Utilidad de los biomarcadores de inflamación e infección en los servicios de urgencias

Diagnostic accuracy of procalcitonin for bacterial infection in the Emergency Department: a systematic review

INTRODUCTION AND OBJECTIVE

The care of patients with a suspected infectious process in hospital emergency departments (ED) accounts for 15%-35% of all daily care in these healthcare areas in Spain and Latin America. The early and adequate administration of antibiotic treatment (AB) and the immediate making of other diagnostic-therapeutic decisions have a direct impact on the survival of patients with severe bacterial infection. The main objective of this systematic review is to investigate the diagnostic accuracy of PCT to predict bacterial infection in adult patients treated with clinical suspicion of infection in the ED, as well as to analyze whether the different studies manage to identify a specific value of PCT as the most relevant from the diagnostic point of view of clinical decision that can be recommended for decision making in ED.

METHOD

A systematic review is carried out following the PRISMA regulations in the database of PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Tripdatabase and ClinicalTrials.gov from January 2005 to May 31, 2023 without language restriction and using a combination of MESH terms: "Procalcitonin", "Infection/Bacterial Infection/Sepsis", "Emergencies/Emergency/Emergency Department", "Adults" and "Diagnostic". Observational cohort studies (diagnostic performance analyses) were included. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the method used and the risk of bias of the included articles. Observational cohort studies were included. No meta-analysis techniques were performed, but results were compared narratively.

RESULTS

A total of 1,323 articles were identified, of which 21 that met the inclusion criteria were finally analyzed. The studies include 10,333 patients with 4,856 bacterial infections (47%). Eight studies were rated as high, 9 as moderate, and 4 as low. The AUC-ROC of all studies ranges from 0.68 (95% CI: 0.61-0.72) to 0.99 (95% CI: 0.98-1). The value of PCT 0.2-0.3 ng/ml is the most used and proposed in up to twelve of the works included in this review whose average estimated performance is an AUC-ROC of 0.79. If only the results of the 5 high-quality studies using a cut-off point of 0.2-0.3 ng/ml PCT are taken into account, the estimated mean AUC-COR result is 0.78 with Se:69 % and Es:76%.

CONCLUSIONS

PCT has considerable diagnostic accuracy for bacterial infection in patients treated in ED for different infectious processes. The cut-off point of 0.25 (0.2-0.3) ng/ml has been positioned as the most appropriate to predict the existence of bacterial infection and can be used to help reasonably rule it out.

Models for bacteraemia risk prediction. Clinical implications

Bacteraemia has important consequences for the patient, as it is associated with worse clinical outcomes. On the other hand, unnecessarily obtaining samples for blood cultures increases costs and the workload in the microbiology laboratory. Its diagnosis implies a time delay, but decisions about start antibiotic treatment, discharge, or admits the patient must be taken during the first attention and, therefore, before known the blood cultures results. This manuscript reviews the different strategies based on clinical scores and biomarkers that are useful for predicting bacteraemia and improving initial decision-making.

Paroxysmal sympathetic hyperactivity concurrent with hypothalamic injury in a patient with intracerebral hemorrhage: A case report

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) is characterized by exacerbated sympathetic discharge following severe brain injury. Here, we reports a patient diagnosed with PSH after ICH concurrent with hypothalamic injury, as demonstrated by diffusion tensor imaging (DTI).

METHODS

A 27-year-old man patient was diagnosed with spontaneous intraventricular hemorrhage and intracerebral hemorrhage in both frontal lobes. Two months after onset, brain magnetic resonance imaging of the brain revealed a leukomalactic lesion in the hypothalamus. Three months after the onset, he presented with intermittent high fever, tachycardia, tachypnea, systolic hypertension, diaphoresis, and aggravated rigidity. Infection was ruled out by a physical examination, laboratory tests, and radiological studies. After administrating morphine and bromocriptine, the clinical manifestations improved dramatically.

RESULTS

PSH after intracranial hemorrhage concurrent with the hypothalamic injury. Fractional anisotropy and mean diffusivity values of DTI were obtained in the hypothalamus. No significant difference in fractional anisotropy value was observed between the patient and control group (10 age-matched healthy male subjects) (P > .05). On the other hand, the mean diffusivity value was higher in the patient group than in the control group (P < .05), indicating hypothalamic injury.

CONCLUSION

PSH concurrent with hypothalamic injury was observed in a patient with stroke. This study suggests that DTI can be a useful imaging method for evaluating the hypothalamic state of patients presenting with PSH after brain injury.

Validation of a predictive model for bacteraemia (MPB5-Toledo) in the patients seen in emergency departments due to infections

OBJECTIVE

To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections.

METHODS

Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0-2 points, intermediate risk by 3-5 points, and high risk by 6-8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70).

CONCLUSION

The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

[Prognostic power of soluble urokinase plasminogen activator receptor (suPAR) for short-term mortality in patients seen in Emergency Departments due to infections]

OBJECTIVE

To analyse and compare 30-day mortality prognostic power of several biomarkers (C-reactive protein, procalcitonin, lactate and suPAR) in patients seen in emergency departments (ED) due to infections. Secondly, if these could improve the accuracy of systemic inflammatory response syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA).

METHODS

A prospective, observational and analytical study was carried out on patients who were treated in an ED of one of the eight participating hospitals. An assessment was made of 32 independent variables that could influence mortality at 30 days. They covered epidemiological, comorbidity, functional, clinical and analytical factors.

RESULTS

The study included 347 consecutive patients, 54 (15.6%) of whom died within 30 days of visiting the ED. SUPAR has got the best biomarker area under the curve (AUC)-ROC to predict mortality at 30 days of 0.836 (95% CI: 0.765-0.907; P <.001) with a cut-off > 10 ng/mL who had a sensitivity of 70% and a specificity of 86%. The score qSOFA ≥ 2 had AUC-ROC of 0.707 (95% CI: 0.621-0.793; P < .001) with sensitivity of 53% and a specificity of 89%. The mixed model (suPAR > 10 ng/mL plus qSOFA ≥ 2) has improved the AUC-ROC to 0.853 [95% CI: 0.790-0.916; P < .001] with the best prognostic performance: sensitivity of 39% and a specificity of 97% with a negative predictive value of 90%.

CONCLUSIONS

suPAR showed better performance for 30-day mortality prognostic power from several biomarkers in the patients seen in ED due to infections. Score qSOFA has better performance that SRIS and the mixed model (qSOFA ≥ 2 plus suPAR > 10 ng/mL) increased the ability of qSOFA.

A bacteraemia risk prediction model: development and validation in an emergency medicine population

OBJECTIVE

Design a risk model to predict bacteraemia in patients attended in emergency departments (ED) for an episode of infection.

METHODS

This was a national, prospective, multicentre, observational cohort study of blood cultures (BC) collected from adult patients (≥ 18 years) attended in 71 Spanish EDs from October 1 2019 to March 31, 2020. Variables with a p value < 0.05 were introduced in the univariate analysis together with those of clinical significance. The final selection of variables for the scoring scale was made by logistic regression with selection by introduction. The results obtained were internally validated by dividing the sample in a derivation and a validation cohort.

RESULTS

A total of 4,439 infectious episodes were included. Of these, 899 (20.25%) were considered as true bacteraemia. A predictive model for bacteraemia was defined with seven variables according to the Bacteraemia Prediction Model of the INFURG-SEMES group (MPB-INFURG-SEMES). The model achieved an area under the curve-receiver operating curve of 0.924 (CI 95%:0.914-0.934) in the derivation cohort, and 0.926 (CI 95%: 0.910-0.942) in the validation cohort. Patients were then split into ten risk categories, and had the following rates of risk: 0.2%(0 points), 0.4%(1 point), 0.9%(2 points), 1.8%(3 points), 4.7%(4 points), 19.1% (5 points), 39.1% (6 points), 56.8% (7 points), 71.1% (8 points), 82.7% (9 points) and 90.1% (10 points). Findings were similar in the validation cohort. The cut-off point of five points provided the best precision with a sensitivity of 95.94%, specificity of 76.28%, positive predictive value of 53.63% and negative predictive value of 98.50%.

CONCLUSION

The MPB-INFURG-SEMES model may be useful for the stratification of risk of bacteraemia in adult patients with infection in EDs, together with clinical judgement and other variables independent of the process and the patient.

Risk assessment of sepsis through measurement of proAVP (copeptin): a secondary analysis of the TRIAGE study

OBJECTIVE

Systemic infections and sepsis lead to strong activation of the vasopressin system, which is pivotal for stimulation of the endocrine stress response and, in addition, has vasoconstrictive and immunomodulatory effects. Our aim was to assess the significance of the vasopressor system through measurement of C-terminal proAVP (copeptin) regarding mortality prediction in a large prospective cohort of patients with systemic infection.

DESIGN AND METHODS

This secondary analysis of the observational cohort TRIAGE study included consecutive, adult, medical patients with an initial diagnosis of infection seeking emergency department care. We used multivariable regression analysis to assess associations of copeptin levels in addition to the Sequential Organ Failure Assessment (SOFA) score with 30-day mortality. Discrimination was assessed by calculation of the area under the curve (AUC).

RESULTS

Overall, 45 of 609 (7.4%) patients with infection died within 30 days. Non-survivors had a marked upregulation of the vasopressin system with a more than four-fold increase in admission copeptin levels compared to non-survivors (199.9 ± 204.7 vs 46.6 ± 77.2 pmol/L). In a statistical model, copeptin was significantly associated with mortality (adjusted odds ratio of 1.04, 95% CI 1.01 to 1.07, P = 0.002). Regarding discrimination, copeptin alone showed an AUC of 0.82, while adding copeptin to the SOFA score significantly improved its prognostic ability (AUC 0.83 vs 0.86, P = 0.027).

CONCLUSION

Activation of the vasopressin system mirrored by an increase in copeptin levels provided significant information regarding mortality risk and improved the SOFA score for prediction of sepsis mortality.

[Utility of the blood culture in infection of the urinary tract with fever in the elderly]

OBJECTIVE

Urinary tract infections are one of the most common community infections. The diagnosis of urinary infections in the elderly is complex because of its presentation and clinic. The aim of this article is to evaluate the usefulness of blood cultures in febrile urinary tract infection in elderly patients, risk factors, causes of discordance between urine and blood cultures, usefulness of biomarkers and mortality.

METHODS

Observational study of patients admitted over 65 years old, with urinary infections.

RESULTS

A total of 216 episodes with urinary infections and blood cultures performed. 70 (32,4%) cases with bacteremia. The most frequently detected isolates in blood cultures were: Escherichia coli 50 (71,4%) and Proteus spp. 6 (8,5%). Only septic shock was associated with a higher frequency of bacteraemia (OR=2,93, IC 95: 1,0-8,5; p=0,04). In 26 of the blood cultures a different isolation of the urine culture was detected. Overall mortality was 9.1%, with no association with the presence of bacteremia (p>0. 05).

CONCLUSIONS

One third of elderly people hospitalized by tract urinary infection had bacteremia. Their detection was not associated with overall mortality. Disagree between blood and urine cultures in febrile is frequent, especially in patients with recent antibiotic treatment or recently hospitalized.

Validation of a predictive model for bacteraemia (MPB5-Toledo) in the patients seen in emergency departments due to infections

OBJECTIVE

To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections.

METHODS

Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥ 5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70).

CONCLUSION

The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

[Predictive factors of bacteraemia in the patients seen in emergency departments due to infections]

Objetivos

Analizar los factores predictivos de bacteriemia en los pacientes atendidos en el servicio de urgencias (SU) por un episodio de infección.

Pacientes y métodos

Estudio observacional, retrospectivo, descriptivo y analítico de todos los hemocultivos extraídos en un SU en los pacientes adultos (≥ 18 años) atendidos por infección desde el 1-1-2018 hasta el 1-7-2018. Se realizó seguimiento durante 30 días. Se analizaron 38 variables independientes (epidemiológicas, de comorbilidad, funcionales, clínicas y analíticas) que pudieran predecir la existencia de bacteriemia. Se realizó un estudio univariado y multivariante mediante regresión logística.

Resultados

Se incluyeron 1.425 episodios de hemocultivos extraídos. De ellos se consideraron como bacteriemias verdaderas 179 (12,6 %) y como HC negativos 1.246 (87,4 %). Entre los negativos, 1.130 (79,3%) no tuvieron crecimiento y 116 (8,1%) se consideraron contaminados. Cinco variables se asociaron de forma significativa como predictoras de bacteriemia verdadera: procalcitonina (PCT) sérica ≥ 0,51 ng/ml [odds ratio (OR): 4,52; intervalo de confianza (IC) al 95%: 4,20-4,84; p <0,001], temperatura > 38,3°C [OR: 1,60; IC al 95%: 1,29-1,90; p <0,001], presión arterial sistólica (PAS) < 100 mmHg [OR: 3,68; IC al 95%: 2,78-4,58; p <0,001], shock séptico [OR: 2,96; IC al 95%: 1,78-4,13; p <0,001] y la existencia de neoplasia [OR: 1,73; IC al 95%: 1,27-2,20; p <0,001].

Conclusiones

. Existen varios factores disponibles tras una primera valoración en el SU, entre ellos la PCT sérica, la temperatura, la hipotensión con/sin criterios de shock séptico y la existencia de neoplasia, que predicen la existencia de bacteriemia verdadera.

Procalcitonin as a biomarker for critically ill patients with sepsis: Effects of vitamin D supplementation

Early diagnosis of sepsis is often difficult in clinical practice, whilst it can be vital for positive patient outcomes in sepsis management. Any delay in diagnosis and treatment may lead to significant organ failure and can be associated with elevated mortality rates. Early diagnosis and effective management of sepsis can allow for prompt antibiotic therapy and a potential reduction in mortality; it can also minimize the unnecessary use of antibiotics. Furthermore, vitamin D supplementation, which is commonly used in the intensive care units to reduce mortality, may interfere with the ability to use procalcitonin (PCT) as a means of assessing clinical progression. This paper aims to explore the diagnostic and prognostic value of serum levels of PCT as an early marker of sepsis and to assess whether it can be used as a guide for using antibiotic therapy. Several serum-based biomarkers such as C-reactive protein, lactate, presepsin, and cytokines, such as interleukin-1 (IL-1), and IL-6 have been evaluated as early indicators of sepsis but none have been proven sensitive and/or specific enough to make a definitive diagnosis. Finally the potential benefits and disadvantages of using serum levels of PCT to diagnose and monitor patients with sepsis and septic shock will be briefly discussed.

[Sepsis biomarkers dynamics as an indicator of intensive care effectiveness]

AIM

To evaluate dynamics of presepsin, procalcitonin and C-reactive protein in survived and dead patients with sepsis.

MATERIAL AND METHODS

There were 41 patients with diagnosis of 'sepsis' ('Sepsis-3' concept) who were divided into 2 groups: survived patients with sepsis (21 people) - group 1, dead patients with sepsis (20 people) - group 2. All patients underwent generally accepted intensive therapy for sepsis. Besides conventional laboratory and instrumental examination, dynamics of presepsin, procalcitonin and C-reactive protein was assessed.

RESULTS

Mean level of presepsin was 1718.00 and 3266.50 pg/ml in groups 1 and group 2, respectively. Half of the values was within (Me (25; 75) 1021.00-3231.00 pg/ml and 1618.50-7469.00 pg/ml in both groups, respectively. Mean level of procalcitonin was 0.995 and 4.465 ng/ml, respectively. Median (25; 75) was 0.49-4.44 ng/ml and 1,625-19.30 ng/ml, respectively. Mean level of C-reactive protein was 95.5 and 215.0 mg/L, respectively, median (25; 75) - 64.00-155.00 mg/L and 155.00-264.00 mg/L, respectively. Significant differences were determined for all variables (p-value 0.000008, 0.000242, 0.0000001 for presepsin, procalcitonin and C-reactive protein, respectively).

CONCLUSION

The levels of C-reactive protein, procalcitonin and presepsin were significantly different in patients with sepsis followed by favorable and unfavorable clinical outcome. Unfavorable outcome was associated with increased levels of all biomarkers. Comprehensive assessment of all biological markers of sepsis is useful to assess an effectiveness of intensive therapy and to predict clinical outcome.

Ability of procalcitonin to differentiate true bacteraemia from contaminated blood cultures in an emergency department

OBJECTIVES

To analyse and compare the ability of procalcitonin (PCT), C-reactive protein (CRP) and leukocytes to differentiate true bacteraemia from contaminated blood cultures in patients seen in the emergency department (ED) for an episode of infectious disease.

METHODS

Observational, retrospective and descriptive analytical study of all blood cultures with positive growth extracted in an ED in adult patients (≥18 years) during 2016 and 2017. The follow-up was carried out over a 30-day period to calculate the predictive power and the prognostic performance for true bacteraemia.

RESULTS

A total of 266 blood cultures with positive growth were included in the study. Out of these, 154 (57.9%) were considered true bacteraemia and 112 (42.1%) were considered to be contaminated blood cultures. The area under the Receiver Operating Characteristic curve (AUC-ROC) for PCT to predict true bacteraemia was 0.983 (95% CI: 0.972-0.994; P<0.001) and, considering a cut-off value of≥0.43 ng/ml, PCT achieved 94% sensitivity, 91% specificity, positive predictive value of 94%, and negative predictive value of 92%. The AUC-ROC obtained for CRP was 0.639 (95% CI: 0.572-0.707, P<.001), for leukocytes of 0.693 (95% CI: 0.630-0.756, P<.001) and for immature leukocytes (>10% bands) of 0.614 (95% CI: 0.547-0.682, P<.001). The mean values for PCT were 3.44 (SD 6.30) ng/ml in true bacteraemia vs. 0.16 (SD 0.18) ng/ml in contaminated blood cultures (P<.001).

CONCLUSIONS

In blood cultures with positive growth extracted in an ED, PCT achieves the best prognostic performance of true bacteraemia vs. contaminated blood cultures, better than CRP and leukocytes.

Comparison of diagnostic accuracy in sepsis between presepsin, procalcitonin, and C-reactive protein: a systematic review and meta-analysis

Background

The soluble cluster of differentiation 14 (or presepsin) is a free fragment of glycoprotein expressed on monocytes and macrophages. Although many studies have been conducted recently, the diagnostic performance of presepsin for sepsis remains debated. We performed a systematic review and meta-analysis of the available literature to assess the accuracy of presepsin for the diagnosis of sepsis in adult patients and compared the performance between presepsin, C-reactive protein (CRP), and procalcitonin (PCT).

Methods

A comprehensive systemic search was conducted in PubMed, EMBASE, and Google Scholar for studies that evaluated the diagnostic accuracy of presepsin for sepsis until January 2017. The hierarchical summary receiver operating characteristic method was used to pool individual sensitivity, specificity, diagnostic odds ratio (DOR), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and area under the receiver operating characteristic curve (AUC).

Results

Eighteen studies, comprising 3470 patients, met our inclusion criteria. The pooled diagnosis sensitivity and specificity of presepsin for sepsis were 0.84 (95% CI 0.80–0.87) and 0.76 (95% CI 0.67–0.82), respectively. Furthermore, the pooled DOR, PLR, NLR, and AUC were 16 (95% CI 10–25), 3.4 (95% CI 2.5–4.6), 0.22 (95% CI 0.17–0.27), and 0.88 (95% CI 0.85–0.90), respectively. Significant heterogeneity was found in both sensitivities (Cochrane Q = 137.43, p < 0.001, I² = 87.63%) and specificities (Cochrane Q = 180.76, p < 0.001, I² = 90.60%). Additionally, we found no significant difference between presepsin and PCT (AUC 0.87 vs. 0.86) or CRP (AUC 0.85 vs. 0.85). However, for studies conducted in ICU, the pooled sensitivity of presepsin was found to be higher than PCT (0.88, 95% CI 0.82–0.92 vs. 0.75, 95% CI 0.68–0.81), while the pooled specificity of presepsin was lower than PCT (0.58, 95% CI 0.42–0.73 vs. 0.75, 95% CI 0.65–0.83).

Conclusion

Based on the results of our meta-analysis, presepsin is a promising marker for diagnosis of sepsis as PCT or CRP, but its results should be interpreted more carefully and cautiously since too few studies were included and those studies had high heterogeneity between them. In addition, continuing re-evaluation during the course of sepsis is advisable.

Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department

Between all patients treated in the Emergency Department (ED), 1.35% are diagnosed with community-acquired pneumonia (CAP). CAP is the main cause of death due to infectious disease (10-14%) and the most frequent reason of sepsis-septic shock in the ED. In the last decade, the search for objective tools to help establishing an early diagnosis, bacterial aetiology, severity, suspicion of bacteremia and the prognosis of mortality has increased. Biomarkers have shown their usefulness in this matter. Procalcitonin (obtains the highest accuracy for CAP diagnosis, bacterial aetiology and the presence of bacteremia), lactate (biomarker of hypoxia and tissue hypoperfusion) and proadrenomedullin (which has the greatest accuracy to predict mortality which in combination with the prognostic severity scales obtains even better results). The aim of this review is to highlight recently published scientific evidence and to compare the utility and prognostic accuracy of the biomarkers in CAP patients treated in the ED.

New role of biomarkers: mid-regional pro-adrenomedullin, the biomarker of organ failure

Mid-regional pro-adrenomedullin (MR-proADM) has a good biomarker profile: its half-life is several hours, and its plasma concentrations can be determined in clinical practice, it is essentially irrelevant, but proportionally represents the levels and activity of adrenomedullin (ADM). ADM synthesis is widely distributed in tissues, including bone, adrenal cortex, kidney, lung, blood vessels and heart. Its fundamental biological effects include vasodilator, positive inotropic, diuretic, natriuretic and bronchodilator. It has been described high levels in septic patients, interacting directly with the relaxation of vascular tone, triggering hypotension of these patients. It is also found high levels in other diseases such as hypertension, heart failure, respiratory failure, renal failure, cirrhosis and cancer. MR-proADM has been identified as a prognostic marker, stratifying the mortality risk in patients with sepsis in emergency department (ED) and ICU. Evolutionary MR-proADM levels and clearance marker to the 2nd-5th days of admission help to determine the poor performance and the risk of mortality in patients with severe sepsis admitted to the ICU. The MR-proADM levels are more effective than procalcitonin (PCT) and C-reactive protein (CRP) levels to determine an unfavorable outcome and the risk of mortality in patients with sepsis admitted to the ICU. It has also proved useful in patients diagnosed with organ dysfunction of infectious etiology. MR-proADM levels are independent of the germ conversely it is related to the magnitude of organ failure and therefore severity. We consider advisable incorporating the MR-proADM the panel of biomarkers necessary for the diagnosis and treatment of critically ill patients admitted to the ICU with severe sepsis. The combined PCT and MR-proADM levels could represent a valid tool in the clinical practice to timely identify patients with bacterial infections and guide the diagnosis and treatment of sepsis and septic shock.

Usefulness of blood and cerebrospinal fluid laboratory testing to predict bacterial meningitis in the emergency department

INTRODUCTION

The classic clinical presentation of bacterial meningitis (BM) is observed in less than half of the cases in adults, and symptoms are less specific in children, the elderly or immunocompromised, and other chronic patients. The usual signs and symptoms do not provide optimal sensitivity and specificity for distinguishing possible BM from viral meningitis (VM), which may lead to a delay in the appropriate antimicrobial therapy. Society therefore stands to benefit from the development of effective, objective, and rapid tools able to predict and identify patients with BM. These tools include laboratory tests for blood and cerebrospinal fluid (CSF). The aim of this review is to summarise recently published scientific evidence in order to clarify existing controversies and compare the usefulness and diagnostic ability of the different parameters used to predict BM.

DEVELOPMENT

Systematic search of the main bibliographic databases and platforms to identify articles published between January 2000 and January 2016. We selected 59 articles that meet the objectives of this review.

CONCLUSIONS

CSF lactate, proportion of polymorphonuclear leukocytes, and CSF glucose, as well as serum procalcitonin (PCT), are the independent factors most predictive of bacterial aetiology. The model that combines serum PCT and CSF lactate achieves the highest predictive power for BM, with a sensitivity and specificity exceeding 99%. We should consider BM when CSF lactate >33 md/dL and/or PCT>0.25ng/mL.

Short-term prognostic factors in the elderly patients seen in emergency departments due to infections

OBJECTIVES

To analyse factors associated with short-term mortality in elderly patients seen in emergency departments (ED) for an episode of infectious disease.

MATERIALS AND METHODS

A prospective, observational, multicentre, analytical study was carried out on patients aged 75years and older who were treated in the ED of one of the eight participating hospitals. An assessment was made of 26 independent variables that could influence mortality at 30days. They covered epidemiological, comorbidity, functional, clinical and analytical factors. Multivariate logistic regression analysis was performed.

RESULTS

The study included 488 consecutive patients, 92 (18.9%) of whom died within 30days of visiting the ED. Three variables were significantly associated with higher mortality: severe functional dependence, with Barthel index ≤60 [odds ratio (OR) 8,92; 95% confidence interval (CI): 4.98-15.98, P=.003], systolic blood pressure <90mmHg [OR 7.34; 95%CI: 4.39-12.26, P=.005] and serum lactate >4mmol/l [OR 21.14; 95%CI: 8.94-49.97, P=.001]. The area under the curve for the model was 0.971 (95%CI: 0.951-0.991; P<.001).

CONCLUSIONS

Several factors evaluated in an initial assessment in the ED, including the level of functional dependence, systolic blood pressure and, especially, serum lactate, were found to determine a poor short-term prognosis in the elderly patients who presented with an episode of an infectious disease.

Usefulness of procalcitonin and C-reactive protein for predicting bacteremia in urinary tract infections in the emergency department

INTRODUCTION

The aim of this study was to analyze and compare the capacity of procalcitonin (PCT), C-reactive protein (CRP), lactate and leukocytes to predict the presence of bacteremia in patients with urinary tract infections (UTIs).

METHODS

Observational, retro-prospective analytical study of adult patients (≥15 years) diagnosed with UTI in an emergency department from August 2012 to January 2013.

RESULTS

The study included 328 patients diagnosed with UTI, with a mean age of 52±22 years, 74% of whom were women. Of these, 43 (13.1%) had bacteremia. For predicting bacteremia, PCT achieved the largest area under the receiver operating characteristic curve (ROC-AUC) at .993 (95% CI .987-1; P<.001). A cutoff≥1.16ng/mL achieves a sensitivity of 100%, a specificity of 97%, a positive predictive value of 84% and a negative predictive value of 100%. Lactate achieved an ROC-AUC of .844, and CRP achieved only .534. The mean values when comparing PCT levels in patients with UTIs with and without bacteremia were 8.08±16.37 and .34±.37ng/mL, respectively (P<.001).

CONCLUSIONS

For patients with UTIs in the emergency department, PCT achieves considerable diagnostic performance for suspecting bacteremia, a performance greater than that of lactate, CRP and leukocytes.

The accuracy of presepsin (sCD14-ST) for the diagnosis of sepsis in adults: a meta-analysis

Introduction

The early diagnosis of sepsis remains a challenge. Recently, soluble cluster of differentiation 14 subtype (sCD14-ST), also known as presepsin, has been identified as a potential biomarker of sepsis. We performed a meta-analysis to assess the diagnostic accuracy of presepsin for sepsis in patients with systemic inflammation.

Methods

We systematically searched the PubMed, Embase, Web of Knowledge and Cochrane databases. Studies were included if they assessed the diagnostic accuracy of presepsin for sepsis in adult patients with systemic inflammatory response syndrome (SIRS). Furthermore, a 2 × 2 contingency table was constructed based on these results. Two authors independently judged the studies and extracted the data. The diagnostic accuracy of presepsin in sepsis was calculated using a bivariate meta-analysis model. The Q-test and I² index were used to test the heterogeneity.

Results

Eight studies involving a total of 1,815 patients were included in the present study. The pooled sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio and negative likelihood ratio were 0.86 (95 % CI: 0.79-0.91), 0.78 (95 % CI: 0.68-0.85), 22 (95 % CI: 10–48), 3.8 (95 % CI: 2.6-5.7), and 0.18 (95 % CI: 0.11-0.28), respectively. The area under the summary receiver operator characteristic curve was 0.89 (95 % CI: 0.86–0.92). Meta-regression analysis revealed that consecutive patient selection, sample size and setting significantly accounted for the heterogeneity of sensitivity.

Conclusions

Our findings suggest that presepsin exhibits very good diagnostic accuracy (AUC=0.89) for the diagnosis for sepsis. Nevertheless, an overall assessment of all the clinical indexes for sepsis diagnosis and continual re-evaluation of presepsin during the course of the disease are needed.

Novel relationships between oxidative stress and angiogenesis-related factors in sepsis: New biomarkers and therapies

Sepsis is a systemic uncontrolled inflammatory response in the presence of an infection. It remains a major cause of morbidity and mortality in hospitalized patients. According to its severity, sepsis can progress to three different states: severe sepsis, septic shock, and multiple organ dysfunction syndrome, related to organ dysfunction and/or tissue hypoperfusion. Different processes underlie its pathophysiology; among them are oxidative stress, endothelial and mitochondrial dysfunction, and angiogenesis-related factors. However, no studies have integrated these elements in sepsis. The main difficulty in sepsis is its diagnosis. Currently, the potential of inflammatory biomarkers in septic patients remains weak. In this context, the research into new biomarkers is essential to aid with sepsis diagnosis and prognostication. Furthermore, even though the current management of severe forms of sepsis has been effective, morbimortality remains elevated. Therefore, it is essential to explore alternative approaches to therapy development. The aim of this review is to present an update of evidence supporting the role of oxidative stress and angiogenesis-related factors in the pathophysiology of the different forms of sepsis. It proposes a novel convergence between both elements in their role in the disease, and it will cover their utility as new diagnostic tools, predictors of outcome, and as novel therapeutic targets.

Value of lipopolysaccharide binding protein as diagnostic marker of infection in adult cancer patients with febrile neutropenia: comparison with C-reactive protein, procalcitonin, and interleukin 6

PURPOSE

Early detection of infection is essential for initial management of cancer patients with chemotherapy-associated febrile neutropenia in the emergency department. In this study, we evaluated lipopolysaccharide binding protein (LBP) as predictor for infection in febrile neutropenia and compared with other biomarkers previously studied: C-reactive protein (CRP), procalcitonin (PCT), and interleukin (IL)-6.

METHODS

A total of 61 episodes of chemotherapy-associated febrile neutropenia in 58 adult cancer patients were included. Serum samples were collected on admission at emergency department and CRP, LBP, PCT, and IL-6 were measured. Patients were classified into fever of unknown origin and infection, including microbiologically and clinically documented infection, groups. Receiver operating characteristic (ROC) curve analysis was performed for each biomarker for the diagnosis of infection.

RESULTS

Thirty-two of the 61 episodes were classified as infection. On admission, CRP, PCT, IL-6, and LBP were significantly increased in patients with infection compared to fever of unknown origin group. Area under the ROC curve (AUC ROC) of CRP, PCT, IL-6, and LBP for discriminating both groups was 0.77, 0.88, 0.82, and 0.82, respectively, without significant difference between them. The combination of IL-6 and PCT or LBP did not lead to a significant improvement of the diagnostic accuracy of PCT or LBP alone.

CONCLUSIONS

On admission, LBP has a similar diagnostic accuracy than PCT or IL-6 for the diagnosis of infection and might be used as additional diagnostic tool in adult cancer patients with chemotherapy-associated febrile neutropenia.

Validity of procalcitonin for the diagnosis of bacterial infection in elderly patients

INTRODUCTION

PCT has been consolidated as a key tool in the diagnosis of bacterial infections in general population. Few studies have been conducted to determine the applicability of this test in elderly patients.

METHODS

Study of validity of PCT on elderly patients. Two groups were formed; the first group was formed by patients aged 75 years or older, under bacterial infection criteria and PCT on the initial Lab test. The second group was formed by patients aged 75 years or older with any noninfectious disease; these patients were asked PCT in the initial Lab test. Sensitivity, specificity, positive and negative likelihood ratio were calculated.

RESULTS

161 patients were included, 95 with probable bacterial infection and 66 without infection. Patients with probable bacterial infection criteria, 72% of them had PCT >0.5 ng/mL. Patients without infection, 8% of the patients had PCT >0.5 ng/mL. Sensitivity and specificity of PCT to bacterial infection with the cutoff value of 0.5 ng/mL was 72% and 92%, respectively.

CONCLUSION

PCT can be used in elderly patients to diagnose bacterial infections because it has proved good sensitivity and high specificity.

Ability of procalcitonin to predict bacterial meningitis in the emergency department

INTRODUCTION

The aim of this study was to analyse and compare procalcitonin (PCT) and C-reactive protein (CRP) as tools for detecting bacterial meningitis and predicting bacteraemia.

METHODS

Prospective, observational, and descriptive analytical study of 98 consecutive patients aged ≥15 years and diagnosed with acute meningitis in an emergency department between August 2009 and July 2013.

RESULTS

We analysed 98 patients with AM (66 males [67%]); mean age was 44±21 years. The diagnosis was bacterial meningitis in 38 patients (20 with bacteraemia); viral meningitis in 33; probable viral meningitis in 15; and presumptively diagnosed partially treated acute meningitis in 12. PCT had the highest area under the ROC curve (AUC) (0.996; 95% CI, 0.987-1; p<0.001). With a cutoff of ≥ 0.74 ng/ml, PCT achieved 94.7% sensitivity, 100% specificity, negative predictive value (NPV) of 93.9%, and positive predictive value (PPV) of 100%. The mean levels for PCT were11.47±7.76 ng/ml in bacterial meningitis vs. 0.10±0.15 ng/ml in viral meningitis (p <0.001). The AUC for CRP was 0.916 and a cutoff of ≥ 90 mg/L achieved 67.5% sensitivity, 86.3% specificity, PPV of 89.2%, and NPV of 90.4%. As a predictor of bacteraemia in bacterial meningitis, only PCT delivered a significant difference (14.7±7.1 ng/mL vs. 4.68±3.54 ng/mL, p<0.001). A cutoff of ≥ 1.1 ng/mL achieved 94.6% sensitivity, 72.4% specificity, NPV of 95.4%, and PPV of 69.2%; the AUC was 0.965 (95% CI, 0.921-1; p<0.001).

CONCLUSIONS

PCT has a high diagnostic power for acute meningitis in emergency department patients. PCT outperforms CRP in the detection of bacterial aetiology and is a good predictor of bacteraemia in bacterial meningitis.