of 174 patients with complicated UTIs were enrolled in this study. From this total, 46 were enrolled in the SIRS group, 88 in the urosepsis group, and 40 in the septic shock group. A total of 23 patients died during hospitalization and were enrolled in the deceased group. An upward trend of age along with worsening symptoms was highlighted with an average of 56.86 years in the case of SIRS, 60.37 years in the sepsis group, 69.03 years in the septic shock, and 71.04 years in the case of deceased patients (p < 0.04). A statistically significant association between PCT and complex scores (SOFA, CCI and qSOFA) with the evolution of urosepsis was highlighted. Increased hospitalization costs can be observed in the case of deceased patients and those with septic shock and statistically significantly lower in the case of those with SIRS. The predictability of discriminating urosepsis stages was assessed by using the area under the ROC curve (AUC) and very good specificity and sensitivity was identified in predicting the risk of death for PCT (69.57%, 77.33%), the SOFA (91.33%, 76.82%), qSOFA (91.30%, 74.17%) scores, and CCI (65.22%, 88.74%). The AUC value was best for qSOFA (90.3%). For the SIRS group, the PCT (specificity 91.30%, sensitivity 85.71%) and SOFA (specificity 84.78%, sensitivity 78.74%), qSOFA scores (specificity 84.78%, sensitivity 76, 34%) proved to be relevant in establishing the diagnosis. In the case of the septic shock group, the qSOFA (specificity 92.5%, sensitivity 82.71%) and SOFA (specificity 97.5%, sensitivity 77.44%) as well as PCT (specificity 80%, sensitivity 85.61%) are statistically significant disease-defining variables. An important deficit in the tools needed to classify patients into the sepsis group is obvious. All the variables have an increased specificity but a low sensitivity. This translates into a risk of a false negative diagnosis. Conclusions: Although SOFA and qSOFA scores adequately describe patients with septic shock and they are independent prognostic predictors of mortality, they fail to be accurate in diagnosing sepsis. These scores should not replace the conventional triage protocol. In our study, PCT proved to be a disease-defining marker and an independent prognostic predictor of mortality. Patients with important comorbidities, CCI greater than 10, should be treated more aggressively because of increased mortality.

Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons

The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.

Diagnostic value of neutrophil CD64, procalcitonin, and interleukin-6 in sepsis: a meta-analysis

Background

The aim of the study was to conduct a meta-analysis to evaluate the accuracy of neutrophil CD64, procalcitonin (PCT), and interleukin-6 (IL-6) as markers for the diagnosis of sepsis in adult patients.

Methods

Various databases were searched to collect published studies on the diagnosis of sepsis in adult patients using neutrophil CD64, PCT, and IL-6 levels. Utilizing the Stata SE 15.0 software, forest plots and the area under the summary receiver operating characteristic curves were drawn. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve (AUC) were calculated.

Results

Fifty-four articles were included in the study. The pooled sensitivity, specificity, and AUC of neutrophil CD64 for the diagnosis of sepsis were 0.88 (95% confidence interval [CI], 0.81–0.92), 0.88 (95% CI, 0.83–0.91), and 0.94 (95% CI, 0.91–0.96), respectively. The pooled sensitivity, specificity, and AUC of PCT for the diagnosis of sepsis were 0.82 (95% CI, 0.78–0.85), 0.78 (95% CI, 0.74–0.82), and 0.87 (95% CI, 0.83–0.89), respectively. Subgroup analysis showed that the AUC for PCT diagnosis of intensive care unit (ICU) sepsis was 0.86 (95% CI, 0.83–0.89) and the AUC for PCT diagnosis of non-ICU sepsis was 0.82 (95% CI, 0.78–0.85). The pooled sensitivity, specificity, and AUC of IL-6 for the diagnosis of sepsis were 0.72 (95% CI, 0.65–0.78), 0.70 (95% CI, 0.62–0.76), and 0.77 (95% CI, 0.73–0.80), respectively.

Conclusions

Of the three biomarkers studied, neutrophil CD64 showed the highest diagnostic value for sepsis, followed by PCT, and IL-6. On the other hand, PCT showed a better diagnostic potential for the diagnosis of sepsis in patients with severe conditions compared with that in patients with non-severe conditions.

Procalcitonin as an early indicator of urosepsis following prostate biopsy

BACKGROUND

To investigate the usefulness of serum procalcitonin (PCT) in the early diagnosis of urinary tract infection (UTI) and urosepsis following transrectal prostate biopsy.

METHODS

In this prospective observational study, 227 patients who underwent transrectal ultrasound-guided prostate biopsy were evaluated. The relationship between urosepsis and age, serum PCT, C-reactive protein, prostate-specific antigen (PSA), prostate volume, PSA density and pathologic results following biopsy was assessed. Serum PCT level was measured in all patients immediately before the biopsy and at the post-biopsy day 2.

RESULTS

Of the 227 patients, 11 (4.8%) developed UTI with positive urine culture without urosepsis and 5 (2.2%) developed urosepsis within 30 days after biopsy. The concentration of PCT was within the normal range before the biopsy. Procalcitonin concentration at post-biopsy day 2 was significantly higher in patients who developed urosepsis (1.91 ± 2.99 ng/ml vs. 0.05 ± 0.08 ng/ml; p = .004) compared with non-UTI patients. Only elevated PCT level at post-biopsy day 2 was a statistically significant independent predictor of post-biopsy urosepsis. The area under the ROC curve for the prediction of urosepsis was 0.976 (95%CI: 0.941-1.000) and a cut-off 0.095 ng/ml in the level of PCT at post-biopsy day 2 yielded a sensitivity of 100% and specificity of 93.8% in detecting urosepsis following biopsy.

CONCLUSIONS

Procalcitonin appears to be a useful early biomarker to predict the urosepsis following prostate biopsy. Patients with elevated PCT value should be closely monitored after the biopsy.

A study of C-reactive protein and D-dimer in patients of appendicitis

BACKGROUND

Acute appendicitis is the most common abdominal surgical emergencies across the world.

OBJECTIVE

The aim of this study was to determine the value of C-reactive protein (CRP) and D-dimer as diagnostic markers of acute appendicitis.

STUDY DESIGN

It was a Prospective observational clinical study.

METHOD

The present study was carried out in General Surgical Unit of University Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi from September 2015 to July 2017. All data including patient's demography, clinical examination, laboratory test results, and appendix histology were summarized. Receiver operating characteristic (ROC) curve of TLC, CRP, and D-dimer was analyzed.

RESULTS

Total 65 patients who presented with periumbilical pain or pain in right iliac fossa (RIF) were included in the study. The mean age of the patients was 31.18 ± 14.59 years (range: 15 to 65 years) with male : female ratio was 2.21:1. The most common symptom was pain in right iliac fossa (100%) followed by nausea/vomiting (69.2%). The mean leucocyte count, CRP, and D-dimer levels were significantly raised in appendicitis group as compared to negative appendicectomy group (P = 0.025, P = 0.036, and P = 0.025, respectively). The receiver operating characteristic (ROC) curve for TLC was not helpful for differentiating between appendicitis and negative appendicitis (P = 0.073). In addition, D-dimer was helpful for differentiating between appendicitis and negative appendicitis (P = 0.002). However, CRP was also found to be helpful for differentiating between appendicitis and negative appendicitis (P = 0.030).

CONCLUSION

The diagnosis of appendicitis remains multifactorial and biochemical markers like CRP and D-dimer may help to guide the surgeon in the decision making.

The procalcitonin/albumin ratio as an early diagnostic predictor in discriminating urosepsis from patients with febrile urinary tract infection

Discrimination between urosepsis and febrile urinary tract infections is important in therapeutic decision-making to indicate suitable treatments to avoid sepsis-related organ failure. Accurate diagnosis is time-consuming and susceptible to false-positive results. Moreover, patient responses to urosepsis are complex and varied. Therefore, this study aimed to develop a new, early diagnostic predictor that could discriminate between patients with urosepsis and those with febrile urinary tract infections using a combination of initial procalcitonin and albumin levels.We conducted a retrospective study involving 140 patients with febrile urinary tract infections from January 2013 to December 2017. Univariate and multivariate logistic analyses were performed to identify the independent risk factors for differentiating urosepsis from febrile urinary tract infection. A receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive accuracy of the procalcitonin/albumin ratio.Patients in the urosepsis group had higher procalcitonin/albumin ratios compared to those in the febrile urinary tract infection group [2.254 (0.978, 6.299) vs 0.021 (0.004, 0.095); P < .001]. Based on multivariate logistic analysis, the procalcitonin/albumin ratio [adjusted odds ratio (OR) 1.029, 95% confidence interval (CI) 1.013-1.045, P < .001] was an independent predictor of urosepsis, which allowed for differentiation from patients with febrile urinary tract infections. The area under the ROC curve (AUC) for the procalcitonin/albumin ratio was 0.937 (95% CI, 0.894-0.980); P < .001. The sensitivity and specificity of the procalcitonin/albumin ratio cut-off values (>0.44) were 84.62% and 96.00%, respectively. Moreover, in the subset of 65 patients with urosepsis, the procalcitonin/albumin ratio in the uroseptic shock group was higher than in the group of patients without uroseptic shock [5.46 (1.43, 6.58) vs 1.24 (0.63, 4.38); P = .009].Our study demonstrates that the procalcitonin/albumin ratio is an early diagnostic predictor that can discriminate between urosepsis and febrile urinary tract infection. Additionally, in patients with urosepsis, those with higher procalcitonin/albumin ratios were more prone to uroseptic shock. Our findings suggest that the procalcitonin/albumin ratio is a rapid and relatively low-cost biomarker that can be used in clinical practice.

Secondary peritonitis: principles of diagnosis and intervention

Secondary peritonitis accounts for 1% of urgent or emergent hospital admissions and is the second leading cause of sepsis in patients in intensive care units globally. Overall mortality is 6%, but mortality rises to 35% in patients who develop severe sepsis. Despite the dramatic growth in the availability and use of imaging and laboratory tests, the rapid diagnosis and early management of peritonitis remains a challenge for physicians in emergency medicine, surgery, and critical care. In this article, we review the pathophysiology of peritonitis and its potential progression to sepsis, discuss the utility and limitations of the physical examination and laboratory and radiographic tests, and present a paradigm for the management of secondary peritonitis.

[Characteristics of postoperative peritonitis]

Postoperative peritonitis is still a life-threatening complication after abdominal surgery and approximately 10,000 patients annually develop postoperative peritonitis in Germany. Early recognition and diagnosis before the onset of sepsis has remained a clinical challenge as no single specific screening test is available. The aim of therapy is a rapid and effective control of the source of infection and antimicrobial therapy. After diagnosis of diffuse postoperative peritonitis surgical revision is usually inevitable after intestinal interventions. Peritonitis after liver, biliary or pancreatic surgery is managed as a rule by means of differentiated therapy approaches depending on the severity.

Biomarkers for diagnosis of sepsis in patients with systemic inflammatory response syndrome: a systematic review and meta-analysis

Background

Sepsis is one of the most common diseases that seriously threaten human health. Although a large number of markers related to sepsis have been reported in the last two decades, the diagnostic accuracy of these biomarkers remains unclear due to the lack of similar baselines among studies. Therefore, we conducted a large systematic review and meta-analysis to evaluate the diagnostic value of biomarkers from studies that included non-infectious systemic inflammatory response syndrome patients as a control group.

Methods

We searched Medline, Embase and the reference lists of identified studies beginning in April 2014. The last retrieval was updated in September 2016.

Results

Ultimately, 86 articles fulfilled the inclusion criteria. Sixty biomarkers and 10,438 subjects entered the final analysis. The areas under the receiver operating characteristic curves for the 7 most common biomarkers, including procalcitonin, C-reactive protein, interleukin 6, soluble triggering receptor expressed on myeloid cells-1, presepsin, lipopolysaccharide binding protein and CD64, were 0.85, 0.77, 0.79, 0.85, 0.88, 0.71 and 0.96, respectively. The remaining 53 biomarkers exhibited obvious variances in diagnostic value and methodological quality.

Conclusions

Although some biomarkers displayed moderate or above moderate diagnostic value for sepsis, the limitations of the methodological quality and sample size may weaken these findings. Currently, we still lack an ideal biomarker to aid in the diagnosis of sepsis. In the future, biomarkers with better diagnostic value as well as a combined diagnosis using multiple biomarkers are expected to solve the challenge of the diagnosis of sepsis.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-3591-5) contains supplementary material, which is available to authorized users.

Predictive values for procalcitonin in the diagnosis of neonatal sepsis

BACKGROUND

Early diagnosis of neonatal sepsis followed by appropriate treatment decreases mortality and morbidity in infants. The aim of this study is to assess the role of procalcitonin (PCT) as a marker in the early diagnosis of neonatal sepsis.

METHODS

We present a cross sectional study where 35 neonates with early onset sepsis (admitted to the Neonatal Intensive Care Units at El-Minia Children University Hospital from August 2012 to August 2013) were included in the study. Another 35 healthy neonates with no clinical or biological data of infection were included as a control group. Subjects were subjected to a thorough history taking and routine laboratory investigations. Serum PCT and C-reactive protein (CRP) levels were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Mean levels of PCT and CRP in neonates with sepsis were significantly higher than in the control group (p=0.0001). There was a moderate, but significant, positive correlation between PCT and C-reactive protein (p=0.001, r=0.55) and an insignificant correlation between procalcitonin and total leukocytic count among the neonates with sepsis (p=0.2, r=0.2). In addition, procalcitonin had high sensitivity, specificity, a high positive predictive value, and a high negative predictive value (80%, 85.7%, 84.8%, and 81.1% respectively). Procalcitonin showed higher sensitivity when compared to CRP.

CONCLUSION

Procalcitonin is a sensitive, independent, and useful biomarker in comparison to CRP in early diagnosis of neonatal sepsis.

A simple bioscore improves diagnostic accuracy of sepsis after surgery

BACKGROUND

Rapid and accurate prediction for sepsis remains a challenge in surgical intensive care units. Detection of individual biomarkers is often of marginal usefulness, and several biomarkers are difficult to measure in the clinical setting. The aim of this study was to evaluate the diagnostic and prognostic performance of three routine biomarkers, procalcitonin (PCT), B-type natriuretic peptide (BNP), and lymphocyte percentage, as individual or in combination for sepsis in surgical critically ill patients.

MATERIALS AND METHODS

Circulating PCT, BNP, and lymphocyte percentage were measured in surgical patients on admission to the intensive care unit. A bioscore system combining these biomarkers was constructed. All studied variables were analyzed according to the diagnosis and clinical outcomes of sepsis.

RESULTS

A total of 320 consecutive patients were included in the analysis. One hundred fifty-six patients presented with sepsis. In the patients with sepsis, levels of PCT and BNP increased and lymphocyte percentage decreased. For individual biomarkers, PCT achieved the best area under the curve for the diagnosis of sepsis, whereas the diagnostic performance of the bioscore was better than that of each individual biomarker (area under the curve, 0.914 [95% confidence interval, 0.862-0.951]). Levels of BNP and bioscore increased in nonsurvivors in the entire cohort, but the accuracy of these two variables for mortality prediction was lower than that shown by Acute Physiology and Chronic Health Evaluation II score. Furthermore, bioscore failed to predict outcomes in septic patients.

CONCLUSIONS

A simple bioscore combining PCT together with BNP and lymphocyte percentage improves the diagnostic accuracy for sepsis in surgical critically ill patients but fails to predict outcomes in surgical patients with sepsis.

Prediction of mortality in patients with colorectal perforation based on routinely available parameters: a retrospective study

INTRODUCTION

Even after surgery and intensive postoperative management, the mortality rate associated with colorectal perforation is high. Identification of mortality markers using routinely available preoperative parameters is important.

METHODS

We enrolled consecutive patients with colorectal perforation who underwent operations from January 2010 to January 2015. We divided them into a mortality and survivor group and compared clinical characteristics between the two groups. Additionally, we compared the mortality rate between different etiologies: malignant versus benign and diverticular versus nondiverticular. We used the χ (2) and Mann-Whitney U tests and a logistic regression model to identify factors associated with mortality.

RESULTS

We enrolled 108 patients, and 52 (48 %) were male. The mean age at surgery was 71 ± 13 years. The postoperative mortality rate was 12 % (13 patients). Multivariate logistic regression analysis showed that a high patient age (odds ratio [OR], 1.09; 95 % confidence interval [CI], 1.020-1.181) and low preoperative systolic blood pressure (OR, 0.98; 95 % CI, 0.953-0.999) were independent risk factors for mortality in patients with colorectal perforation. In the subgroup analysis, there was no significant difference between the malignant and benign group (11.8 % vs. 23.9 %, respectively; p = 0.970), while the diverticular group had a significantly lower mortality rate than the nondiverticular group (2.6 % vs. 17.1 %, respectively; p = 0.027).

CONCLUSIONS

Older patients and patients with low preoperative blood pressure had a high risk of mortality associated with colorectal perforation. For such patients, operations and postoperative management should be performed carefully.

Role of inflammatory markers as predictors of laparotomy in patients presenting with acute abdomen

BACKGROUND

There is a need for an ideal indicator of surgery in patients presenting with acute abdomen. Several markers have been analysed, but the search still continues as none have proven effective. This study aimed to analyse and compare the predictive value of plasma procalcitonin (PCT) strip test in patients presenting with acute abdomen and identify a useful cut-off value to differentiate patients that would benefit with surgery from those that require conservative management.

METHODS

A prospective study was conducted in the department of general surgery from June 2012 to June 2013. Plasma PCT was estimated by the semi-quantitative strip test. The levels of plasma PCT and other routinely used markers of inflammation were analysed and compared.

RESULTS

Of the total of 58 patients, 44 patients (76%) were men with a mean age of 45 years. Forty patients required emergency surgical intervention. A plasma PCT value of >0.5 ng/mL at admission was 80% sensitive and 100% specific for predicting need for antibiotics in patients with acute abdomen that were managed conservatively. The mean plasma PCT value in the patients undergoing surgery (5.0-10.0 ng/mL) was significantly more than in those managed conservatively (0.5-2.0 ng/mL). Using receiver operating characteristic (ROC) curves a cut-off for plasma PCT of >5.0 ng/mL was 75% sensitive and 100% specific for considering surgical intervention in patients presenting with acute abdomen.

CONCLUSIONS

Plasma PCT (value >5 ng/mL) could be used as an adjunct to clinical examination to predict requirement of surgery in patients presenting with acute abdomen.

Procalcitonin as an early diagnostic and monitoring tool in urosepsis following percutaneous nephrolithotomy

To evaluate the value of procalcitonin (PCT) as an early marker for diagnosis and differentiation of without urosepsis, urosepsis, severe urosepsis, and uroseptic shock following PCNL and the ability of PCT to assess the effectiveness of antibiotic therapy in patients with urosepsis. From June 2012 to August 2013, 267 patients undergoing PCNL for renal calculi, and who fulfilled selection criteria, were recruited into our study. The patients' medical records were reviewed retrospectively. One of selection criteria was the scores of PCT and WBC were collected at operative day, postoperative day one, day two, day three, day five and day seven. The area under the ROC curve for the prediction of urosepsis was 0.960 for PCT and 0.634 for WBC. PCT concentrations were higher in patients with uroseptic shock versus severe urosepsis versus urosepsis versus without urosepsis following PCNL. WBC values showed no significant difference between patients with urosepsis, severe urosepsis and uroseptic shock following PCNL. With time, in patients with successfully treated urosepsis following PCNL, the PCT concentrations significantly declined and kept decreasing from postoperative day two to postoperative day seven and the WBC scores showed no significant change over the first postoperative 2 days and were decreased only after postoperative day three. PCT appears to be a useful early marker to diagnosis and discriminate urosepsis, severe urosepsis and uroseptic shock following PCNL. Daily PCT measurements may be a valuable tool in monitoring the effectiveness of antibiotic therapy in urosepsis following PCNL.

Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis

BACKGROUND

Procalcitonin is a promising marker for identification of bacterial infections. We assessed the accuracy and clinical value of procalcitonin for diagnosis of sepsis in critically ill patients.

METHODS

We searched Medline, Embase, ISI Web of Knowledge, the Cochrane Library, Scopus, BioMed Central, and Science Direct, from inception to Feb 21, 2012, and reference lists of identified primary studies. We included articles written in English, German, or French that investigated procalcitonin for differentiation of septic patients--those with sepsis, severe sepsis, or septic shock--from those with a systemic inflammatory response syndrome of non-infectious origin. Studies of healthy people, patients without probable infection, and children younger than 28 days were excluded. Two independent investigators extracted patient and study characteristics; discrepancies were resolved by consensus. We calculated individual and pooled sensitivities and specificities. We used I(2) to test heterogeneity and investigated the source of heterogeneity by metaregression.

FINDINGS

Our search returned 3487 reports, of which 30 fulfilled the inclusion criteria, accounting for 3244 patients. Bivariate analysis yielded a mean sensitivity of 0 · 77 (95% CI 0 · 72-0 · 81) and specificity of 0 · 79 (95% CI 0 · 74-0 · 84). The area under the receiver operating characteristic curve was 0 · 85 (95% CI 0 · 81-0 · 88). The studies had substantial heterogeneity (I(2)=96%, 95% CI 94-99). None of the subgroups investigated--population, admission category, assay used, severity of disease, and description and masking of the reference standard--could account for the heterogeneity.

INTERPRETATION

Procalcitonin is a helpful biomarker for early diagnosis of sepsis in critically ill patients. Nevertheless, the results of the test must be interpreted carefully in the context of medical history, physical examination, and microbiological assessment.

FUNDING

Ministry of Education and Research, the Deutsche Forschungsgemeinschaft, Thuringian Ministry for Education, Science and Culture, the Thuringian Foundation for Technology, Innovation and Research, and the German Sepsis Society.

The value of C-reactive protein and lactate in the acute abdomen in the emergency department

CASE PRESENTATION

This report describes the presentation of three critically ill patients with non-traumatic acute abdominal pain and increased concentrations of the biomarkers C-reactive protein (CRP) and lactate. In these three patients an exploratory laparotomy was carried out. Remarkably, the laparotomy showed no intra-abdominal abnormalities. We discuss the usefulness of these biomarkers in practice and their influence on establishing a diagnose and making a decision to perform an intervention.

CONCLUSION

We conclude that biomarkers lactate and CRP in patients with acute abdominal pain should only be used in adjunct to the history and clinical findings, as they are not specific and can be misleading in establishing a diagnosis. In addition, relying on these biomarkers may contribute to more diagnostic examinations and/or unnecessary invasive interventions (for example laparotomy).

The diagnostic value of D-dimer, procalcitonin and CRP in acute appendicitis

BACKGROUND

The early diagnosis of acute abdomen is of great importance. To date, several inflammatory markers have been used for the diagnosis of acute abdominal conditions, including acute appendicitis. The aim of this study was to evaluate the diagnostic utility of D-dimer, Procalcitonin (PCT) and C-reactive protein (CRP) measurements in the acute appendicitis.

METHODS

This prospective study was conducted between March 1(st), 2010 and July 1(st), 2011. In this period, seventy-eight patients were operated with the diagnosis of acute appendicitis, and D-dimer, PCT and CRP levels of the patients were measured. The patients were grouped as phlegmonous appendicitis (Group 1), gangrenous appendicitis (Group 2), perforated appendicitis (Group 3) and negative appendectomy (Group 4) according to the surgical findings and histopathological results.

RESULTS

Of 78 patients, 54 (69.2 %) were male and 24 (30.8 %) were female, and the mean age was 25.4 ± 11.1 years (range, 18 to 69 years). 66 (84.6 %) patients had increased leukocyte count (white blood cell count). The PCT values were higher than the upper normal limit in 20 (25.6%) patients, followed by D-dimer in 22 (28.2 %) patients and CRP in 54 (69.2 %) patients. The diagnostic value of leukocyte count and CRP in acute appendicitis was higher than that of the other markers, whereas leukocyte count showed very low specificity. CRP values were higher in perforated appendicitis when compared with the phlegmonous appendicitis (p < 0.05). However, PCT and D-dimer showed lower diagnostic values (26% and 31%, respectively).

CONCLUSION

An increase in CRP levels alone is not sufficient to make the diagnosis of acute appendicitis. However, CRP levels may differentiate between phlegmonous appendicitis and perforated appendicitis. Due to their low sensitivity and diagnostic value, PCT and D-dimer are not better markers than CRP for the diagnosis of acute appendicitis.

[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.

PCR-based rapid sepsis diagnosis effectively guides clinical treatment in patients with new onset of SIRS

INTRODUCTION

Early detection of the causing microorganism and timely therapeutic intervention are crucial for improved outcome of patients with sepsis. Quite recently, we evaluated the technical and diagnostic feasibility of a commercial multiplex real-time polymerase chain reaction (PCR) (LightCycler SeptiFast® assay) for detection of blood stream infections in a cohort of intensive care unit (ICU) patients with the risk of abdominal sepsis.

RESULTS AND FINDINGS

The PCR positivity rate showed a high coincidence with systemic inflammatory response syndrome (SIRS; 75.8%). In this study, we focussed on patients from the same surgical ICU with upcoming SIRS and addressed the utility on therapeutic decision making following diagnostic application of PCR in addition and comparison to conventional microbiological and laboratory tests. In total, 104 patients on the ICU fulfilling the American College of Chest Physicians/Society of Critical Care Medicine SIRS criteria were enrolled. Blood samples were taken within 24 h of upcoming SIRS. Some 39.9% (n = 59) of the blood samples (n (Total) = 148) were positive using multiplex-PCR and 20.3% (n = 30) using conventional culture. In 11.4% of all samples, multiplex-PCR detected more than one microorganism. Among the 77 microorganisms identified by multiplex-PCR, only 25 (32.5%) could be confirmed by blood culture; an additional 17 could be confirmed by microbiological test results from other significant patient specimen. Positive blood samples independent of the detection method were characterised by significant elevated levels of procalcitonin (p < 0.05) but not C-reactive protein. In 25 cases (16.9%, n = 148), the rapid identification of involved pathogens by multiplex-PCR led to prompt adjustment of therapy.

CONCLUSIONS

Our study demonstrates improved detection of specific pathogens with a high intrinsic resistance and positive impact on therapeutic decision-making by additional multiplex-PCR-based analysis of blood samples for infectious agents in patients with new onset of SIRS. Thus, we showed for the first time that PCR test results guide clinical treatment successfully.

C-reactive protein is superior to bilirubin for anticipation of perforation in acute appendicitis

OBJECTIVE

Very recently it has been shown that hyperbilirubinemia is a specific predictor of perforation in acute appendicitis. We compared the diagnostic importance of bilirubin, C-reactive protein (CRP), leukocyte count and age as markers of perforation in acute appendicitis.

MATERIAL AND METHODS

A two-center retrospective cohort study was completed. Patients with acute appendicitis (n = 725) were divided into two groups, group A with perforation (n = 155) and group B without (n = 570).

RESULTS

In group A an elevated CRP (> 5 mg/l) was measured in 98% of cases versus 72.5% in group B. Hyperbilirubinemia (> 20 micromol/l) was measured in 38% of cases in group A versus 22.3% in group B. Leukocytosis (> 10 x 10(9)/l) was measured in 85% of cases in group A versus 79.3% in group B. Analysis of qualitative and quantitative data showed every marker to be significantly correlated with perforation except elevated white cell blood count. However CRP showed the strongest correlation. The logistic regression model showed CRP to be by far the most significant marker of perforation.

CONCLUSIONS

Our results confirm hyperbilirubinemia to be a statistically significant marker of perforation in acute appendicitis. However, CRP is superior to bilirubin for anticipation of perforation in acute appendicitis.

[Prospective study of procalcitonin as a diagnostic marker of the severity of secondary peritonitis]

INTRODUCTION

It has been shown that procalcitonin (PCT) is a good marker for sepsis as the more severe the infection the higher the plasma levels. The Mannheim peritonitis index (MPI) is very effective in assessing the prognosis of secondary peritonitis. The aim of this study is to find out whether there is any correlation between preoperative PCT levels and the postoperative MPI, as well as the prognostic value of preoperative PCT levels.

PATIENTS AND METHOD

Prospective study of 57 patients operated on between December 2006-August 2008 for secondary peritonitis and classified into three groups (A: 23 patients, B: 24 patients and C: 10 patients) from lowest to highest severity of MPI. The preoperative values of procalcitonin were obtained with PCT-Q test (BRAHMS).

RESULTS

PCT-Q was normal (<0.5ng/ml) in 19 patients in group A, in 2 patients in group B and none in group C (p<0.001). PCT-Q between 2-10ng/ml were found in one patient in group A, 13 in group B and none in group C (p<0.001). PCT-Q >10ng/ml were found in 10 cases in group C, 6 in group B and none in group A (p<0.001). Of the 19 patients admitted to the intensive care unit, the PCT-Q was >10ng/ml in 15 cases vs a PCT-Q<10mg/ml (p<0.001) in 4 cases. Seven patients died, all of them with a PCT-Q >10mg/ml (p<0.001).

CONCLUSIONS

The correlation between preoperative PCT-Q and postoperative MPI is positive and significant. The values of PCT-Q are higher as the MPI severity increases. Values >10ng/ml are significant for admission to the ICU and a poor clinical prognosis.

Treatment of the open abdomen with the commercially available vacuum-assisted closure system in patients with abdominal sepsis: low primary closure rate

BACKGROUND

Abdominal Vacuum-Assisted Closure (V.A.C.) systems for treatment of open abdomens have been predominantly used for trauma patients with a high primary fascial closure rate. Use of the V.A.C. technique in abdominal sepsis is less well established.

METHODS

All patients with abdominal sepsis and treatment with the abdominal V.A.C. system between 2004 and 2007 were prospectively assessed. End points were fascial closure, V.A.C.-related morbidity, and quality of life score (SF-36) at follow-up.

RESULTS

Thirty patients with abdominal sepsis were included in the study. Primary fascial closure was feasible in 10, partial closure in 4, and no closure in 16 patients. Median number of V.A.C. changes was 3 (range, 1-10). Nine patients died. V.A.C.-related morbidity was as follows: two fistulas, three fascial edge necroses, one skin blister, and four prolapses of small bowel between the fascia and foam. Univariate analysis showed no variables influencing primary closure rate or V.A.C.-related morbidity. Mortality was significantly influenced by age (P < 0.001), respiratory failure (P = 0.01), and pneumonia (P = 0.03). At follow-up, V.A.C. patients scored lower in the physical health scores and similar in the mental health scores compared with the normal population.

CONCLUSIONS

Treatment of the open abdomen in patients with abdominal sepsis with the abdominal V.A.C. system is safe with good long-term quality of life. Primary closure rate in these patients is substantially lower than in trauma patients. Stepwise closure of the fascia during V.A.C. changes should be attempted to avoid additional lateral retraction of fascial edges. V.A.C.-related complications may be avoided with careful surgical technique.