Biomarkers for sepsis: a review with special attention to India

Combining C-reactive protein and quick sequential organ failure assessment (qSOFA) to improve prognostic accuracy for sepsis and mortality in adult inpatients: A systematic review

Background and Aims

Infections are common in hospitals, and if mismanaged can develop into sepsis, a leading cause of death and disability worldwide. This study aimed to examine whether combining C-reactive protein (CRP) with the quick sequential organ failure assessment (qSOFA) improves its accuracy for predicting mortality and sepsis in adult inpatients.

Methods

PubMed, MEDLINE, EMBASE, Scopus, Web of Science, Science Direct, CINAHL, Open Grey, Grey Literature Report, and the Clinical Trials registry were searched using CRP and qSOFA search terms. Title, abstract, and full-text screening were performed by two independent reviewers using pre-determined eligibility criteria, followed by data extraction and a risk of bias assessment using the Quality Assessment tool for Diagnostic Accuracy Studies 2 (QUADAS-2). Disagreements were settled through discussion and consultation with a third reviewer.

Results

Four retrospective studies with a total of 2070 patients were included in this review. Adding CRP to qSOFA improved the Area Under the Receiver Operating Characteristic Curve up to 9.7% for predicting mortality and by 14.9% for identifying sepsis. The sensitivity and specificity of the combined score for mortality prediction were available in two studies. CRP improved the sensitivity of qSOFA by 43% and 71% while only decreasing the specificity by 12% and 7%, respectively. A meta-analysis was not performed due to study heterogeneity.

Conclusion

This comprehensive review provided initial evidence that combining CRP with qSOFA may improve the accuracy of qSOFA alone in identifying sepsis or patients at risk of dying in hospital. The combined tool demonstrated the potential to improve patient outcomes, with implications for low-resource settings given its simplicity and low-cost.

The Role of C-Reactive Protein and White Blood Cell Count as a Diagnostic, Prognostic, and Monitoring Markers in Bacterial Orofacial Infections

PURPOSE

1) To assess the efficacy of C reactive protein (CRP) and white blood cell count (WBC) levels as a diagnostic, prognostic, and monitoring tools for determining the severity of bacterial orofacial infections, length of hospital stay (LOS), and the effectiveness of treatment. 2) To evaluate the sensitivity and specificity of CRP and WBC as an inflammatory markers in bacterial orofacial infections.

METHODS

This prospective study included 30 patients. The predictor variables were serial readings of CRP and WBC that were correlated with clinical course of orofacial infection including severity of infection, length of hospital stay, and effectiveness of treatment. P value was set at (<.05).

RESULTS

The sample composed of 30 patients with a mean age of 26.7 years, 47% female. Predrainage CRP and WBC were significantly positive in predicting severity of infection and length of hospital stay. Predrainage CRP readings were elevated in 93% of patients whereas WBC predrainage readings were elevated in only 56% of patients with orofacial infections. Sensitivity and specificity of CRP are 87.5 and 68%, respectively while sensitivity and specificity of WBC are 62.6 and 86.4%, respectively.

CONCLUSION

The results of this study suggest that CRP and WBC are useful diagnostic and prognostic, as well as monitoring, tools in bacterial orofacial infections CRP being more sensitive than WBC.

A systematic review of biomarkers associated with maternal infection in pregnant and postpartum women

BACKGROUND

Serum biomarkers are commonly used to support the diagnosis of infection in non-pregnant patients whose clinical presentation suggests infection. The utility of serum biomarkers for infection in pregnant and postpartum women is uncertain.

SEARCH STRATEGY

PubMed, CINAHL, EMBASE, ClinicalTrials.gov, Cochrane Library, CINAHL, and SCOPUS were searched from inception to February 2020.

SELECTION CRITERIA

Full-text manuscripts in English were included if they reported the measurement of maternal serum biomarkers-and included a control group-to identify infection in pregnant and postpartum women.

DATA COLLECTION AND ANALYSIS

two authors independently screened manuscripts, extracted data, and assessed methodologic quality.

MAIN RESULTS

Interleukin-6 (IL-6), C-reactive protein, procalcitonin, insulin-like growth factor binding protein 1, tumor necrosis factor-α, calgranulin B, neopterin, and interferon-γ inducible protein 10 reliably indicated infection. Intercellular adhesion molecule 1, monocyte chemotactic and activating factor, soluble IL-6 receptor, and IL-8 were not useful markers in pregnant and postpartum women.

CONCLUSIONS

Findings suggest that certain biomarkers have diagnostic value when maternal infection is suspected, but also confirms limitations in this population.

Considering the Effect of Rosa damascena Mill. Essential Oil on Oxidative Stress and COX-2 Gene Expression in the Liver of Septic Rats

OBJECTIVES

Sepsis is a clinical illness with a high rate of mortality all over the world. Oxidative stress is considered the main phenomenon that occurs in sepsis. Rosa damascena Mill. is an ancient herbal plant with high pharmacological activities.

MATERIALS AND METHODS

Cecal ligation and puncture (CLP) as a standard model was used to induce sepsis in rats. Male adult rats were randomly divided into 5 groups. Different doses of R. damascena essential oil (50 and 100 mg/kg.bw) were gavaged orally for 14 days and on day 15 CLP was performed. After 24 h, blood samples and liver tissues were removed in order to measure oxidative stress [myeloperoxidase (MPO), malondialdehyde (MDA), glutathione (GSH), glutathione-S-transferase, and ferric reducing ability of plasma (FRAP)] and biochemical parameters [alkaline phosphatase (ALP), aspartate transaminase (AST), alanine transaminase (ALT), and bilirubin] together with plasma prostaglandin E2 (PGE2) and COX-2 expression.

RESULTS

The essential oil was capable of modulating all of the oxidative stress, antioxidant, and anti-inflammatory parameters induced by CLP as characterized by elevations in MPO and MDA levels as well as increases in AST and ALT concentrations concomitant with PGE2 and COX-2 increments. The antioxidant defense system such as GSH and FRAP was also increased in the essential oil treated groups.

CONCLUSION

Our results showed that the essential oil has antioxidative and hepatoprotective activities through reducing the oxidative injury in sepsis caused by CLP.

The Pathogenesis of Sepsis and Potential Therapeutic Targets

Sepsis is defined as “a life-threatening organ dysfunction caused by a host’s dysfunctional response to infection”. Although the treatment of sepsis has developed rapidly in the past few years, sepsis incidence and mortality in clinical treatment is still climbing. Moreover, because of the diverse manifestations of sepsis, clinicians continue to face severe challenges in the diagnosis, treatment, and management of patients with sepsis. Here, we review the recent development in our understanding regarding the cellular pathogenesis and the target of clinical diagnosis of sepsis, with the goal of enhancing the current understanding of sepsis. The present state of research on targeted therapeutic drugs is also elaborated upon to provide information for the treatment of sepsis.

Hepatic and Renal Biochemical Markers as Predictors of Mortality Among Critically Ill Systemic Inflammatory Response Syndrome Patients

Systemic inflammatory response syndrome (SIRS) is a frequently encountered complication seen in intensive care unit patients and remains a common cause of mortality. Assessing prognosis of those becomes a priority and indeed we have various efficient scoring systems for the same. However they use enormous data and involve complex calculations for scoring. We intended to find a simple, inexpensive, accurate diagnostic tool of certain markers to predict mortality outcome among critically ill SIRS patients and to evaluate their efficiency in comparison to Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system. Eighty-seven patients were selected and general hepatic, renal and urinary investigations were done for them at 24 h of admission and were followed up for a period of 4 weeks from admission date to classify them as survivors and non-survivors. Twenty-one percent patients had succumbed to death during study period. Urine albumin-creatinine ratio, alanineaminotransferase, aspartate aminotransferase and prothrombin time/International Normalized Ratio were found to be correlating with APACHE II scores and mortality significantly. Specific individual cut-offs were found for these parameters and were combined to form combined predictors which showed good discrimination (AUC = 0.715) and good calibration (p = 0.811) with specificity of 98.6% in predicting mortality. SIRS patients falling above combined predictor's cutoff are 54 times more likely to have an unfavorable outcome compared to the ones below. Overall predictive accuracy of first day combined predictors was such that within 24 h of ICU admission 87% of ICU SIRS admissions could be given a risk estimate for hospital death.

Comparison of serum procalcitonin level with erythrocytes sedimentation rate, C-reactive protein, white blood cell count, and blood culture in the diagnosis of bacterial infections in patients hospitalized in Motahhari hospital of Urmia (2016)

Blood infection is one of the causes of morbidity in hospitalized patients. While some scholars have identified procalcitonin (PCT) as a potential biomarker for the diagnosis of blood infection, others have questioned its diagnostic value. Thus, the present study was conducted to compare the diagnostic values of PCT with C-reactive protein (CRP), erythrocytes sedimentation rate (ESR), white blood cell (WBC) count, and blood culture in patients with bacterial blood infections. In a prospective case–control study, 45 septic patients (6 months–5 years old), who were hospitalized in Shahid Motahhari Hospital of Urmia over the year 2016 and 45 patients with noninfectious diseases, whose gender and age range were similar to the members of the septic group, were examined. The participants’ blood samples were taken for the sake of blood culture and measurement of PCT level, ESR, and CRP. Finally, the collected data were analyzed through the SPSS-21 software. the results indicated that the average PCT, ESR, CRP, and WBC count was significantly higher in septic patients. Moreover, the blood culture of patients with negative or intermediate serum PCT levels was negative, while 50% of blood culture results in patients with positive PCT were positive and the rest were negative. Finally, a significant relationship was detected between the frequency of blood culture results and results of serum PCT tests (P = 0.003). serum PCT level can be considered a diagnostic marker of bacterial infections. If used in conjunction with tests of CRP, ESR, and WBC count, the PCT test can enhance the diagnosis of bacterial infections.

Inflammatory Cytokine and Chemokine Patterns in Paediatric Patients with Suspected Serious Bacterial Infection

Background and objectives: In children, acute infection is the most common cause of visits to the emergency department. Although most of them are self-limiting, mortality due to severe bacterial infections (SBI) in developed countries is still high. When the risk of serious bacterial infection is too high to ignore, yet too low to justify admission and hospital observation, clinicians try to improve diagnostic accuracy by performing various laboratory tests. The aim of the study was to investigate whether an early inflammatory cytokine and chemokine panel can add information in diagnostics of SBI and assessment of efficacy of early therapies in hospitalized children with fever. Methods: This study included 51 children with febrile infections that were admitted to the emergency department (ED). Clinical examination and microbiological and radiological tests were used as reference standards for the definition of SBI. Study population was categorized into two groups: (1) patients with SBI (n = 21); (2) patients without SBI (n = 30). Inflammatory cytokine and chemokine panels were analyzed from the first routine blood samples at hospital admission and after 24 h. Results: Out of 12 cytokines and chemokines, only Eotaxin and granulocyte colony-stimulating factor (G-CSF) had statistically significant differences between groups at the time of inclusion. Receiver operator characteristic analysis to predict SBI showed an area under the curve (AUC) of 0.679 for G-CSF. Conclusions: Analysis of inflammatory cytokine profiles may provide additional information in early diagnostics of SBI.

Inflammatory cytokine expression in patients with sepsis at an intensive care unit

Sepsis is a systemic inflammatory response syndrome caused by infection of bacteria, fungi and/or viruses in clinical patients. It is known that inflammatory cytokine levels have an essential role in the progression of sepsis. The present study investigated the role of inflammatory markers in human peripheral blood mononuclear cells (hPBMCs) of patients with sepsis at an intensive care unit. In addition, the plasma levels of inflammatory cytokines were compared between sepsis patients and healthy individuals. The results demonstrated that the serum levels of interleukin-1, -17 and -6, as well as tumor necrosis factor-α, were upregulated in sepsis patients. The serum levels of high mobility group box 1 and C-reactive protein were increased in sepsis patients compared with those in healthy individuals. The expression levels of nuclear factor-κB-p65 and its inhibitor IκBα, as well as the ratio of CD25⁺ cells, and the levels of neutrophil gelatinase-associated lipocalin and peptidoglycan recognition protein were higher in hPBMCs in sepsis patients compared with those in healthy individuals. It was also indicated that balance of T helper type 1/2 cytokines was also disturbed in patients with sepsis compared with that in healthy individuals. In conclusion, these results indicated that inflammation is involved in the progression of sepsis by interfering with the expression of various molecules, suggesting a potential therapeutic strategy for the treatment of sepsis patients.

Predictive efficacy of procalcitonin, platelets, and white blood cells for sepsis in pediatric patients undergoing cardiac surgeries who are admitted to intensive care units: Single-center experience

Background:

Sepsis is one of the major contributor of morbidity and mortality in pediatric cardiac surgeries.

Aim:

The aim of this study was to compare the predictive efficacy of total leukocyte counts (TC), platelet count (PC), and procalcitonin (PCT) for sepsis in patients undergoing cardiac surgeries who are admitted to the Intensive Care Unit.

Materials and Methods:

This prospective, single-center study included 300 neonates, infants, and pediatric patients who had undergone various open heart surgeries at our center from September 2014 to November 2015.

Results:

Overall, the incidence of sepsis was 14% in pediatric patients undergoing cardiac surgeries. TC of postoperative 48 h were significantly lower (11889.19 ± 5092.86 vs. 14583.22 ± 6562.96; P = 0.004) in septic patients. The low levels of platelets on postoperative 24 h and 72 h were observed in patients with sepsis as compared to patients without sepsis, whereas the levels of PCT at various time intervals (preoperative, postoperative - 24 h, 48 h, and 72 h) had shown no association with sepsis in the study population. Low PC (24 h) was the strongest predictor of sepsis showing an odds ratio of 1.9 (95% confidence interval [CI]: 1.42–3.51; P = 0.001) and area under curve of 0.688 with 95% CI of 0.54–0.83 (P = 0.018).

Conclusion:

We may conclude that in Indian pediatric population platelet levels are highly associated with sepsis as compared to any other hematological parameter. The immediate postoperative level of platelet is the strongest predictor of sepsis and could be effectively used in the clinical settings.

The role of C-reactive protein as a diagnostic predictor of sepsis in a multidisciplinary Intensive Care Unit of a tertiary care center in Nepal

Aim:

C-reactive protein (CRP) is a commonly used biomarker of sepsis, the leading cause of mortality in Intensive Care Units (ICUs). However, sufficient data are still lacking to strongly recommend it in clinical practice. The present study is aimed to find out its reliability in diagnosing sepsis.

Materials and Methods:

CRP was measured in ICU-admitted patients with systemic inflammatory response syndrome and compared using a cutoff of 50 mg/L with the gold standard for diagnosing sepsis, taken as isolation of organism from a suspected source of infection or the Centers for Disease Control criteria for clinical sepsis.

Results:

CRP had a sensitivity and specificity of 84.3% and 46.15%, respectively. Area under the receiver operating characteristics curve was calculated to be 0.683 (±0.153, P < 0.05). The cutoff value with the best diagnostic accuracy was found to be 61 mg/L.

Conclusion:

CRP is a sensitive marker of sepsis, but it is not specific.

Could Neutrophil CD64 Expression Be Used as a Diagnostic Parameter of Bacteremia in Patients with Febrile Neutropenia?

OBJECTIVE

The aim of this study is to investigate if neutrophil CD64 expression in febrile neutropenia patients could be used as an early indicator of bacteremia.

MATERIALS AND METHODS

All consecutive patients older than 18 years of age who had developed febrile neutropenia episodes due to hematological malignancies were included in the study. Those patients who had significant growth in their blood cultures constituted the case group, while those who had febrile neutropenia without any growth in their cultures and who did not have any documented infections formed the control group. Blood culture bottles were incubated in the Bact ALERT 3D system (bioMerieux, France), identification and susceptibility testing were performed using an automated broth microdilution method (VITEK 2, bioMerieux), and CD64 expression analysis was performed by the flow cytometry method. C-reactive protein (CRP) was measured by turbidimetric methods (Biosystems, Spain) and erythrocyte sedimentation rate (ESR) was measured by the Wintrobe method.

RESULTS

In total, we prospectively evaluated 31 febrile episodes. The case group consisted of 17 patients while the control group included 14 patients. CD64 was found on neutrophils of the case group patients with a mean count of 8006 molecules/cell and of control group with a mean count of 2786 molecules/cell. CD64 levels of the case group were significantly higher than those of the control group (p=0.005). In the differentiation of the case group from the control group, a 2500 cut-off value for CD64 had significant [AUC=0.792 (0.619-0.965)] predictive value (p=0.001). In the prediction of patients with a 2500 cut-off value for CD64, sensitivity was 94.1%, positive predictive value was 76.2%, specificity was 64.3%, and negative predictive value was 90.0%. CRP levels and ESR values did not differ significantly between the groups (p=0.005).

CONCLUSION

Neutrophil CD64 expression could be a good predictor as an immune parameter with high sensitivity and a negative predictive value for bacteremia in febrile neutropenic patients.

The emerging role of miR-223 as novel potential diagnostic and therapeutic target for inflammatory disorders

Since their discovery of more than a decade ago, microRNAs have been demonstrated to have profound effects on almost every aspect of biology. Specific microRNAs have emerged as key players in disease biology by playing crucial role in disease development and progression. This review draws attention to miR-223 that has been reported to be abnormally expressed in several diseases like diabetes-type2, sepsis, rheumatoid arthritis, viral infections likes' human immunodeficiency virus-1 (HIV-1) and inflammatory disorders. It regulates inflammation by targeting different targets, including cytoplasmic activation/proliferation-associated protein-1 (Caprin-1), Insulin-like growth factor-1 receptor (IGF-1R), heat shock protein 90 (Hsp90), STAT5, artemin, EPB41L3, Ect2, Pknox1, C/EBPα, C/EBPβ, E2F1, FOXO1, NFI-A and other transcription factors. In this review, we summarized the recent studies of miR-223, their mechanisms to develop inflammation diseases and its importance role to use as biomarkers for early diagnosis and therapeutic target against inflammation diseases.

Procalcitonin levels in salmonella infection

Aim:

Procalcitonin (PCT) as a diagnostic marker for bacteremia and sepsis has been extensively studied. We aimed to study PCT levels in Salmonella infections whether they would serve as marker for early diagnosis in endemic areas to start empiric treatment while awaiting blood culture report.

Materials and Methods:

BACTEC blood culture was used to isolate Salmonella in suspected enteric fever patients. Serum PCT levels were estimated before starting treatment.

Results:

In 60 proven enteric fever patients, median value of serum PCT levels was 0.22 ng/ml, values ranging between 0.05 and 4 ng/ml. 95% of patients had near normal or mild increase (<0.5 ng/ml), only 5% of patients showed elevated levels. Notably, high PCT levels were found only in severe sepsis.

Conclusion:

PCT levels in Salmonella infections are near normal or minimally increased which differentiates it from other systemic Gram-negative infections. PCT cannot be used as a specific diagnostic marker of typhoid.

Risk Stratification of Necrotizing Fasciitis Based on the Initial Procalcitonin Concentration: A Single Center Observational Study

BACKGROUND

Necrotizing fasciitis (NF) is a potentially fatal subcutaneous tissue and fascia infection. We studied the role of serum procalcitonin in the identification and assessment of severity of sepsis in patients with NF.

METHODS

A retrospective analysis was conducted from January 2000 to December 2013 for all patients who admitted to surgical intensive care with provisional diagnosis of NF. Patients were categorized into four groups based on the initial procalcitonin concentrations (Group I: <0.5 low risk, Group II: ≥0.5-<2 moderate risk, Group III: ≥2-<10 high risk, and Group IV: ≥10 ng/mL high likelihood of severe sepsis).

RESULTS

During the study period, 331 cases were identified to have NF with a mean age of 51 ± 14 years. Serum procalcitonin was tested in 62 cases (only between 2011 and December 2013) and all were positive (Group I: 22%, Group II: 18%, Group III: 21%, and Group IV: 39%). The most common affected regions were thigh and chest in Group II (46% and 9%, respectively), lower limbs in Group III (46%), and perineum and abdomen in Group IV (25% and 21%, respectively). In the four groups, 21 patients developed septic shock (Group I: 0%, Group II: 14%, Group III: 24%, and Group IV: 62%). The cut off procalcitonin value for septic shock was 5.6 ng/mL. Using receiver-operating characteristic curve, this cut off with the Area under the Curve (AUC) of 0.77 was found to have sensitivity 81% and specificity 67%. Sequential Organ Failure Assessment (SOFA) score was substantially greater in Group III and Group IV in comparison to Group I and Group II, p = 0.006. Procalcitonin levels were correlated well with SOFA score (r = 0.34, p = 0.007). There were 17 deaths in the four groups (Group I: 6%, Group II: 23%, Group III: 12%, and Group IV: 59%).

CONCLUSION

Initial procalcitonin concentration in NF carries an important prognostic value and it correlates well with SOFA score and can predict the development of septic shock early in patients with NF.

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.

Sepsis induced by Staphylococcus aureus: participation of biomarkers in a murine model

BACKGROUND

This study aimed to evaluate the role of biomarkers in the pathophysiological process induced by a Staphylococcus aureus strain obtained in a hospital environment. For this, we intraperitoneally inoculated groups of male BALB/c mice with S. aureus, using a clinical isolate (CI) of S. aureus.

MATERIAL/METHODS

Mice were divided into groups according to time of euthanasia (24, 48, 72, 96, 120, 144, and 168 hours of infection). After being euthanized, blood samples were collected for quantification of microorganisms and leukocytes, as well as measurement of biomarkers of tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), C-reactive protein (CRP), and Procalcitonin (PCT) by ELISA. Heart, kidneys, and lungs were removed for histopathological analysis, assessment of biomarkers of tissue expression by RT-PCR (polymerase chain reaction with reverse transcriptase), and quantification of microorganisms by real-time quantitative PCR (real-time PCR).

RESULTS

The animals infected at between 120 hours and 168 hours had the highest blood levels of S. aureus. We observed that infection promoted increases in the levels of circulating neutrophils and monocytes. However, there was a reduction of circulating neutrophils and monocytes after 96 hours of infection. The infected mice also had increased levels of blood lymphocytes. In this model of infection with S. aureus, IL-6, CRP, and PCT demonstrated greater fidelity as markers of infection, since serum levels were elevated and lowered along with the number of circulating neutrophils and monocytes after resolution of the infection. The lungs showed hyperemia, with enlargement of the alveolar septa. On the other hand, infection with S. aureus did not promote visible change in histological tissue in the heart and kidneys.

CONCLUSIONS

In this model of infection with S. aureus, IL-6, CRP, and PCT demonstrated greater fidelity as markers of infection, since serum levels were elevated and lowered along with the number of circulating neutrophils and monocytes after resolution of the infection. We believe our results may provide a better understanding of the pathophysiology, as well as aid in the search for a more reliable method of diagnosis.