[Prognostic value of lipopolysaccharide binding protein and procalcitonin in patients with severe sepsis and septic shock admitted to intensive care]

Mortality prediction model from combined serial lactate, procalcitonin and calprotectin levels in critically ill patients with sepsis: A retrospective study according to Sepsis-3 definition

OBJECTIVE

1) To evaluate the ability of baseline and on 24 h serum calprotectin, in comparison to canonical biomarkers (lactate and procalcitonin), for prognosis of 28-day mortality in critically ill septic patients; and 2) To develop a predictive model combining the three biomarkers.

DESIGN

A single-center, retrospective study.

SETTING

Intensive Care Unit of a university hospital.

PATIENTS OR PARTICIPANTS

One hundred and seventy three septic pacientes were included.

INTERVENTIONS

Measurement of baseline lactate, procalcitonin and calprotectin level and procalcitonin and calprotectin levels on 24 h.

MAIN VARIABLES OF INTEREST

Demographics and comorbidities, SOFA score on ICU admission, baseline lactate, procalcitonin and calprotectin on admission and on 24 h and 28-day mortality.

RESULTS

1) On ICU admission, lactate was the only biomarker achieving a significant accuracy (AUC: 0.698); 2) On 24 h, no differences were found on procalcitonin and calprotectin levels. Procalcitonin and calprotectin clearances were significantly lower in non-survivors and both achieved a moderate performance (AUCs: 0.668 and 0.664, respectively); 3) A biomarker based-model achieved a significant accuracy (AUC: 0.766), trending to increase (AUC: 0.829) to SOFA score alone; y 4) Baseline lactate levels and procalcitonin and calprotectin clearance were independent predictors for the outcome.

CONCLUSIONS

1) Baseline and on 24 h calprotectina and procalcitonin levels lacked ability in predicting 28-day mortality; 2) Accuracy of clearance of both biomarkers was moderate; and 3) Combination of SOFA score and the predictive biomarker based-model showed a high prognostic accuracy.

Current Status of Antibiotic Stewardship and the Role of Biomarkers in Antibiotic Stewardship Programs

The importance of antibiotic stewardship is increasingly emphasized in accordance with the increasing incidences of multidrug-resistant organisms and accompanying increases in disease burden. This review describes the obstacles in operating an antibiotic stewardship program (ASP), and whether the use of biomarkers within currently available resources can help. Surveys conducted around the world have shown that major obstacles to ASPs are shortages of time and personnel, lack of appropriate compensation for ASP operation, and lack of guidelines or appropriate manuals. Sufficient investment, such as the provision of full-time equivalent ASP practitioners, and adoption of computerized clinical decision systems are useful measures to improve ASP within an institution. However, these methods are not easy in terms of both time commitments and cost. Some biomarkers, such as C-reactive protein, procalcitonin, and presepsin are promising tools in ASP due to their utility in diagnosis and forecasting the prognosis of sepsis. Recent studies have demonstrated the usefulness of algorithmic approaches based on procalcitonin level to determine the initiation or discontinuation of antibiotics, which would be helpful in decreasing antibiotics use, resulting in more appropriate antibiotics use.

Procalcitonin in clinical practice: from diagnosis of sepsis to antibiotic therapy

A diagnostic algorithm that allows for the rapid identification of sepsis and possibly guides the appropriate antimicrobial therapy application is the cornerstone to obtaining effective treatment and better results. The use of emerging surrogate markers could significantly improve clinical practice, but the validity and clinical utility have been proved only for very few of them, and their availability in clinical routine is limited. For this purpose, numerous scientific evidence has indicated procalcitonin as a marker linked to sepsis and its evolution. This review aims to retrace the main evidence relating to the use of procalcitonin in sepsis. We analyzed the primary studies in the literature and the existing meta-analysis evaluating the behavior of procalcitonin as a marker of bacterial sepsis, its prognostic power, and its ability to influence antibiotic therapy. Recent evidence has suggested that procalcitonin could be an efficient marker for diagnosing sepsis and its therapeutic management in many types of patients. The choice of the appropriate timing to initiate and suspend antibiotic therapy, with obvious clinical advantages, the favorable effects could also include reducing health costs, both avoiding the administration of inappropriate antibiotic therapies, and reducing the duration of hospitalization. Moreover, limited studies reported high procalcitonin levels in coronavirus disease 2019 patients with a worse prognosis. Despite the considerable evidence in favor of the potential of procalcitonin as an index for managing septic patients, there are conflicting data that deserve specific and detailed studies.

Should serial monitoring of procalcitonin be done routinely in critically ill patients of ICU: A systematic review and meta-analysis

Sepsis is a life-threatening condition with dysregulated host response to infection. It is a major determinant of mortality in the intensive care unit (ICU). Procalcitonin (PCT) is widely investigated for prognosis in patients with sepsis. Most of the studies have cited that elevated PCT concentrations and PCT non-clearance are associated with poor outcomes in patients with sepsis and some studies have cited as having no additional benefit. Most of the studies have evaluated single PCT measurement and correlated with prognosis and outcome in septic patients. Limited literature is there about serial PCT levels and its impact on the outcome of patients with sepsis. We searched literature through PubMed, Embase, Web of Knowledge, and the Cochrane Library from 2007 to 2017 and present a systematic review and meta-analysis of studies evaluating the utility of serial measurement of PCT for prognosis in critically ill patients. Articles that assessed PCT non-clearance as a marker of mortality data were included. The primary objective of this meta-analysis was to pool the results of all the available studies on serial PCT non-clearance as a mortality predictor and formulate overall area under receiver operating curve (AUROC). To find out the overall proportion of mortality in PCT non-clearance was our secondary objective. To detect the mortality using PCT non-clearance, ROC curve analysis was done. Area under curve (AUC) of the studies was varying between 0.52 and 0.86. Overall AUC was observed 0.711 (95% confidence interval (CI): 0.662–0.760) under fixed effect model and 0.708 (95% CI: 0.648–0.769) under random effect model. There was moderate variation among the studies, i.e., I² 50.80% (95% CI: 0.00–80.42%). The overall proportion of mortality was 37.54% with much heterogeneity (I² 88.24%) among the studies. PCT non-clearance is a fair predictor of mortality. Further studies are needed to define optimal cut off point for PCT non-clearance in ICU patients with sepsis.

Prognostic performance of pancreatic stone protein in critically ill patients with sepsis

Aim: To assess the prognostic value for 28-day mortality of PSP in critically ill patients with sepsis. Material & methods: 122 consecutive patients with sepsis were enrolled in this study. Blood samples were collected on admission and day 2. Results: On admission, the combination of PSP and lactate achieved an area under the receiver operating characteristic (AUC-ROC) of 0.796, similar to sequential organ failure assessment score alone (AUC-ROC: 0.826). On day 2, PSP was the biomarker with the highest performance (AUC-ROC: 0.844), although lower (p = 0.041) than sequential organ failure assessment score (AUC-ROC: 0.923). Conclusion: The combination of PSP and lactate and PSP alone, on day 2, have a good performance for prognosis of 28-day mortality and could help to identify patients who may benefit most from tailored intensive care unit management.

Postmortem microbiology sampling following death in hospital: an ESGFOR task force consensus statement

Postmortem microbiology (PMM) is a valuable tool in the identification of the cause of death and of factors contributory to death where death has been caused by infection. The value of PMM is dependent on careful autopsy planning, appropriate sampling, minimisation of postmortem bacterial translocation and avoidance of sample contamination. Interpretation of PMM results requires careful consideration in light of the clinical history, macroscopic findings and the histological appearances of the tissues. This consensus statement aims to highlight the importance of PMM in the hospital setting and to give microbiological and pathological advice on sampling in deaths occurring in hospital.

Effectiveness and safety of procalcitonin evaluation for reducing mortality in adults with sepsis, severe sepsis or septic shock

BACKGROUND

Serum procalcitonin (PCT) evaluation has been proposed for early diagnosis and accurate staging and to guide decisions regarding patients with sepsis, severe sepsis and septic shock, with possible reduction in mortality.

OBJECTIVES

To assess the effectiveness and safety of serum PCT evaluation for reducing mortality and duration of antimicrobial therapy in adults with sepsis, severe sepsis or septic shock.

SEARCH METHODS

We searched the Central Register of Controlled Trials (CENTRAL; 2015, Issue 7); MEDLINE (1950 to July 2015); Embase (Ovid SP, 1980 to July 2015); Latin American Caribbean Health Sciences Literature (LILACS via BIREME, 1982 to July 2015); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO host, 1982 to July 2015), and trial registers (ISRCTN registry, ClinicalTrials.gov and CenterWatch, to July 2015). We reran the search in October 2016. We added three studies of interest to a list of 'Studies awaiting classification' and will incorporate these into formal review findings during the review update.

SELECTION CRITERIA

We included only randomized controlled trials (RCTs) testing PCT-guided decisions in at least one of the comparison arms for adults (≥ 18 years old) with sepsis, severe sepsis or septic shock, according to international definitions and irrespective of the setting.

DATA COLLECTION AND ANALYSIS

Two review authors extracted study data and assessed the methodological quality of included studies. We conducted meta-analysis with random-effects models for the following primary outcomes: mortality and time spent receiving antimicrobial therapy in hospital and in the intensive care unit (ICU), as well as time spent on mechanical ventilation and change in antimicrobial regimen from a broad to a narrower spectrum.

MAIN RESULTS

We included 10 trials with 1215 participants. Low-quality evidence showed no significant differences in mortality at longest follow-up (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.65 to 1.01; I2 = 10%; 10 trials; N = 1156), at 28 days (RR 0.89, 95% CI 0.61 to 1.31; I2 = 0%; four trials; N = 316), at ICU discharge (RR 1.03, 95% CI 0.50 to 2.11; I2 = 49%; three trials; N = 506) and at hospital discharge (RR 0.98, 95% CI 0.75 to 1.27; I2 = 0%; seven trials; N = 805; moderate-quality evidence). However, mean time receiving antimicrobial therapy in the intervention groups was -1.28 days (95% CI to -1.95 to -0.61; I2 = 86%; four trials; N = 313; very low-quality evidence). No primary study has analysed the change in antimicrobial regimen from a broad to a narrower spectrum.

AUTHORS' CONCLUSIONS

Up-to-date evidence of very low to moderate quality, with insufficient sample power per outcome, does not clearly support the use of procalcitonin-guided antimicrobial therapy to minimize mortality, mechanical ventilation, clinical severity, reinfection or duration of antimicrobial therapy of patients with septic conditions.

Prognostic Value of Procalcitonin in Adult Patients with Sepsis: A Systematic Review and Meta-Analysis

Procalcitonin (PCT) has been widely investigated for its prognostic value in septic patients. However, studies have produced conflicting results. The purpose of the present meta-analysis is to explore the diagnostic accuracy of a single PCT concentration and PCT non-clearance in predicting all-cause sepsis mortality. We searched PubMed, Embase, Web of Knowledge and the Cochrane Library. Articles written in English were included. A 2 × 2 contingency table was constructed based on all-cause mortality and PCT level or PCT non-clearance in septic patients. Two authors independently evaluated study eligibility and extracted data. The diagnostic value of PCT in predicting prognosis was determined using a bivariate meta-analysis model. We used the Q-test and I² index to test heterogeneity. Twenty-three studies with 3,994 patients were included. An elevated PCT level was associated with a higher risk of death. The pooled relative risk (RR) was 2.60 (95% confidence interval (CI), 2.05–3.30) using a random-effects model (I² = 63.5%). The overall area under the summary receiver operator characteristic (SROC) curve was 0.77 (95% CI, 0.73–0.80), with a sensitivity and specificity of 0.76 (95% CI, 0.67–0.82) and 0.64 (95% CI, 0.52–0.74), respectively. There was significant evidence of heterogeneity for the PCT testing time (P = 0.020). Initial PCT values were of limited prognostic value in patients with sepsis. PCT non-clearance was a prognostic factor of death in patients with sepsis. The pooled RR was 3.05 (95% CI, 2.35–3.95) using a fixed-effects model (I² = 37.9%). The overall area under the SROC curve was 0.79 (95% CI, 0.75–0.83), with a sensitivity and specificity of 0.72 (95% CI, 0.58–0.82) and 0.77 (95% CI, 0.55–0.90), respectively. Elevated PCT concentrations and PCT non-clearance are strongly associated with all-cause mortality in septic patients. Further studies are needed to define the optimal cut-off point and the optimal definition of PCT non-clearance for accurate risk assessment.