Procalcitonin-guided algorithms of antibiotic therapy in the intensive care unit: A systematic review and meta-analysis of randomized controlled trials:

MicroRNA Expression Profile in Patients Admitted to ICU as Novel and Reliable Approach for Diagnostic and Therapeutic Purposes

The ability to detect early metabolic changes in patients who have an increased mortality risk in the intensive care units (ICUs) could increase the likelihood of predicting recovery patterns and assist in disease management. Markers that can predict the disease progression of patients in the ICU might also be beneficial for improving their medical profile. Although biomarkers have been used in the ICU more frequently in recent years, the clinical use of most of them is limited. A wide range of biological processes are influenced by microRNAs (miRNAs) that modulate the translation and stability of specific mRNAs. Studies suggest that miRNAs may serve as a diagnostic and therapeutic biomarker in ICUs by profiling miRNA dysregulation in patient samples. To improve the predictive value of biomarkers for ICU patients, researchers have proposed both investigating miRNAs as novel biomarkers and combining them with other clinical biomarkers. Herein, we discuss recent approaches to the diagnosis and prognosis of patients admitted to an ICU, highlighting the use of miRNAs as novel and robust biomarkers for this purpose. In addition, we discuss emerging approaches to biomarker development and ways to improve the quality of biomarkers so that patients in ICU get the best outcomes possible.

Evaluation of Serial Procalcitonin Levels for the Optimization of Antibiotic Use in Non-Critically Ill COVID-19 Patients

BACKGROUND

Procalcitonin (PCT) has been used as a biomarker to guide antibiotic therapy in various patient populations. However, its role in optimizing antibiotic use in COVID-19 patients has not been well studied to date. Thus, we aimed to evaluate the use of serial PCT monitoring as an antimicrobial stewardship tool for COVID-19 patients.

METHODS

This retrospective study included 240 COVID-19 patients who were admitted to a tertiary medical institution in Saudi Arabia between January 2020 and February 2022. Patients who received empiric antibiotic therapy for community-acquired pneumonia (CAP) and had serial procalcitonin levels were included. The patients were divided into two groups: the normal procalcitonin arm (PCT level < 0.5 ng/mL) and the elevated PCT arm (PCT level > 0.5 ng/mL). The primary and secondary outcomes were the effect of PCT monitoring on the duration of antibiotic exposure and the length of hospital stay, respectively. To measure the accuracy of PCT, the receiver-operating characteristic area under the curve (ROC-AUC) was determined.

RESULTS

Among the included patients, 142 were in the normal procalcitonin arm (median PCT, 0.12 ng/mL), and 78 were in the elevated PCT arm (median PCT, 4.04 ng/mL). The baseline characteristics were similar between the two arms, except for the higher prevalence of kidney disease in the elevated PCT arm. There was no statistically significant difference in the duration of antibiotic exposure between the normal and elevated PCT arms (median duration: 7 days in both arms). However, the length of hospital stay was significantly shorter in the normal PCT arm (median stay, 9 days) than in the elevated PCT arm (median stay, 13 days; p = 0.028). The ROC-AUC value was 0.54 (95% CI: 0.503-0.595).

CONCLUSIONS

Serial PCT monitoring did not lead to a reduction in the duration of antibiotic exposure in COVID-19 patients. However, it was associated with a shorter hospital stay. These findings suggest that PCT monitoring may be useful for optimizing antibiotic use and improving outcomes in COVID-19 patients. While PCT-guided algorithms have the potential to enable antibiotic stewardship, their role in the context of COVID-19 treatment requires further investigation.

The Role of Biomarkers in the Diagnosis and Management of Pneumonia

Biomarkers are used in the diagnosis, severity determination, and prognosis for patients with community-acquired pneumonia (CAP). Selected biomarkers may indicate a bacterial infection and need for antibiotic therapy (C-reactive protein, procalcitonin, soluble triggering receptor expressed on myeloid cells). Biomarkers can differentiate CAP patients who require hospital admission and severe CAP requiring intensive care unit admission. Biomarker-guided antibiotic therapy may limit antibiotic exposure without compromising outcome and thus improve antibiotic stewardship. The authors discuss the role of biomarkers in diagnosing, determining severity, defining the prognosis, and limiting antibiotic exposure in CAP and ventilator-associated pneumonia patients.

Reliability of Admission Procalcitonin Testing for Capturing Bacteremia Across the Sepsis Spectrum: Real-World Utilization and Performance Characteristics, 65 U.S. Hospitals, 2008-2017

OBJECTIVES

Serum procalcitonin is often ordered at admission for patients with suspected sepsis and bloodstream infections (BSIs), although its performance characteristics in this setting remain contested. This study aimed to evaluate use patterns and performance characteristics of procalcitonin-on-admission in patients with suspected BSI, with or without sepsis.

DESIGN

Retrospective cohort study.

SETTING

Cerner HealthFacts Database (2008-2017).

PATIENTS

Adult inpatients (≥ 18 yr) who had blood cultures and procalcitonin drawn within 24 hours of admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Testing frequency of procalcitonin was determined. Sensitivity of procalcitonin-on-admission for detecting BSI due to different pathogens was calculated. Area under the receiver operating characteristic curve (AUC) was calculated to assess discrimination by procalcitonin-on-admission for BSI in patients with and without fever/hypothermia, ICU admission and sepsis defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. AUCs were compared using Wald test and p values were adjusted for multiple comparisons. At 65 procalcitonin-reporting hospitals, 74,958 of 739,130 patients (10.1%) who had admission blood cultures also had admission procalcitonin testing. Most patients (83%) who had admission day procalcitonin testing did not have a repeat procalcitonin test. Median procalcitonin varied considerably by pathogen, BSI source, and acute illness severity. At a greater than or equal to 0.5 ng/mL cutoff, sensitivity for BSI detection was 68.2% overall, ranging between 58.0% for enterococcal BSI without sepsis and 96.4% for pneumococcal sepsis. Procalcitonin-on-admission displayed moderate discrimination at best for overall BSI (AUC, 0.73; 95% CI, 0.72-0.73) and showed no additional utility in key subgroups. Empiric antibiotic use proportions were not different between blood culture sampled patients with a positive procalcitonin (39.7%) and negative procalcitonin (38.4%) at admission.

CONCLUSIONS

At 65 study hospitals, procalcitonin-on-admission demonstrated poor sensitivity in ruling out BSI, moderate-to-poor discrimination for both bacteremic sepsis and occult BSI and did not appear to meaningfully alter empiric antibiotic usage. Diagnostic stewardship of procalcitonin-on-admission and risk assessment of admission procalcitonin-guided clinical decisions is warranted.

Management of Intra-Abdominal Infections: The Role of Procalcitonin

Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections.

Comprehensive Comparison of the Capacity of Functionalized Sepharose, Magnetic Core, and Polystyrene Nanoparticles to Immuno-Precipitate Procalcitonin from Human Material for the Subsequent Quantification by LC-MS/MS

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The fast and accurate diagnosis of sepsis by procalcitonin (PCT) has emerged as an essential tool in clinical medicine. Although in use in the clinical laboratory for a long time, PCT quantification has not yet been standardized. The International Federation of Clinical Chemistry working group on the standardization of PCT (IFCC-WG PCT) aims to provide an LC-MS/MS-based reference method as well as the highest metrological order reference material to address this diagnostic need. Here, we present the systematic evaluation of the efficiency of an immuno-enrichment method, based on functionalized Sepharose, magnetic-core, or polystyrene (latex) nano-particles, to quantitatively precipitate PCT from different human sample materials. This method may be utilized for both mass spectrometric and proteomic purposes. In summary, only magnetic-core nano-particles functionalized by polyclonal PCT antibodies can fulfil the necessary requirements of the international standardization of PCT. An optimized method proved significant benefits in quantitative and specific precipitation as well as in the subsequent LC-MS/MS detection of PCT in human serum samples or HeLa cell extract. Based on this finding, further attempts of the PCT standardization process will utilize a magnetic core-derived immuno-enrichment step, combined with subsequent quantitative LC-MS/MS detection.

Non-thyroidal illness syndrome and its relationship with mortality risk in critically ill children

Introduction

Non-thyroidal illness syndrome (NTIS) is considered to be associated with adverse outcomes in critically ill children.The hypothesis that thyroid hormones and inflammatory markers are associated with increased prediction of mortality risk scores is tested in this paper.

Methods

A prospective observational study was set up in a pediatric intensive care unit (PICU). One hundred and three patients were included. NTIS was defined as a low free triiodothyronine (FT3) value for the patient's age. Thyroid hormones levels and inflammatory markers were determined at admission: FT3, FT4 (free thyroxine), TSH (thyroid-stimulating hormone), rT3 (reverse triiodothyronine), CRP (C-reactive protein) and PCT (Procalcitonin). They were compared between children with a pediatric risk of mortality score PRISM-III >75th percentile (group A, n= 25) and the rest (group B, n = 78).

Results

A FT4 value lower than 16.6 pmol/L showed an area under the curve (AUC) of 0.655 (0.56-0.78, p = 0.02), with 76% sensitivity and 61.5% specificity to detect a high risk of mortality. A multiple regression analysis revealed that a FT4 lower than 16.6 pmol/L [OR: 4.92 (1.60-18.19), p = 0.009] and having NTIS [OR: 6.04 (1.45-27.93), p = 0.016] could predict a high risk of mortality.

Conclusions

In unselected critically ill children, FT4 and FT3 values at admission could be used as a good predictor of a high mortality risk. We have not achieved a predictive model that combines hormones with inflammatory markers.

Utility of healthcare-worker-targeted antimicrobial stewardship interventions in hospitals of low- and lower-middle-income countries: a scoping review of systematic reviews

BACKGROUND

Antimicrobial stewardship (AMS) initiatives in hospitals often include the implementation of clustered intervention components to improve the surveillance and targeting of antibiotics. However, impacts of the individual components of AMS interventions are not well known, especially in low- and lower-middle-income countries (LLMICs).

OBJECTIVE

A scoping review was conducted to summarize evidence from systematic reviews (SRs) on the impact of common hospital-implemented healthcare-worker-targeted components of AMS interventions that may be appropriate for LLMICs.

METHODS

Major databases were searched systematically for SRs of AMS interventions that were evaluated in hospitals. For SRs to be eligible, they had to report on at least one intervention that could be categorized according to the Effective Practice and Organisation of Care taxonomy. Clinical and process outcomes were considered. Primary studies from LLMICs were consulted for additional information.

RESULTS

Eighteen SRs of the evaluation of intervention components met the inclusion criteria. The evidence shows that audit and feedback, and clinical practice guidelines improved several clinical and process outcomes in hospitals. An unintended consequence of interventions was an increase in the use of antibiotics. There was a cumulative total of 547 unique studies, but only 2% (N=12) were conducted in hospitals in LLMICs. Two studies in LLMICs reported that guidelines and educational meetings were effective in hospitals.

CONCLUSION

Evidence from high- and upper-middle-income countries suggests that audit and feedback, and clinical practice guidelines have the potential to improve various clinical and process outcomes in hospitals. The lack of evidence in LLMIC settings prevents firm conclusions from being drawn, and highlights the need for further research.

Application of Biomarkers in the Diagnostic Distinction of Bacterial and Viral Infections

Infectious diseases, which pose a great threat worldwide, have a significant impact on public health and the world economy. It contributes to increased healthcare costs, unnecessary drug-related side effects, and increased antimicrobial resistance. It is not always easy to distinguish the etiological differentiation of diseases that can develop with bacteria and viruses. Therefore, one of the biggest challenges in medicine is how to correctly distinguish between the different causes of these infections and how to manage the patient. Because bacterial and viral infections often present similar symptoms. The real decision is whether the infection is caused by bacteria or viruses and whether to treat the patient with antibiotics. There are many different methodological approaches to diagnosing infections. Biomarkers have been used in the diagnosis of diseases and other conditions for many years. Biomarkers are molecules found in blood and body fluids in measurable amounts, which can evaluate biological and pathological processes. These key indicators can provide vital information in determining disease prognosis, predicting response to treatments, adverse events and drug interactions, and identifying key risks. An effective biomarker is extremely important for the early diagnosis of various diseases. The explosion of interest in biomarker research is driving the development of new predictive, diagnostic, and prognostic products in modern medical practice. The purpose of this review is to demonstrate the use and diagnostic potential of current and investigational biomarkers in the distinction between bacterial and viral infections.

Evidence for the circulating microRNA hsa-let-7d-3p as a potential new biomarker for sepsis in human subjects

Background

Current biomarkers for the early detection of sepsis have low sensitivity and specificity. Serum microRNAs (miRNAs) have been proposed as novel noninvasive biomarkers for various diseases. The aim of the present study was to discover a novel diagnostic biomarker for sepsis in human subjects.

Methods

miRNA expression profiling was performed using peripheral blood from three sepsis patients in the sepsis stage and improved condition stage using microarray screening. The differentially expressed miRNAs were primary validated by real-time quantitative polymerase chain reaction (RT-qPCR) in a further set of 20 sepsis patients in the sepsis stage and improved condition stage. Finally, we validated the differentially expressed miRNAs in 95 sepsis patients and 66 nonsepsis patients. The validated miRNAs and patients’ clinical indictors were analysed in a multivariate logistic regression model. The diagnostic value of the changed miRNA in sepsis was determined and compared with CRP and WBC by analysing the receiver operating characteristic (ROC) curves.

Results

According to the criteria, we detected 11 miRNAs regulated by the miRNA chip. RT-qPCR detection showed that the expression of hsa-let-7d-3p in sepsis patients was upregulated compared with that in nonsepsis patients. In a multiple logistic regression analysis, serum miRNA hsa-let-7d-3p was found to be an independent predictor of sepsis. Receiver operating characteristic curve (ROC) analysis showed that the area under the ROC curve of serum hsa-let-7d-3p was 0.696 [95% confidence interval (0.615, 0.778)].

Conclusion

The miRNA hsa-let-7d-3p was identified as a novel biomarker for the early detection of sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00763-3.

Lactylated Histone H3K18 as a Potential Biomarker for the Diagnosis and Predicting the Severity of Septic Shock

Objective

To date, there are no studies regarding the lactylation profile and its role in critically ill patients. Thus, we aimed to examine expression of histone H3 lysine 18 (H3K18) lactylation and its role in patients with septic shock.

Methods

Thirteen healthy volunteers and 35 critically ill patients from the Department of Surgical Intensive Care Medicine, Beijing Hospital were enrolled in our study. Baseline information and clinical outcomes were obtained prospectively. Lactylation levels of all proteins and H3K18 from peripheral blood mononuclear (PBMC) were determined by western blotting and serum levels of inflammatory cytokines by flow cytometry. Arginase-1 (Arg1) and Krüppel-like factor-4 (Klf4) mRNA expression was evaluated by quantitative real-time PCR (qRT-PCR).

Results

Lactylation was found to be an all-protein post-translational modification and was detected in PBMCs from both healthy volunteers and critically ill patients, with a significantly higher relative density in shock patients (t=2.172, P=0.045). H3K18la was expressed in all subjects, including healthy volunteers, with the highest level in septic shock patients (compared with non-septic shock patients, critically ill without shock patients and healthy volunteers P=0.033, 0.000 and 0.000, respectively). Furthermore, H3K18la protein expression correlated positively with APACHE II scores, SOFA scores on day 1, ICU stay, mechanical ventilation time and serum lactate (ρ=0.42, 0.63, 0.39, 0.51 and 0.48, respectively, ρ=0.012, 0.000, 0.019, 0.003 and 0.003, respectively). When we matched patients with septic shock and with non-septic shock according to severity, we found higher H3K18la levels in the former group (t=-2.208, P =0.040). Moreover, H3K18la exhibited a close correlation with procalcitonin levels (ρ=0.71, P=0.010). Patients with high H3K18la expression showed higher IL-2, IL-5, IL-6, IL-8, IL-10, IL-17, IFN-α levels (ρ=0.33, 0.37, 0.62, 0.55, 0.65, 0.49 and 0.374 respectively, P=0.024, 0.011, 0.000, 0.000, 0.000 and 0.000 respectively). H3K18la expression also displayed a positive correlation with the level of Arg1 mRNA (ρ=0.561, P=0.005).

Conclusions

Lactylation is an all-protein post-translational modification occurring in both healthy subjects and critically ill patients. H3K18la may reflect the severity of critical illness and the presence of infection. H3K18la might mediate inflammatory cytokine expression and Arg1 overexpression and stimulate the anti-inflammatory function of macrophages in sepsis.

Serial analysis of blood biomarker concentrations in dogs with pneumonia, septic peritonitis, and pyometra

BACKGROUND

Prolonged antimicrobial drug (AMD) treatment is associated with antimicrobial resistance development. Biomarker measurement may aid treatment decision-making.

OBJECTIVES

Investigate temporal changes in blood biomarker concentrations in dogs undergoing treatment for pulmonary and intra-abdominal infections; compare time to biomarker concentration normalization with duration of clinician-directed AMD treatment.

ANIMALS

Forty-two client-owned dogs with pneumonia (n = 22), septic peritonitis (n = 10), or pyometra (n = 10).

METHODS

Plasma concentrations of C-reactive protein (CRP), serum amyloid A (SAA), haptoglobin, procalcitonin, nucleosomes, cell-free DNA (cfDNA), high-mobility group box-1 (HMGB1), CC-motif chemokine ligand-2 (CCL2), CXC-motif chemokine ligand-8 (CXCL8), and keratinocyte chemoattractant-like (KC-Like) were quantitated in samples collected on days 1, 3, 7, 14, 28, and 60. Treatment was directed by clinicians blinded to biomarker concentrations.

RESULTS

Concentrations of CCL2, CRP, and KC-Like were maximal on D1, concentrations of SAA, cfDNA, HMGB1, and nucleosomes were maximal on D3 and haptoglobin concentrations were maximal on D7. These maximal concentrations were significantly different from those on D60. Concentrations of CRP and SAA decreased by 80% from peak and into respective reference intervals before AMDs were discontinued. For CRP, the median (interquartile range [IQR]) times to 20% peak and normal were 7 (6-9) and 7 (6-12) days, respectively, and for SAA they were 4 (4, 5) and 6 (5-8) days, respectively, compared to a median (IQR) duration of AMD prescribing of 16 (12-23) days (all P < .0001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Biomarker concentrations normalized within 7 to 14 days. Serial measurements of CRP and SAA might aid identification of disease resolution and could help guide AMD prescription decision-making.

Potential Value of Presepsin Guidance in Shortening Antibiotic Therapy in Septic Patients: a Multicenter, Prospective Cohort Trial

INTRODUCTION

Long-term use of antibiotics for septic patients leads to bacterial resistance, increased mortality, and hospital stay. In this study, we investigated an emerging biomarker presepsin-guided strategy, which can be used to evaluate the shortening of antibiotic treatment in patients with sepsis without risking a worse outcome.

METHODS

In this multicenter prospective cohort trial, patients were assigned to the presepsin or control groups. In the presepsin group, antibiotics were ceased based on predefined cut-off ranges of presepsin concentrations. The control group stopped antibiotics according to international guidelines. The primary endpoints were the number of days without antibiotics within 28 days and mortality at 28 and 90 days. Secondary endpoints were the percentage of patients with a recurrent infection, length of stay in ICU and hospital, hospitalization costs, days of first episode of antibiotic treatment, percentage of antibiotic administration and multidrug-resistant bacteria, and SOFA score.

RESULTS

Overall, 656 out of an initial 708 patients were eligible and assigned to the presepsin group (n = 327) or the control group (n = 329). Patients in the presepsin group had significantly more days without antibiotics than those in the control group (14.54 days [SD 9.01] vs. 11.01 days [SD 7.73]; P < 0.001). Mortality in the presepsin group showed no difference to that in the control group at days 28 (17.7% vs. 18.2%; P = 0.868) and 90 (19.9% vs. 19.5%; P = 0.891). Patients in the presepsin group had a significantly shorter mean length of stay in the hospital and lower hospitalization costs than control subjects. There were no differences in the rate of recurrent infection and multidrug-resistant bacteria and the SOFA score tendency between the two groups.

CONCLUSIONS

Presepsin guidance has potential to shorten the duration of antibiotic treatment in patients with sepsis without risking worse outcomes of death, recurrent infection, and aggravation of organ failure.

TRIAL REGISTRATION

ChiCTR, ChiCTR1900024391. Registered 9 July 2019-Retrospectively registered, http://www.chictr.org.cn.

MicroRNA as an Early Biomarker of Neonatal Sepsis

Sepsis is a major cause of lethality in neonatal intensive care units. Despite significant advances in neonatal care and growing scientific knowledge about the disease, 4 of every 10 infants born in developed countries and suffering from sepsis die or experience considerable disability, including substantial and permanent neurodevelopmental impairment. Pharmacological treatment strategies for neonatal sepsis remain limited and mainly based upon early initiation of antibiotics and supportive treatment. In this context, numerous clinical and serum-based markers have been evaluated for diagnosing sepsis and evaluating its severity and etiology. MicroRNAs (miRNAs) do not encode for proteins but regulate gene expression by inhibiting the translation or transcription of their target mRNAs. Recently, it was demonstrated in adult patients that miRNAs are released into the circulation and that the spectrum of circulating miRNAs is altered during various pathologic conditions, such as inflammation, infection, and sepsis. Here, we summarize current findings on the role of circulating miRNAs in the diagnosis and staging of neonatal sepsis. The conclusions point to substantial diagnostic potential, and several miRNAs have been validated independently by different teams, namely miR-16a, miR-16, miR-96-5p, miR-141, miR-181a, and miR-1184.

[Which biomarkers for diagnosis and guidance of anti-infection treatment in sepsis?]

To date no biomarker has been identified bringing together perfect sensitivity and specificity to discriminate between inflammation and infections. Since the 1930s new markers of tissue damage and endothelial damage have been identified but which are incapable of identifying infections in every clinical setting to enable initiation of early antibiotic treatment. In this review the most important classical biomarkers and upcoming new PCR-based approaches are addressed. These markers are highlighted with respect to special clinical settings and to control the success of antibiotic treatment. The issue of discrimination between inflammation and infection is not yet solved. Based on one single biomarker it is impossible to decide whether infection is the reason for the patient's worsening condition but the combination of biomarkers or the integration of new biomarkers may be a meaningful supplement. The measurement of different biomarkers of infection or inflammation is part of the routine in critical care and will be essential in the future.

Long Non-Coding RNAs as Biomarkers and Therapeutic Targets in Sepsis

Sepsis, an infection-induced systemic inflammatory disorder, is often accompanied by multiple organ dysfunction syndromes with high incidence and mortality rates, and those who survive are often left with long-term sequelae, bringing great burden to social economy. Therefore, novel approaches to solve this puzzle are urgently needed. Previous studies revealed that long non-coding RNAs (lncRNAs) have exerted significant influences on the process of sepsis. The aim of this review is to summarize our understanding of lncRNAs as potential sepsis-related diagnostic markers and therapeutic targets, and provide new insights into the diagnosis and treatment for sepsis. In this study, we also introduced the current diagnostic markers of sepsis and discussed their limitations, while review the research advances in lncRNAs as promising biomarkers for diagnosis and prognosis of sepsis. Furthermore, the roles of lncRNAs in sepsis-induced organ dysfunction were illustrated in terms of different organ systems. Nevertheless, further studies should be carried out to elucidate underlying molecular mechanisms and pathological process of sepsis.

Early Elevation of Thioredoxin-1 Serum Levels Predicts 28-Day Mortality in Patients with Sepsis

Background

Sepsis is the leading cause of death in critically ill patients, and the prevention of which requires precise outcome prediction and early intervention. We evaluated the prognostic prediction value of serum thioredoxin-1 (Trx-1) as an anti-inflammatory factor in patients with sepsis.

Methods

As a prospective study, patients with sepsis admitted to the intensive care unit (ICU) of our hospital during 2020 were recruited. Medical history collection, sequential organ failure assessment (ΔSOFA), and laboratory tests were performed within 24 h of admission. Serum levels of Trx-1 and other inflammatory biomarkers were detected with samples dynamically collected before, during, and after septic shock. Patients were categorized as survivors and non-survivors according to survival status on day 28. Correlation between Trx-1 and other sepsis-associated parameters as well as the correlation of Trx-1 and other sepsis-associated parameters with 28-day mortality were evaluated. Prognostic factors were identified by Cox regression analyses.

Results

A total of 187 patients were recruited. Serum Trx-1 level was positively correlated with inflammatory factors (interleukin-6, C-reactive protein, procalcitonin) and index of sepsis severity (ΔSOFA score, partial pressure of oxygen/fraction of inspired oxygen), all of which were significantly higher in non-survivors than survivors. While Trx-1 level at different timepoints and its evolution over time significantly differed between survivors and non-survivors, the initial Trx-1 level outperformed the other parameters in predicting 28-day survival. With 38.27 ng/mL as the cutoff value, serum Trx-1 predicted 28-day survival with optimal sensitivity and specificity.

Conclusion

Early increases in serum levels of Trx-1 can predict 28-day mortality in sepsis patients in the ICU.

Use of a Novel Clinical Decision Support Tool for Pharmacist-Led Antimicrobial Stewardship in Patients with Normal Procalcitonin

In 2018, a clinical decision support (CDS) tool was implemented as part of a "daily checklist" for frontline pharmacists to review patients on antibiotics with procalcitonin (PCT) <0.25 mcg/L. This study used a retrospective cohort design to assess change in antibiotic use from pharmacist interventions after this PCT alert in patients on antibiotics for lower respiratory tract infections (LRTI). The secondary outcome was antibiotic days of therapy (DOT), with a subgroup analysis examining antibiotic use and the length of stay (LOS) in patients with a pharmacist intervention. From 1/2019 to 11/2019, there were 165 alerts in 116 unique patients on antibiotics for LRTI. Pharmacists attempted interventions after 34 (20.6%) of these alerts, with narrowing spectrum or converting to oral being the most common interventions. Pharmacist interventions prevented 125 DOT in the hospital. Vancomycin was the most commonly discontinued antibiotic with an 85.3% use reduction in patients with interventions compared to a 27.4% discontinuation in patients without documented intervention (p = 0.0156). The LOS was similar in both groups (median 6.4 days vs. 7 days, p = 0.81). In conclusion, interventions driven by a CDS tool for pharmacist-driven antimicrobial stewardship in patients with a normal PCT resulted in fewer DOT and significantly higher rates of vancomycin discontinuation.

The Effects of Neutrophil-Lymphocyte Ratio, Platelet-Lymphocyte Ratio and Prognostic Markers in Determining the Mortality in Patients Diagnosed With Pneumonia in Intensive Care

Objective

In this study, we aimed to reveal the level of predicting mortality of the Neutrophil/Lymphocyte (NLR) and Platelet/Lymphocyte Ratios (TLR) calculated in patients hospitalized with the diagnosis of pneumonia in the intensive care unit when compared with other prognostic scores.

Method

The hospital records of 112 patients who were admitted to the intensive care unit between January 2015 and January 2018 and met the inclusion criteria were retrospectively reviewed. The patients’ demographic data, the NLR and PLR levels, and the APACHE II (Acute Physiology and Chronic Health Evaluation II) and SOFA (Sequential Organ Failure Assessment) scores were calculated from the patient files.

Results

Of the 112 patients examined, 70 were males. The risk analysis showed that the male gender had 2.7 times higher risk of mortality. The NLR, PLR, APACHE II, and SOFA values were found statistically significant in predicting mortality (p<0.001). An evaluation of the risk ratios demonstrated that each one point increase in the NLR increased the mortality risk by 5%, and each one point increase in the SOFA score increased the mortality risk by 13% (p<0.05). In the ROC (receiver operating characteristic) analysis, the NLR assessment proved to be the most powerful, most specific, and sensitive test. The cut-off values were 11.3 for the NLR, 227 for the PLR, 29.8 for the APACHE II scores, and 5.5 for the SOFA scores

Conclusion

We believe that NLR and PLR are strong and independent predictors of mortality that can be easily and cost-effectively tested.

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.

Current Evidence and Limitation of Biomarkers for Detecting Sepsis and Systemic Infection

Sepsis was recently redefined as a life-threatening disease involving organ dysfunction caused by a dysregulated host response to infection. Biomarkers play an important role in early detection, diagnosis, and prognostication. We reviewed six promising biomarkers for detecting sepsis and systemic infection, including C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), CD64, presepsin, and sTREM-1. Among the recent studies, we found the following risks of bias: only a few studies adopted the random or consecutive sampling strategy; extensive case-control analysis, which worsened the over-estimated performance; most of the studies used post hoc cutoff values; and heterogeneity with respect to the inclusion criteria, small sample sizes, and different quantitative synthesis methods applied in meta-analyses. We recommend that CD64 and presepsin should be considered as the most promising biomarkers for diagnosing sepsis. Future studies should enroll a larger sample size with a cohort rather than a case-control study design. A random or consecutive study design with a pre-specified laboratory threshold, consistent sampling timing, and an updated definition of sepsis will also increase the reliability of the studies. Further investigations of appropriate specimens, testing assays, and cutoff levels for specific biomarkers are also warranted.

[Prevention and control of antimicrobial stewardship: a review of evidenceGestión de las intervenciones en materia de prevención y control de la resistencia a los antimicrobianos en los hospitales: revisión de la evidencia]

Objective

To identify effective interventions to manage antimicrobial resistance in hospital settings and potential barriers to their implementation.

Method

A synthesis of evidence for health policy was performed using SUPPORT tools. Literature searches were performed in November and December 2018 in 14 databases. A face-to-face deliberative dialogue workshop to identify implementation barriers was performed with 23 participants (manager, researchers, and health care professionals) and 14 listeners divided into three groups. Researchers with experience in deliberative dialogue acted as facilitators.

Results

Twenty-seven systematic reviews focusing on antimicrobial stewardship using combined or individual strategies were identified. The interventions included education, electronic systems, use of biomarkers, and several strategies of antimicrobial management. The main barriers to the implementation of interventions, identified in the literature and deliberative dialogue workshop, were poor infrastructure and insufficient human resources, patient complaints regarding the treatment received, cultural differences within the multidisciplinary team, work overload, and lack of financing/planning.

Conclusion

Most of the strategies identified were effective for antimicrobial stewardship in hospital settings. The reliability of results may be strengthened with the performance of additional research of higher methodological quality.

Biomarkers and newer laboratory investigations in the diagnosis of sepsis

Sepsis is a major cause of death in hospitalised patients accounting for mortality rates as high as 60% and, hence, is called 'a hidden public health disaster'. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis is not a disease but is a clinical syndrome, where the initial features are nonspecific resulting in delayed diagnosis. Lack of specific laboratory tests to diagnose the syndrome adds to the diagnostic confusion. Failure to identify sepsis in the early stages itself delays effective treatment resulting in high morbidity and mortality. Various biomarkers and newer laboratory tests help to address these issues. However, to date there is no ideal test to diagnose sepsis. The most commonly used markers are C-reactive protein (CRP) and procalcitonin (PCT). There are around 180 biomarkers reported to be useful in sepsis. In addition to CRP and PCT, various emerging laboratory markers, such as like serum amyloid A, soluble triggering receptor expressed on myeloid cell-1, mannan and antimannan antibodies, and interferon γ inducible protein-10 etc., have been reviewed and their clinical usefulness discussed in this paper.

Pancreatic Stone Protein Predicts Sepsis in Severely Burned Patients Irrespective of Trauma Severity: A Monocentric Observational Study

OBJECTIVE

The burn victim's inherent state of hyperinflammation frequently camouflages septic events delaying the initiation of targeted intensive care therapy. Accurate biomarkers are urgently needed to support sepsis detection before patients' clinical deterioration.

SUMMARY OF BACKGROUND DATA

Evidence on the usefulness of pancreatic stone protein (PSP) as a powerful diagnostic and prognostic marker in critically ill patients has recently accumulated.

METHODS

Analysis of biomarker kinetics (PSP, routine markers) was performed on 90 patients admitted to the Zurich Burn Center between May 2015 and October 2018 with burns ≥15% total body surface area with regard to infection and sepsis (Sepsis-3) over a 14-day time course.

RESULTS

PSP differentiated between sepsis, infection and sterile inflammation from day 3 onward with an area under the curve of up to 0.89 (P < 0.001), therefore, competing with procalcitonin (area under the curve = 0.86, P < 0.001). Compared to routine inflammatory biomarkers, only PSP demonstrated a significant interaction between time and presence of sepsis - signifying a steeper increase in PSP levels in septic patients as opposed to those exhibiting a nonseptic course (interaction P < 0.001). Event-related analysis demonstrated tripled PSP serum levels within 72 hours and doubled levels within 48 hours before a clinically apparent sepsis.

CONCLUSION

PSP is able to differentiate between septic and nonseptic patients during acute burn care. Its steep rise up to 72 hours before clinically overt deterioration has the potential for physicians to timely initiate treatment with reduced mortality and costs.

Biomarkers of Infection and Sepsis

The role of biomarkers for detection of sepsis has come a long way. Molecular biomarkers are taking front stage at present, but machine learning and other computational measures using bigdata sets are promising. Clinical research in sepsis is hampered by lack of specificity of the diagnosis; sepsis is a syndrome with no uniformly agreed definition. This lack of diagnostic precision means there is no gold standard for this diagnosis. The final conclusion is expert opinion, which is not bad but not perfect. Perhaps machine learning will displace expert opinion as the final and most accurate definition for sepsis.

Procalcitonin-guided antibiotic therapy in acute exacerbation of chronic obstructive pulmonary disease: An updated meta-analysis

BACKGROUND

The benefit of a procalcitonin (PCT)-guided antibiotic strategy in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) remains uncertain.

OBJECTIVES

This updated meta-analysis was performed to reevaluate the therapeutic potential of PCT-guided antibiotic therapy in AECOPD.

DATA SOURCES

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov up to February 2019 to identify randomized controlled trials (RCTs) investigating the role of PCT-guided antibiotic strategies in treating adult patients with AECOPD. Relative risk (RR) or mean differences (MD) with accompanying 95% confidence intervals (CIs) were calculated with a random-effects model.

RESULTS

Eight RCTs with a total of 1376 participants were included. The results suggested that a PCT-guided antibiotic strategy reduced antibiotic prescriptions (RR: 0.55; 95% CI: 0.39-0.76; P = .0003). However, antibiotic exposure duration (MD: -1.34; 95% CI: -2.83-0.16; P = .08), antibiotic use after discharge (RR: 1.61; 95% CI: 0.61-4.23; P = .34), clinical success (RR: 1.02; 95% CI: 0.96-1.08; P = .47), all-cause mortality (RR: 1.05; 95% CI: 0.72-1.55; P = .79), exacerbation at follow-up (RR: 0.97; 95% CI: 0.80-1.18; P = .78), readmission at follow-up (RR: 1.12; 95% CI: 0.82-1.53; P = .49), length of hospital stay (MD: -0.36; 95% CI: -1.36-0.64; P = .48), and adverse events (RR: 1.33; 95% CI: 0.79-2.23; P = .28) were similar in both groups.

IMPLICATIONS OF KEY FINDINGS

A PCT-guided antibiotic strategy is associated with fewer antibiotic prescriptions, and has similar efficacy and safety compared with standard antibiotic therapy in AECOPD patients.

Procalcitonin-Guided Antibiotic Discontinuation and Mortality in Critically Ill Adults: A Systematic Review and Meta-analysis

BACKGROUND

Procalcitonin (PCT)-guided antibiotic discontinuation appears to decrease antibiotic use in critically ill patients, but its impact on survival remains less certain.

METHODS

We searched PubMed, Embase, Scopus, Web of Science, and CENTRAL for randomized controlled trials (RCTs) of PCT-guided antibiotic discontinuation in critically ill adults reporting survival or antibiotic duration. Searches were conducted without language restrictions from inception to July 23, 2018. Two reviewers independently conducted all review stages; another adjudicated differences. Data were pooled using random-effects meta-analysis. Study quality was assessed with the Cochrane risk of bias tool, and evidence was graded using GRADEpro.

RESULTS

Among critically ill adults (5,158 randomized; 5,000 analyzed), PCT-guided antibiotic discontinuation was associated with decreased mortality (16 RCTs; risk ratio [RR], 0.89; 95% CI, 0.83-0.97; I2 = 0%; low certainty). Death was the primary outcome in only one study and a survival benefit was not observed in the subset specified as sepsis (10 RCTs; RR, 0.94; 95% CI, 0.85-1.03; I2 = 0%), those without industry sponsorship (nine RCTs; RR, 0.98; 95% CI, 0.87-1.10; I2 = 0%), high PCT-guided algorithm adherence (five RCTs; RR, 0.93; 95% CI, 0.71-1.22; I2 = 0%), and PCT-guided algorithms without C-reactive protein (eight RCTs; RR, 0.96; 95% CI, 0.87-1.06; I2 = 0%). PCT-guided antibiotic discontinuation decreased antibiotic duration (mean difference, 1.31 days; 95% CI, -2.27 to -0.35; I2 = 93%) (low certainty).

CONCLUSIONS

Our findings of increased survival and decreased antibiotic utilization associated with PCT-guided antibiotic discontinuation represent low-certainty evidence with a high risk of bias. This relationship was primarily observed in studies without high protocol adherence and in studies with algorithms combining PCT and C-reactive protein. Properly designed studies with mortality as the primary outcome are needed to address this question.

TRIAL REGISTRY

International Prospective Register of Systematic Reviews (PROSPERO); No.: CRD42016049715; URL: http://www.crd.york.ac.uk/PROSPERO_REBRANDING/display_record.asp?ID=CRD42016049715.

Individualising Therapy to Minimize Bacterial Multidrug Resistance

The scourge of antibiotic resistance threatens modern healthcare delivery. A contributing factor to this significant issue may be antibiotic dosing, whereby standard antibiotic regimens are unable to suppress the emergence of antibiotic resistance. This article aims to review the role of pharmacokinetic and pharmacodynamic (PK/PD) measures for optimising antibiotic therapy to minimise resistance emergence. It also seeks to describe the utility of combination antibiotic therapy for suppression of resistance and summarise the role of biomarkers in individualising antibiotic therapy. Scientific journals indexed in PubMed and Web of Science were searched to identify relevant articles and summarise existing evidence. Studies suggest that optimising antibiotic dosing to attain defined PK/PD ratios may limit the emergence of resistance. A maximum aminoglycoside concentration to minimum inhibitory concentration (MIC) ratio of > 20, a fluoroquinolone area under the concentration-time curve to MIC ratio of > 285 and a β-lactam trough concentration of > 6 × MIC are likely required for resistance suppression. In vitro studies demonstrate a clear advantage for some antibiotic combinations. However, clinical evidence is limited, suggesting that the use of combination regimens should be assessed on an individual patient basis. Biomarkers, such as procalcitonin, may help to individualise and reduce the duration of antibiotic treatment, which may minimise antibiotic resistance emergence during therapy. Future studies should translate laboratory-based studies into clinical trials and validate the appropriate clinical PK/PD predictors required for resistance suppression in vivo. Other adjunct strategies, such as biomarker-guided therapy or the use of antibiotic combinations require further investigation.

Sepsis Biomarkers

Sepsis-related biomarkers have a variety of potential applications. The most well-known application is to differentiate patients with signs of systemic inflammation caused by infection, from those with systemic inflammation due to a non-infectious cause. This application is important for timely and judicious prescription of antibiotics. Apart from diagnostic applications, biomarkers can also be used to identify patients with sepsis who are at risk for poor outcome and to subgroup patients with sepsis based on biological commonalities. The latter two applications embody the concepts of prognostic and predictive enrichment, which are fundamental to precision medicine. This review will elaborate on these concepts, provide relevant examples, and discuss important considerations in the process of biomarkers discovery and development.

[Inflammatory markers in diagnosis and prognosis of abdominal sepsis]

For today, it is necessary to recognize, that treatment of patients with abdominal sepsis remains the basic problem in urgent surgery due to the invariably high mortality. Early diagnostics and targeted therapy are the key points for improving of sepsis outcome. At present, researchers around the world have proposed a large number of biological markers for diagnosing sepsis and predicting mortality. Ideally, doctors can use biomarkers for risk stratification, diagnosing, monitoring of treatment effectiveness and outcome prediction. The biomarker is a laboratory parameter that can be objectively measured and characterized as an indicator of normal and pathological biological processes. The article presents the modern concept of the sepsis pathogenesis for understanding the role of various biomarkers and inflammatory indicators in its development. We have analyzed literature data and summarized information on the possible use of biological markers and their combinations in the early detection of sepsis, for monitoring sepsis and predicting its outcome.

Implementation of a Pragmatic Biomarker-Driven Algorithm to Guide Antibiotic Use in the Pediatric Intensive Care Unit: the Optimizing Antibiotic Strategies in Sepsis (OASIS) II Study

BACKGROUND

Biomarkers can facilitate safe antibiotic discontinuation in critically ill patients without bacterial infection.

METHODS

We tested the ability of a biomarker-based algorithm to reduce excess antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) without bacterial infections (uninfected) in our pediatric intensive care unit (PICU). The algorithm suggested that PICU clinicians stop antibiotics if (1) C-reactive protein <4 mg/dL and procalcitonin <1 ng/mL at SIRS onset and (2) no evidence of bacterial infection by exam/testing by 48 hours. We evaluated excess broad-spectrum antibiotic use, defined as administration on days 3-9 after SIRS onset in uninfected children. Incidence rate ratios (IRRs) compared unadjusted excess length of therapy (LOT) in the 34 months before (Period 1) and 12 months after (Period 2) implementation of this algorithm, stratified by biomarker values. Segmented linear regression evaluated excess LOT among all uninfected episodes over time and between the periods.

RESULTS

We identified 457 eligible SIRS episodes without bacterial infection, 333 in Period 1 and 124 in Period 2. When both biomarkers were below the algorithm's cut-points (n = 48 Period 1, n = 31 Period 2), unadjusted excess LOT was lower in Period 2 (IRR, 0.53; 95% confidence interval, 0.30-0.93). Among all 457 uninfected episodes, there were no significant differences in LOT (coefficient 0.9, P = .99) between the periods on segmented regression.

CONCLUSIONS

Implementation of a biomarker-based algorithm did not decrease overall antibiotic exposure among all uninfected patients in our PICU, although exposures were reduced in the subset of SIRS episodes where biomarkers were low.

Antibiotic therapy in the critically ill - expert opinion of the Intensive Care Medicine Scientific Subcommittee of the European Society of Anaesthesiology

Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.

Significant Publications on Infectious Diseases Pharmacotherapy in 2017

PURPOSE

The most significant peer-reviewed articles pertaining to infectious diseases (ID) pharmacotherapy, as selected by panels of ID pharmacists, are summarized.

SUMMARY

Members of the Houston Infectious Diseases Network (HIDN) were asked to nominate peer-reviewed articles that they believed most contributed to the practice of ID pharmacotherapy in 2017, including the areas of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). A list of 33 articles related to general ID pharmacotherapy and 4 articles related to HIV/AIDS was compiled. A survey was distributed to members of the Society of Infectious Diseases Pharmacists (SIDP) for the purpose of selecting 10 articles believed to have made the most significant impact on general ID pharmacotherapy and the single significant publication related to HIV/AIDS. Of 524 SIDP members who responded, 221 (42%) and 95 (18%) members voted for general pharmacotherapy- and HIV/AIDS-related articles, respectively. The highest ranked articles are summarized below.

CONCLUSION

Remaining informed on the most significant ID-related publications is a challenge when considering the large number of ID-related articles published annually. This review of significant publications in 2017 may aid in that effort.

Is Procalcitonin Useful in Pediatric Critical Care Patients?

This review examines the use of procalcitonin in different clinical situations in the pediatric patient, with special emphasis on those requiring intensive care. We review the latest articles on its potency as a biomarker in both infectious processes at diagnosis and on the response to treatment.

Diagnostic and prognostic properties of procalcitonin in patients with acute dyspnea: Data from the ACE 2 Study

BACKGROUND

Procalcitonin (PCT) concentrations increase during bacterial infections and could improve diagnosis of pneumonia and risk stratification in patients with acute dyspnea.

METHODS

PCT concentrations were measured <24 h of admission in 310 patients with acute dyspnea and compared to C-reactive protein (CRP) and white blood cells (WBC) in the total cohort and the subset of patients with concomitant acute heart failure (HF).

RESULTS

We diagnosed pneumonia in 16 out of 140 patients with acute HF (11%) and in 45 out of 170 patients with non-HF-related dyspnea (27%). PCT concentrations were higher in patients with pneumonia vs. patients without pneumonia, both among acute HF patients (median 2.79 [Q1-3 0.18-5.80] vs. 0.10 [0.07-0.14] ng/mL, p < .001) and non-HF patients (0.22 [Q1-3 0.13-0.77] vs. 0.07 [0.05-0.10] ng/mL, p < .001). CRP and WBC were also higher in patients with pneumonia in both groups, but among acute HF patients, only PCT concentrations were associated with pneumonia in multivariate analysis. In patients with acute HF, receiver-operating statistics area under the curve (ROC-AUC) to diagnose pneumonia was 0.90 (95% CI 0.81-0.98) for PCT, 0.84 (0.73-0.94) for CRP, and 0.72 (0.57-0.87) for WBC. The corresponding ROC-AUCs among patients with non-HF-related dyspnea were 0.88 (0.82-0.93), 0.94 (0.90-0.98), and 0.79 (0.72-0.87), respectively. During a median follow-up of 823 days (Q1-3 471-998) 114 patients died, and PCT and CRP, but not WBC concentrations were associated with all-cause mortality.

CONCLUSION

In acute HF patients, PCT concentrations were superior to CRP and WBC to diagnose concurrent pneumonia.

Adherence to a procalcitonin-guided antibiotic treatment protocol in patients with severe sepsis and septic shock

Background

In randomised controlled trials, procalcitonin (PCT)-guided antibiotic treatment has been proven to significantly reduce length of antibiotic therapy in intensive care unit (ICU) patients. However, concern was raised on low protocol adherence and high rates of overruling, and thus the value of PCT-guided treatment in real clinical life outside study conditions remains unclear. In this study, adherence to a PCT protocol to guide antibiotic treatment in patients with severe sepsis and septic shock was analysed.

Methods

From 2012 to 2014, surgical ICU patients with severe sepsis or septic shock were retrospectively screened for PCT measurement series appropriate to make treatment decisions on antibiotic therapy. We compared (1) patients with appropriate PCT measurement series to patients without appropriate series; (2) patients who reached the antibiotic stopping advice threshold (PCT < 0.5 ng/mL and/or decrease to 10% of peak level) to patients who did not reach a stopping advice threshold; and (3) patients who were treated adherently to the PCT protocol to non-adherently treated patients. The groups were compared in terms of antibiotic treatment duration, PCT kinetics, and other clinical outcomes.

Results

Of 81 patients with severe sepsis or septic shock, 14 were excluded due to treatment restriction or short course in the ICU. The final analysis was performed on 67 patients. Forty-two patients (62.7%) had appropriate PCT measurement series. In patients with appropriate PCT series, median initial PCT (p = 0.001) and peak PCT levels (p < 0.001) were significantly higher compared to those with non-appropriate series. In 26 patients with appropriate series, PCT levels reached an antibiotic stopping advice. In 8 of 26 patients with stopping advice, antibiotics were discontinued adherently to the PCT protocol (30.8%). Patients with adherently discontinued antibiotics had a shorter antibiotic treatment (7d [IQR 6–9] vs. 12d [IQR 9–16]; p = 0.002). No differences were seen in terms of other clinical outcomes.

Conclusion

In patients with severe sepsis and septic shock, procalcitonin testing was irregular and adherence to a local PCT protocol was low in real clinical life. However, adherently treated patients had a shorter duration of antibiotic treatment without negative clinical outcomes. Procalcitonin peak values and kinetics had a clear impact on the regularity of PCT testing.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0415-5) contains supplementary material, which is available to authorized users.

Role of Procalcitonin in the Management of Infected Patients in the Intensive Care Unit

The combination of molecular pathogen diagnostics and the biomarker procalcitonin (PCT) are changing the use of antimicrobials in patients admitted to critical care units with severe community-acquired pneumonia, possible septic shock, or other clinical syndromes. An elevated serum PCT level is good supportive evidence of a bacterial pneumonia, whereas a low serum PCT level virtually eliminates an etiologic role for bacteria even if the culture for a potential bacterial pathogen is positive. Serum PCT levels can be increased in any shocklike state; a low PCT level eliminates invasive bacterial infection as an etiology in more than 90% of patients.

Checking procalcitonin suitability for prognosis and antimicrobial therapy monitoring in burn patients

Background

Due to greater infection susceptibility, sepsis is the main cause of death in burn patients. Quick diagnosis and patient stratification, early and appropriated antimicrobial therapy, and focus control are crucial for patients' survival. On the other hand, superfluous extension of therapy is associated with adverse events and arousal of microbial resistance. The use of biomarkers, necessarily coupled with close clinical examination, may predict outcomes, stratifying patients who need more intensive care, and monitor the efficacy of antimicrobial therapy, allowing faster de-escalation or stop, reducing the development of resistance and possibly the financial burden, without increasing mortality. The aim of this work is to check the suitability of procalcitonin (PCT) to fulfill these goals in a large sample of septic burn patients.

Methods

One hundred and one patients, with 15% or more of total body surface area (TBSA) burned, admitted from January 2011 to December 2014 at Coimbra Burns Unit (CBU), in Portugal were included in the sample. All patients had a diagnosis of sepsis, according to the American Burn Association (ABA) criteria. The sample was factored by survival (68 survivors and 33 non-survivors). The maximum value of PCT in each day was used for statistical analysis. Data were summarized by location measures (mean, median, minimum, maximum, quartiles) and dispersion measures (standard error and range measures). Statistical analysis was performed with SPSS© 23.0 IBM© for Windows©.

Results

There were statistically significant differences between PCT levels of patients from the survivor and non-survivor groups during the first and the last weeks of hospitalization as well as during the first week after sepsis suspicion, being slightly higher during this period. During the first 7 days of antimicrobial therapy, PCT was always higher in the non-survivor, still without reaching statistical significance, but when the analysis was extended till the 15th day, PCT increased significantly, rapidly, and steadily, denouncing therapy failure.

Conclusion

Despite being not an ideal biomarker, PCT proved to have good prognostic power in septic burn patients, paralleling the evolution of the infectious process and reflecting the efficacy of antimicrobial therapy, and the inclusion of its serial dosing may be advised to reinforce antimicrobial stewardship programs at burn units; meanwhile, more accurate approaches are not available.

The use of mid-regional proadrenomedullin to identify disease severity and treatment response to sepsis - a secondary analysis of a large randomised controlled trial

Background

This study assessed the ability of mid-regional proadrenomedullin (MR-proADM) in comparison to conventional biomarkers (procalcitonin (PCT), lactate, C-reactive protein) and clinical scores to identify disease severity in patients with sepsis.

Methods

This is a secondary analysis of a randomised controlled trial in patients with severe sepsis or septic shock across 33 German intensive care units. The association between biomarkers and clinical scores with mortality was assessed by Cox regression analysis, area under the receiver operating characteristic and Kaplan-Meier curves. Patients were stratified into three severity groups (low, intermediate, high) for all biomarkers and scores based on cutoffs with either a 90% sensitivity or specificity.

Results

1089 patients with a 28-day mortality rate of 26.9% were analysed. According to the Sepsis-3 definition, 41.2% and 58.8% fulfilled the criteria for sepsis and septic shock, with respective mortality rates of 20.0% and 32.1%. MR-proADM had the strongest association with mortality across all Sepsis-1 and Sepsis-3 subgroups and could facilitate a more accurate classification of low (e.g. MR-proADM vs. SOFA: N = 265 vs. 232; 9.8% vs. 13.8% mortality) and high (e.g. MR-proADM vs. SOFA: N = 161 vs. 155; 55.9% vs. 41.3% mortality) disease severity. Patients with decreasing PCT concentrations of either ≥ 20% (baseline to day 1) or ≥ 50% (baseline to day 4) but continuously high MR-proADM concentrations had a significantly increased mortality risk (HR (95% CI): 19.1 (8.0–45.9) and 43.1 (10.1–184.0)).

Conclusions

MR-proADM identifies disease severity and treatment response more accurately than established biomarkers and scores, adding additional information to facilitate rapid clinical decision-making and improve personalised sepsis treatment.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2001-5) contains supplementary material, which is available to authorized users.