Recent advances in sepsis and septic shock

Predictive value of C-reactive protein for the diagnosis of meningitis in febrile infants under 3 months of age in the emergency department

Background

Fever is a common cause of pediatric consultation in the emergency department. However, identifying the source of infection in many febrile infants is challenging because of insufficient presentation of signs and symptoms. Meningitis is a critical cause of fever in infants, and its diagnosis is confirmed invasively by lumbar puncture. This study aimed to evaluate potential laboratory markers for meningitis in febrile infants.

Methods

We retrospectively analyzed infants aged <3 months who visited the emergency department of our hospital between May 2012 and May 2017 because of fever of unknown etiology. Clinical information and laboratory data were evaluated. Receiver operating characteristic (ROC) curves were constructed.

Results

In total, 145 febrile infants aged <3 months who underwent lumbar punctures were evaluated retrospectively. The mean C-reactive protein (CRP) level was significantly higher in the meningitis group than in the non-meningitis group, whereas the mean white blood cell count or absolute neutrophil count (ANC) did not significantly differ between groups. The area under the ROC curve (AUC) for CRP was 0.779 (95% confidence interval [CI], 0.701–0.858). The AUC for the leukocyte count was 0.455 (95% CI, 0.360–0.550) and that for ANC was 0.453 (95% CI, 0.359–0.547). The CRP cut-off value of 10 mg/L was optimal for identifying possible meningitis.

Conclusion

CRP has an intrinsic predictive value for meningitis in febrile infants aged <3 months. Despite its invasiveness, a lumbar puncture may be recommended to diagnose meningitis in young, febrile infants with a CRP level >10 mg/L.

Diagnostic Value of PCT and CRP for Detecting Serious Bacterial Infections in Patients With Fever of Unknown Origin: A Systematic Review and Meta-analysis

BACKGROUND

It is vital to recognize the cause of an infection to enable earlier treatment. Studies have shown that procalcitonin (PCT) and C-reactive protein (CRP) have very high sensitivity and specificity for diagnosing serious bacterial infections (SBIs), with PCT performing better than CRP.

METHODS

Multiple databases were searched for relevant studies, and full-text articles involving diagnosis with PCT and CRP were reviewed. All meta-analyses were conducted with Review Manager 5.0. Sensitivity and bias analyses were performed to evaluate the quality of articles. In addition, a funnel plot and Egger test were used to assess possible publication bias.

RESULT

A total of 17 articles met the criteria for inclusion. The concentrations of both PCT and CRP were higher in the SBI group than in the nonbacterial infection group. Sensitivity for differentiating bacterial infections from nonbacterial infections was higher for PCT compared with CRP, whereas there was no significant difference in specificity. The area under the summary receiver operating characteristic curve for PCT was larger than that for CRP.

CONCLUSION

Both PCT and CRP are useful markers and should be used to evaluate SBIs with fever of unknown origin.

Sepsis epidemiology and outcome in the paediatric intensive care unit of Vilnius University Children's Hospital

Research was carried out at the paediatric intensive care unit (paediatric ICU) of the Children’s Hospital, affiliate of Vilnius University Hospital Santariškių klinikos.

[Fluid balance and acute kidney injury in septic shock]

BACKGROUND

In patients with septic shock, excessive fluid administration can lead to increased morbidity and mortality. The aim of this study was to evaluate the association between fluid balance, acute kidney injury and mortality in patients with septic shock.

METHODS

A study of cases and controls was conducted in a Pediatric Intensive Care Unit. The fluid balance in the first 72h and the presence of acute kidney injury was compared in patients diagnosed with septic shock who died against patients who survived the same condition. Univariate and multivariate analyses were performed.

RESULTS

Forty-five cases and forty-five controls were included in the analysis. Mortality was associated with Pediatric Risk of Mortality (PRISM III) ≥ 26 points (OR 7.5, 95% CI 2.8-18.7; p=0.000), Pediatric Logistic Organ Dysfunction (PELOD) ≥ 24 points (OR 11.0, 95% CI 4.1-29.4; p=0.000), creatinine ≥ 0.65mg/dl (OR 5.6, 95% CI 2.2-13.9; p=0.000), lactate ≥ 2.5 mmol/l (OR 2.5, 95% CI 1.1-5.9; p=0.033), SvO2 < 60% (OR 4.6, 95% CI 4.5-4.5; p=0.001), positive balance > 9% in 72h (OR 4.3, 95% CI 1.6-11.7; p=0.003), acute kidney injury (OR 5.7, 95% CI: 2.2-15.1; p=0.000). In the multivariate model, the values of PRISM ≥26 and PELOD ≥24 points were significant.

CONCLUSIONS

In patients who died due to septic shock, the multivariate model showed an association with PRISM ≥26 and PELOD ≥24 and a trend toward association with SvO2 <60% and positive balance of liquids > 9%.

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.