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Chen YJ, Hou MC, Yang TC, Lee PC, Wang YP, Huang YH, Lee FY. Effectiveness of betadine-coating gastrostomy tube to reduce peristomal infection after percutaneous endoscopic gastrostomy: a randomized controlled trial. BMC Gastroenterol 2023; 23:155. [PMID: 37189057 DOI: 10.1186/s12876-023-02702-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/27/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Peristomal wound infection is a common complication in patients receiving percutaneous endoscopic gastrostomy (PEG). The main reason for peristomal infection might be the oral microbes coating the gastrostomy tube during implantation. Povidone-iodine solution can be applied for skin and oral decontamination. We designed a randomized controlled trial to test the effectiveness of a Betadine® (povidone-iodine) coated gastrostomy tube to reduce peristomal infection after percutaneous endoscopic gastrostomy. METHODS A total of 50 patients were randomized to Betadine and control groups (25 patients in each group) from April 2014 to August 2021 at a tertiary medical center. All patients received the pull method for PEG implantation using a 24-french gastrostomy tube. The primary endpoint was peristomal wound infection rate 2 weeks after the procedure. RESULTS Changes in Neutrophil/Lymphocyte ratio (N/L ratio) and C-Reative protein (Delta CRP) at 24 h after PEG were higher in the control group than in the Betadine group (N/L ratio, 3.1 vs. 1.2, p = 0.047; CRP, 2.68 vs.1.16, p = 0.009). The two groups did not differ in post-PEG fever, peristomal infection, pneumonia, or all-cause infection. Delta CRP could predict peristomal infection and all-cause infection within 2 weeks (AUROC 0.712 vs. 0.748; p = 0.039 vs. 0.008). The best cut-off-point of Delta CRP for the diagnosis of peristomal wound infection was 3 mg/dl. CONCLUSION The betadine coating gastrostomy tube method could not reduce peristomal infection after percutaneous endoscopic gastrostomy. CRP elevation of less than 3 mg/dl may be used to exclude the potential peristomal wound infection. TRIAL REGISTRATION NCT04249570 ( https://clinicaltrials.gov/ct2/show/NCT04249570 ).
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Affiliation(s)
- Yu-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei 112, Taipei, Taiwan
- National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei 112, Taipei, Taiwan.
- National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan, ROC.
| | - Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei 112, Taipei, Taiwan
- National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei 112, Taipei, Taiwan
- National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Yen-Po Wang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei 112, Taipei, Taiwan
- National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Endoscopy Center For Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei 112, Taipei, Taiwan
- National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Fa-Yauh Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei 112, Taipei, Taiwan
- National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan, ROC
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2
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Athan S, Athan D, Wong M, Hussain N, Vangaveti V, Gangathimmaiah V, Norton R. Pathology stewardship in emergency departments: a single-site, retrospective, cohort study of the value of C-reactive protein in patients with suspected sepsis. Pathology 2023:S0031-3025(23)00118-6. [PMID: 37248118 DOI: 10.1016/j.pathol.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/09/2023] [Accepted: 03/07/2023] [Indexed: 05/31/2023]
Abstract
Increasing awareness of the importance of pathology stewardship in reducing low value care has led to scrutiny of appropriate laboratory test ordering. The objective of this study is to investigate the value of a commonly ordered laboratory test, the C-reactive protein (CRP), in decisions regarding diagnosis, management and disposition of emergency department (ED) patients with suspected sepsis. Retrospective chart reviews were performed on 1716 adult patients with suspected sepsis presenting to the Townsville University Hospital ED between 1 January 2021 and 30 June 2021. Suspected sepsis was defined as the emergency clinicians' decision to perform a blood culture. A CRP value of 10 mg/L or higher was defined as an elevated CRP. The primary outcome of interest was commencement of antibiotics in ED. Secondary outcomes include hospital admission (ward and ICU), hospital length of stay, mortality, documentation of indication for CRP testing, test parameters of CRP in detecting culture-positive bacteraemia and rates of bacteraemia with presumptive ED diagnosis. This study found no significant association between CRP values and antibiotic commencement (p=0.222), ward admission (p=0.071), ICU admission (p=0.248), hospital length of stay (p=0.164) or mortality (p=1.000). CRP had an area under the curve of 0.58 (95% CI 0.51-0.66) for detecting culture-positive bacteraemia. Sensitivity and specificity of CRP were 62.5% and 47.7%, respectively, at a threshold of 46 mg/dL. CRP testing is of little value in ED patients with suspected sepsis as it does not influence decision making about diagnosis, management, or disposition. Avoiding CRP testing in this patient cohort can contribute to pathology stewardship and optimal use of finite healthcare resources.
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Affiliation(s)
| | - David Athan
- Townsville University Hospital, Douglas, Qld, Australia
| | - Michael Wong
- Townsville University Hospital, Douglas, Qld, Australia
| | - Nurul Hussain
- Townsville University Hospital, Douglas, Qld, Australia
| | - Venkat Vangaveti
- Townsville University Hospital, Douglas, Qld, Australia; College of Medicine and Dentistry, James Cook University, Douglas, Qld, Australia
| | - Vinay Gangathimmaiah
- Townsville University Hospital, Douglas, Qld, Australia; College of Medicine and Dentistry, James Cook University, Douglas, Qld, Australia
| | - Robert Norton
- Townsville University Hospital, Douglas, Qld, Australia
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3
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Niemantsverdriet MSA, de Hond TAP, Hoefer IE, van Solinge WW, Bellomo D, Oosterheert JJ, Kaasjager KAH, Haitjema S. A machine learning approach using endpoint adjudication committee labels for the identification of sepsis predictors at the emergency department. BMC Emerg Med 2022; 22:208. [PMID: 36550392 PMCID: PMC9784058 DOI: 10.1186/s12873-022-00764-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Accurate sepsis diagnosis is paramount for treatment decisions, especially at the emergency department (ED). To improve diagnosis, clinical decision support (CDS) tools are being developed with machine learning (ML) algorithms, using a wide range of variable groups. ML models can find patterns in Electronic Health Record (EHR) data that are unseen by the human eye. A prerequisite for a good model is the use of high-quality labels. Sepsis gold-standard labels are hard to define due to a lack of reliable diagnostic tools for sepsis at the ED. Therefore, standard clinical tools, such as clinical prediction scores (e.g. modified early warning score and quick sequential organ failure assessment), and claims-based methods (e.g. ICD-10) are used to generate suboptimal labels. As a consequence, models trained with these "silver" labels result in ill-trained models. In this study, we trained ML models for sepsis diagnosis at the ED with labels of 375 ED visits assigned by an endpoint adjudication committee (EAC) that consisted of 18 independent experts. Our objective was to evaluate which routinely measured variables show diagnostic value for sepsis. We performed univariate testing and trained multiple ML models with 95 routinely measured variables of three variable groups; demographic and vital, laboratory and advanced haematological variables. Apart from known diagnostic variables, we identified added diagnostic value for less conventional variables such as eosinophil count and platelet distribution width. In this explorative study, we show that the use of an EAC together with ML can identify new targets for future sepsis diagnosis research.
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Affiliation(s)
- Michael S. A. Niemantsverdriet
- grid.7692.a0000000090126352Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Room Number G03.551, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands ,SkylineDx, Rotterdam, The Netherlands
| | - Titus A. P. de Hond
- grid.7692.a0000000090126352Department of Internal Medicine and Acute Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Imo E. Hoefer
- grid.7692.a0000000090126352Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Room Number G03.551, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Wouter W. van Solinge
- grid.7692.a0000000090126352Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Room Number G03.551, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | | | - Jan Jelrik Oosterheert
- grid.7692.a0000000090126352Department of Internal Medicine, Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Karin A. H. Kaasjager
- grid.7692.a0000000090126352Department of Internal Medicine and Acute Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Saskia Haitjema
- grid.7692.a0000000090126352Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Room Number G03.551, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Brajkovic D, Zjalic S, Aleksandar K. Evaluation of clinical parameters affecting the prognosis in surgically treated patients with descending necrotizing mediastinitis - A retrospective study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e731-e737. [PMID: 35580784 DOI: 10.1016/j.jormas.2022.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Descending necrotizing mediastinitis (DNM) is the most serious complication of maxillofacial infections followed with high mortality. The objective of this retrospective study was to evaluate possible prognostic clinical factors for survival of patients with DNM based on single center clinical data. METHODS The study enrolled patients admitted to the Emergency Center of Vojvodina with the diagnosis of DNM either as the primary diagnosis or with discharged diagnosis after surgical treatment during 11-years period. The data were obtained from patient medical records. RESULTS After final analysis total of 28 charts were randomized for statystical analysis, 19 charts in survivors and 9 in non-survivors group. The most common cause of infection in survivors group was odontogenic and in non-survivors group pharyngeal infection. On multivariate regression analysis of collected data results of control computed tomography, preoperative Endo status, early postoperative C-reactive protein (CRP) and procalcitonine (PCT) values and postoperative complications were statistically significant predictors for mortality. CONCLUSIONS Based on results of this study, extent of infection in the mediastinum based on Endo's criteria, progression of infection on control cervicothoracic CT, increase of CRP and PCT values in immediate postoperative period and presence of postoperative complications and septic shock provide poor prognosis for patients with DNM.
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Affiliation(s)
- Denis Brajkovic
- Clinical Center of Vojvodina, Clinic for Maxillofacial and Oral Surgery, Novi Sad, Serbia; University of Novi Sad, Faculty of medicine, Department for dentistry and maxillofacial surgery, Novi Sad, Serbia.
| | - Severina Zjalic
- Clinical Center of Vojvodina, Clinic for Anesthesiology, intensive care and pain management, Novi Sad, Serbia
| | - Kiralj Aleksandar
- Clinical Center of Vojvodina, Clinic for Maxillofacial and Oral Surgery, Novi Sad, Serbia; University of Novi Sad, Faculty of medicine, Department for dentistry and maxillofacial surgery, Novi Sad, Serbia
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5
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Manandhar S, Scott-Thomas A, Harrington M, Sinha P, Pilbrow A, Richards AM, Cameron V, Bhatia M, Chambers ST. Hydrogen Sulfide and Substance P Levels in Patients with Escherichia coli and Klebsiella pneumoniae Bacteraemia. Int J Mol Sci 2022; 23:ijms23158639. [PMID: 35955767 PMCID: PMC9368963 DOI: 10.3390/ijms23158639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 02/07/2023] Open
Abstract
Hydrogen sulfide (H2S) and substance P (SP) are known from animal models and in vitro studies as proinflammatory mediators. In this study, peripheral blood concentrations of H2S and SP were measured in patients with Escherichia coli or Klebsiella pneumoniae bacteraemia. Fifty patients were recruited from general wards at Christchurch Hospital, during 2020–2021. Samples from age- and sex-matched healthy subjects previously recruited as controls for studies of cardiovascular disease were used as controls. The concentrations of H2S were higher than controls on day 0, day 1, and day 2, and SP was higher than controls on all 4 days. The concentrations of H2S were highest on day 0, whereas SP concentrations were higher on day 2 than other days. Interleukin-6 and C-reactive protein were significantly higher on day 0 and day 1, respectively. The concentrations of H2S and SP did not differ between 15 non-septic (SIRS 0-1) and the 35 septic subjects (SIRS ≥ 2). Substance P concentrations were higher in subjects with abdominal infection than urinary tract infections on day 0 (p = 0.0002) and day 1 (p = 0.0091). In conclusion, the peak H2S concentrations precede the SP peak in patients with Gram-negative bacteraemia, but this response varies with the site of infection.
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Affiliation(s)
- Sumeet Manandhar
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8140, New Zealand; (S.M.); (A.S.-T.); (P.S.); (S.T.C.)
| | - Amy Scott-Thomas
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8140, New Zealand; (S.M.); (A.S.-T.); (P.S.); (S.T.C.)
| | - Michael Harrington
- Microbiology Department, Canterbury Health Laboratories, Christchurch 8140, New Zealand;
| | - Priyanka Sinha
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8140, New Zealand; (S.M.); (A.S.-T.); (P.S.); (S.T.C.)
| | - Anna Pilbrow
- Department of Medicine, University of Otago, Christchurch 8140, New Zealand; (A.P.); (A.M.R.); (V.C.)
| | - Arthur Mark Richards
- Department of Medicine, University of Otago, Christchurch 8140, New Zealand; (A.P.); (A.M.R.); (V.C.)
| | - Vicky Cameron
- Department of Medicine, University of Otago, Christchurch 8140, New Zealand; (A.P.); (A.M.R.); (V.C.)
| | - Madhav Bhatia
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8140, New Zealand; (S.M.); (A.S.-T.); (P.S.); (S.T.C.)
- Correspondence: ; Tel.: +64-3-378-6238
| | - Stephen T. Chambers
- Department of Pathology and Biomedical Science, University of Otago, Christchurch 8140, New Zealand; (S.M.); (A.S.-T.); (P.S.); (S.T.C.)
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6
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Nasser BA, Mesned AR, Tageldein M, Kabbani MS, Sayed NS. Can acute-phase response biomarkers differentiate infection from inflammation postpediatric cardiac surgery? Avicenna J Med 2021; 7:182-188. [PMID: 29119086 PMCID: PMC5655650 DOI: 10.4103/ajm.ajm_51_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Infection is a common serious complication postpediatric cardiac surgery. Diagnosis of infection after cardiopulmonary bypass (CPB) is difficult in the presence of surgical stress, hemodynamic instability, and inflammatory reaction. Aim: The purpose of this study is to investigate the value of available inflammatory biomarkers and its validity to differentiate infection from inflammation postpediatric cardiac surgery and to find the trend and the change in the level of these biomarkers shortly after cardiac surgery. Methods: We conducted a prospective study that included all children who underwent cardiac surgery in Prince Sultan Cardiac Centre-Qassim from November 2013 to October 2015. C-reactive protein, erythrocyte sedimentation rate, white blood cell count, and neutrophil count were measured for all patients presurgery, 4 consecutive days postsurgery, and predischarge. Patients were divided into two groups (the infected and the noninfected group). We compared the level of biomarkers between both groups. Then, we further analyzed the effects of CPB and preoperative steroid on postoperative inflammatory biomarker levels. Collected data were then reviewed and analyzed. Results: There were 134 pediatric cardiac patients included during the study period. Group 1 (bacterial negative culture group) had 125 cases and Group 2 (bacterial positive culture group) had nine cases. We found no statistically significant difference in inflammatory biomarker elevation between both groups. Only Group 2 had higher (RACHS) Risk adjustment for congenital heart surgery score, more ventilator days, and more drop in platelet count on the 2nd and 3rd postoperative days in comparison with the noninfected group 1. Both groups of patients who were in on and off CPB had the same level of inflammatory biomarkers with no significant differences. Giving corticosteroid preoperatively did not affect the trend of biomarker elevation and made no difference when it was compared to the group of patients who did not receive corticosteroid before surgery. Conclusion: Common inflammatory biomarkers cannot differentiate between infection and inflammation within the first 5 days postpediatric cardiac surgery as these reflect the inflammatory process rather than infection. Trend is more important than single reading.
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Affiliation(s)
- Bana Agha Nasser
- Prince Sultan Cardiac Center, Pediatric Cardiac Intensive Care, Qassim, Kingdom of Saudi Arabia
| | - Abdu Rahman Mesned
- Prince Sultan Cardiac Center, Pediatric Cardiac Intensive Care, Qassim, Kingdom of Saudi Arabia
| | - Mohamad Tageldein
- Prince Sultan Cardiac Center, Pediatric Cardiac Surgery, Qassim, Kingdom of Saudi Arabia
| | - Mohamed S Kabbani
- Department of Cardiac Sciences, Pediatric Cardiac Intensive Care, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Nada Siddig Sayed
- Prince Sultan Cardiac Center, Pediatric Cardiac Surgery, Qassim, Kingdom of Saudi Arabia
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7
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Moniz P, Coelho L, Póvoa P. Antimicrobial Stewardship in the Intensive Care Unit: The Role of Biomarkers, Pharmacokinetics, and Pharmacodynamics. Adv Ther 2021; 38:164-179. [PMID: 33216323 PMCID: PMC7677101 DOI: 10.1007/s12325-020-01558-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/31/2020] [Indexed: 02/06/2023]
Abstract
The high prevalence of infectious diseases in the intensive care unit (ICU) and consequently elevated pressure for immediate and effective treatment have led to increased antimicrobial therapy consumption and misuse. Moreover, the emerging global threat of antimicrobial resistance and lack of novel antimicrobials justify the implementation of judicious antimicrobial stewardship programs (ASP) in the ICU. However, even though the importance of ASP is generally accepted, its implementation in the ICU is far from optimal and current evidence regarding strategies such as de-escalation remains controversial. The limitations of clinical guidance for antimicrobial therapy initiation and discontinuation have led to multiple studies for the evaluation of more objective tools, such as biomarkers as adjuncts for ASP. C-reactive protein and procalcitonin can be adequate for clinical use in acute infectious diseases, the latter being the most studied for ASP purposes. Although promising, current evidence highlights challenges in biomarker application and interpretation. Furthermore, the physiological alterations in the critically ill render pharmacokinetics and pharmacodynamics crucial parameters for adequate antimicrobial therapy use. Individual pharmacokinetic and pharmacodynamic targets can reduce antimicrobial therapy misuse and risk of antimicrobial resistance.
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Affiliation(s)
- Patrícia Moniz
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Luís Coelho
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark.
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8
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Gaddam RR, Chambers S, Murdoch D, Shaw G, Bhatia M. Circulating levels of hydrogen sulfide and substance P in patients with sepsis. J Infect 2017; 75:293-300. [DOI: 10.1016/j.jinf.2017.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 12/18/2022]
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9
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Pentraxin 3 as an early marker in diagnosis of ventilator associated pneumonia. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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10
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Kragstrup TW, Juul-Madsen K, Christiansen SH, Zhang X, Krog J, Vorup-Jensen T, Kjaergaard AG. Altered levels of soluble CD18 may associate immune mechanisms with outcome in sepsis. Clin Exp Immunol 2017; 190:258-267. [PMID: 28714582 DOI: 10.1111/cei.13016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 12/26/2022] Open
Abstract
The pathogenesis of sepsis involves a dual inflammatory response, with a hyperinflammatory phase followed by, or in combination with, a hypoinflammatory phase. The adhesion molecules lymphocyte function-associated antigen (LFA-1) (CD11a/CD18) and macrophage-1 (Mac-1) (CD11b/CD18) support leucocyte adhesion to intercellular adhesion molecules and phagocytosis through complement opsonization, both processes relevant to the immune response during sepsis. Here, we investigate the role of soluble (s)CD18 in sepsis with emphasis on sCD18 as a mechanistic biomarker of immune reactions and outcome of sepsis. sCD18 levels were measured in 15 septic and 15 critically ill non-septic patients. Fifteen healthy volunteers served as controls. CD18 shedding from human mononuclear cells was increased in vitro by several proinflammatory mediators relevant in sepsis. sCD18 inhibited cell adhesion to the complement fragment iC3b, which is a ligand for CD11b/CD18, also known as Mac-1 or complement receptor 3. Serum sCD18 levels in sepsis non-survivors displayed two distinct peaks permitting a partitioning into two groups, namely sCD18 'high' and sCD18 'low', with median levels of sCD18 at 2158 mU/ml [interquartile range (IQR) 2093-2811 mU/ml] and 488 mU/ml (IQR 360-617 mU/ml), respectively, at the day of intensive care unit admission. Serum sCD18 levels partitioned sepsis non-survivors into one group of 'high' sCD18 and low CRP and another group with 'low' sCD18 and high C-reactive protein. Together with the mechanistic data generated in vitro, we suggest the partitioning in sCD18 to reflect a compensatory anti-inflammatory response syndrome and hyperinflammation, respectively, manifested as part of sepsis.
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Affiliation(s)
- T W Kragstrup
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - K Juul-Madsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - X Zhang
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - J Krog
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Anaesthesiology and Intensive Care, Randers Regional Hospital, Randers, Denmark
| | - T Vorup-Jensen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - A G Kjaergaard
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Anaesthesiology and Intensive Care, Randers Regional Hospital, Randers, Denmark
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11
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A point-of-care microfluidic biochip for quantification of CD64 expression from whole blood for sepsis stratification. Nat Commun 2017; 8:15949. [PMID: 28671185 PMCID: PMC5500847 DOI: 10.1038/ncomms15949] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/12/2017] [Indexed: 01/20/2023] Open
Abstract
Sepsis, a potentially life-threatening complication of an infection, has the highest burden of death and medical expenses in hospitals worldwide. Leukocyte count and CD64 expression on neutrophils (nCD64) are known to correlate strongly with improved sensitivity and specificity of sepsis diagnosis at its onset. A major challenge is the lack of a rapid and accurate point-of-care (PoC) device that can perform these measurements from a minute blood sample. Here, we report a PoC microfluidic biochip to enumerate leukocytes and quantify nCD64 levels from 10 μl of whole blood without any manual processing. Biochip measurements have shown excellent correlation with the results from flow cytometer. In clinical studies, we have used PoC biochip to monitor leukocyte counts and nCD64 levels from patients’ blood at different times of their stay in the hospital. Furthermore, we have shown the biochip’s utility for improved sepsis diagnosis by combining these measurements with electronic medical record (EMR). Sepsis is a potentially life–threatening complication of infection and diagnosis depends on rapid assessment of leukocyte count and CD64 expression. Here the authors present a microfluidic chip that can quantify these parameters from minimal amounts of whole blood with no manual processing.
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12
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Bloodstream infections caused by Acinetobacter species with reduced susceptibility to tigecycline: clinical features and risk factors. Int J Infect Dis 2017; 62:26-31. [PMID: 28676346 DOI: 10.1016/j.ijid.2017.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/02/2017] [Accepted: 06/26/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION During recent decades, the rates of multidrug resistance, including resistance to carbapenems, have increased dramatically among Acinetobacter species. Tigecycline has activity against multidrug-resistant Acinetobacter spp, including carbapenem-resistant isolates. However, reports of tigecycline-resistant Acinetobacter spp are emerging from different parts of the world. The purpose of this study was to evaluate potential risk factors associated with tigecycline non-susceptible Acinetobacter bacteremia. METHODS The medical records of 152 patients with Acinetobacter bacteremia attending Samsung Medical Center between January 2010 and December 2014 were reviewed. Non-susceptibility to tigecycline was defined as a minimum inhibitory concentration (MIC) of tigecycline ≥4μg/ml. Cases were patients with tigecycline non-susceptible Acinetobacter bacteremia and controls were those with tigecycline-susceptible Acinetobacter bacteremia. RESULTS Of the 152 patients included in the study, 61 (40.1%) had tigecycline non-susceptible Acinetobacter bacteremia (case group). These patients were compared to 91 patients with tigecycline-susceptible Acinetobacter bacteremia (control group). The case group showed high resistance to other antibiotics (>90%) except colistin (6.6%) and minocycline (9.8%) when compared to the control group, which exhibited relatively low resistance to other antibiotics (<50%). Multivariate analysis showed that recent exposure to corticosteroids (minimum 20mg per day for more than 5 days within 2 weeks) (adjusted odds ratio (OR) 2.887, 95% confidence interval (CI) 1.170-7.126) and carbapenems (within 2 weeks) (adjusted OR 4.437, 95% CI 1.970-9.991) were significantly associated with tigecycline non-susceptible Acinetobacter bacteremia. Although prior exposure to tigecycline was more common in the case group than in the control group (9.8%, 6/61 vs. 2.2%, 2/91; p=0.046), this variable was found not to be a significant factor associated with tigecycline non-susceptibility after adjustment for other variables (adjusted OR 1.884, 95% CI 0.298-11.920; p=0.501). CONCLUSIONS These data suggest that tigecycline non-susceptible Acinetobacter spp have emerged and disseminated in the hospital in association with a recent exposure to carbapenems and an immunosuppressed state. This indicates that the rational use of antibiotics through a comprehensive antimicrobial stewardship program, especially in immunosuppressed patients, may be essential in limiting the emergence and spread of multidrug-resistant organisms such as tigecycline-resistant Acinetobacter spp, which are difficult to treat.
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Pradhan S, Ghimire A, Bhattarai B, Khanal B, Pokharel K, Lamsal M, Koirala S. 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. Indian J Crit Care Med 2016; 20:417-20. [PMID: 27555697 PMCID: PMC4968065 DOI: 10.4103/0972-5229.186226] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
| | - Ashish Ghimire
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Balkrishna Bhattarai
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Bashudha Khanal
- Department of Microbiology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Krishna Pokharel
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Madhab Lamsal
- Department of Biochemistry, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Sidhhartha Koirala
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
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Serum C-reactive protein and CRP genotype in pediatric inflammatory bowel disease: influence on phenotype, natural history, and response to therapy. Inflamm Bowel Dis 2015; 21:596-605. [PMID: 25636121 DOI: 10.1097/mib.0000000000000296] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND C-reactive protein (CRP) is an acute phase reactant. Patients with pediatric inflammatory bowel disease (PIBD) differ from adult patients with inflammatory bowel disease with regard to phenotype, inflammatory profile, and treatment response. We hypothesized that variations in CRP and CRP genotype influence PIBD phenotype, natural history, and remission after anti-tumor necrosis factor alpha therapy. METHODS Six single nucleotide polymorphisms tagging CRP (rs1935193, rs1130864, rs1205, rs1417938, rs11265263, and rs1800947) were genotyped in 465 patients with PIBD (diagnosed <17 yr). Phenotyping was serially performed until last follow-up and serum CRP levels recorded at diagnosis and before biological therapy in a subgroup. RESULTS CRP haplotype (ATGCTC) differed in those diagnosed <10 years, with rs1205T more frequent in Crohn's disease (CD) than ulcerative colitis (UC) (P = 0.009); the haplotype ATGCTC was less frequent in UC (P = 0.002). Three single nucleotide polymorphisms (rs1205, rs1130864, and rs1417938) showed association with elevated CRP levels at diagnosis. CRP genotype had no association with CD phenotype or natural history. CRP was more frequently raised at diagnosis in CD than UC (63% versus 22%, P < 0.0001). Elevated CRP at diagnosis was associated with a higher risk of progression to surgery in patients with CD (P < 0.0001) and the need for azathioprine in the overall PIBD cohort (P = 0.002). There was no effect of CRP genotype or serum CRP on the achievement of remission using anti-tumor necrosis factor alpha therapy. CONCLUSIONS CRP and CRP genotype differ between pediatric patients with CD and UC with a high inflammatory burden at diagnosis suggesting a worse prognosis. Additional evaluation of CRP in inflammatory bowel disease pathogenesis and natural history is now warranted.
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The role of procalcitonin as a guide for the diagnosis, prognosis, and decision of antibiotic therapy for lower respiratory tract infections. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013; 62:687-695. [PMID: 32288126 PMCID: PMC7126862 DOI: 10.1016/j.ejcdt.2013.07.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/31/2013] [Indexed: 01/09/2023] Open
Abstract
Objectives To assess the value of PCT as a rapid and sensitive marker for diagnosis, prognosis, and therapy of lower respiratory tract bacterial infections necessitating antimicrobial treatment and comparing this marker with other markers of infections including C-reactive protein (CRP) and total white-blood cell counts (WBCs). Patients and methods Sixty Patients were enrolled in the study, they were subjected to complete history taking, physical examination, laboratory investigations including complete blood count, blood gases, blood chemistry, bacteriological culture for sputum and blood, serology for atypicals, and PCR for respiratory viruses, serum C-reactive protein (CRP) and PCT levels were measured. The patients were divided into two groups, group 1 included 26 patients who were culture negative for bacterial infection and group 2 included 34 patients who were culture positive. Group 2 patients were given antibiotic therapy according to the culture sensitivity. Result The results revealed that, there was no significant difference between group 1 and group 2 patients as regards age, sex, clinical manifestations, final diagnosis, white blood cell counts, blood gases, number of admitted patients, intensive care unit admission and length of hospital stay. A significant increase of PCT and CRP levels was detected in group 2 compared to group 1 at initial diagnosis. At cutoff value >0.5 ng/ml, PCT gave a sensitivity of 94.1%, specificity of 88.4%, positive predictive value (PPV) of 91.4%, negative predictive value (NPV) of 92% and diagnostic efficiency of 91.6% for diagnosis of respiratory tract bacterial infections. However, at a cutoff value >8 mg/L, CRP gave a sensitivity of 85.2%, specificity of 76.9%, PPV of 82.8%, NPV of 80% and diagnostic efficiency of 81.7%. After antibiotic therapy PCT and CRP levels dropped in group 2 patients as compared to their pre-treatment levels. Conclusion Serum PCT level could be used as a novel marker of lower respiratory tract bacterial infections for diagnosis, prognosis and follow up of therapy. This reduces side-effects of an unnecessary antibiotic use, lowers costs, and in the long-term, leads to diminishing drug resistance.
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Kornblit B, Hellemann D, Munthe-Fog L, Bonde J, Strøm JJ, Madsen HO, Johansen JS, Garred P. Plasma YKL-40 and CHI3L1 in systemic inflammation and sepsis-experience from two prospective cohorts. Immunobiology 2013; 218:1227-34. [PMID: 23706599 DOI: 10.1016/j.imbio.2013.04.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 04/16/2013] [Indexed: 01/01/2023]
Abstract
YKL-40, derived from the CHI3L1 gene, has been associated with outcome of infectious and inflammatory diseases. We hypothesized that plasma YKL-40 concentrations and CHI3L1 genotype could be used as prognostic biomarkers in the assessment of systemic inflammatory response syndrome (SIRS) and sepsis. The objective of the study was to assess the prognostic value of plasma YKL-40 and CHI3L1 genotype in patients with SIRS and sepsis. Plasma YKL-40 and CHI3L1 genotype (rs4950928) were analyzed at time of admission to intensive care units (ICU), in two prospective cohorts of consecutive SIRS patients (cohort 1, n=272; cohort 2, n=502). The plasma YKL-40 cut-off for predicting survival was determined in cohort 1 by receiver operator characteristic analyses and validated in cohort 2. In cohort 1 patients with plasma YKL-40 ≤505ng/ml (area under the curve 0.64 (95% confidence interval (CI) 0.57-0.70), p<0.001, sensitivity 53%, specificity 76%) had superior day 90 survival (81% vs. 55%, p<0.001, hazard ratio (HR) 2.29 (95% CI 1.29-4.07)). In the second cohort plasma YKL-40 ≤505ng/ml was also associated with superior survival (61% vs. 38%, p<0.001, HR 1.43 (1.03-1.99)). CHI3L1 minor allele homozygosity was associated with low plasma YKL-40 at time of admission (p=0.002) and no variation (p=0.462) in concentrations throughout the first 14 days in the ICU, but this was not associated with better survival. In conclusion patients with SIRS and sepsis, plasma YKL-40 ≤505ng/ml at time of ICU admission was associated with better survival. However, this association was not observed for patients homozygous for the low expressing YKL-40 CHI3L1 allele.
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Affiliation(s)
- Brian Kornblit
- Laboratory of Molecular Medicine, Department of Clinical Immunology 7631, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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Jabłoński S, Brocki M, Krzysztof K, Wawrzycki M, Santorek-Strumiłło E, Łobos M, Kozakiewicz M. Evaluation of prognostic value of selected biochemical markers in surgically treated patients with acute mediastinitis. Med Sci Monit 2012; 18:CR308-15. [PMID: 22534711 PMCID: PMC3560636 DOI: 10.12659/msm.882737] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Monitoring of biochemical markers of inflammation in acute mediastinitis (AM) can be useful in the modification of treatment. This study was a retrospective evaluation of selected biochemical parameters with negative impact on the prognosis in surgically treated patients. MATERIAL/METHODS There were 44 consecutive patients treated surgically due to AM of differentiated etiology. Selected biochemical markers (WBC, RBC, HGB, HCT, PLT, CRP, PCT, ionogram, protein and albumins) were assessed before surgery and on the 3rd day after surgery. ANOVA was applied to find factors influencing observations. Numerical data [laboratory parameters] were compared by means of medians. RESULTS The overall hospital mortality rate was 31.82%. In the group of dead patients, there were observed statistically significant lower mean preoperative values of RBC [p=0.0090], HGB [p=0.0286], HCT [p=0.0354], protein [p= 0.0037], albumins [p=0.0003] and sodium [p<0.0001] and elevated values of CRP [P=0.0107] and PCT p<0.0001]. High level of inflammatory markers on day 3 after surgery was found to increase the risk of death - for WBC (by 67%), for CRP (by 88%) and for PCT (by 100%). CONCLUSIONS Poor prognosis was more frequent in patients with preoperative high levels of CRP, PCT, anemia, hypoproteinemia and hyponatremia. The risk of death increases significantly if in the immediate postoperative period no distinct decrease in WBC count and of the CRP and PCT level is observed. In such a situation the patients should be qualified earlier for broadened diagnostic workup and for reoperation.
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Affiliation(s)
- Sławomir Jabłoński
- Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, Lodz, Poland.
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Abstract
THE AIM OF THE STUDY was to answer the question whether or not determination of C-reactive protein in patients after serious abdominal surgeries can be prognostic of septic complications. MATERIAL AND METHODS 36 patients who underwent elective surgeries were included in the study. The patients were included either in the group where no postoperative SIRS developed or in the group where postoperative SIRS did occur. In the seven-day period after the surgery, in 26 patients SIRS was found, and in 10 - sepsis was suspected (according to the ACCP/SCCM definitions). In patients who underwent abdominal surgeries blood concentration of C-reactive protein was determined prior to the surgery (measurement '0'), and then on postoperative days 1, 2, 3, 5 and 7. RESULTS The test for two variables (C-reactive protein on postoperative days five and seven) showed statistically significant difference, and for one variable (C-reactive protein on day three) - difference at the limit of significance. Thus, it was found that in the postoperative SIRS group the level of C-reactive protein is higher than in the non-SIRS group. CONCLUSIONS Serial measurements of C-reactive protein are useful in the first week after surgery, as they can be prognostic of postoperative septic complications. Such complications can be anticipated if CRP on postoperative day 5 is higher than 1/2 of the maximum CRP concentration on day 2 or day 3, or CRP > 150 mg/L as of postoperative day 3. Unfortunately, the severity of the disease cannot be projected based on C-reactive protein level.
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Moretti D, Ramírez MM, Settecase CJ, Bagilet DH, Quaglino MB. [Usefulness of procalcitonin upon admission to intensive care in the diagnosis and prognosis of sepsis]. Med Intensiva 2012; 37:156-62. [PMID: 22658964 DOI: 10.1016/j.medin.2012.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 03/29/2012] [Accepted: 03/31/2012] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To assess the usefulness of procalcitonin (PCT) upon admission to the Intensive Care Unit (ICU) in the diagnosis and prognosis of sepsis DESIGN A 12-month prospective observational cohort study was carried out SETTING An 11-bed polyvalent ICU Belonging to a University hospital PATIENTS Fifty patients with systemic inflammatory response syndrome (SIRS) were included. The mean age of the patients was 51.66 years, and 68% of them were males VARIABLES OF INTEREST Upon admission, the concentration of PCT and C-reactive protein (CRP) was assessed. At discharge, the final diagnosis and outcome were reviewed RESULTS Thirty-six patients had sepsis. Mean PCT ± SD was higher in sepsis than in non-infectious SIRS (19.3 ± 4.9 vs. 0.65 ± 0.2) ng/ml) (P=.001). PCT had greater discriminating power than CRP (AUC 0.932 vs. 0.827). The cut-off value of PCT for the diagnosis of sepsis was 0.92 ng/dl, with a sensitivity of 80.56%, specificity 85.71%, positive predictive value 93.55% and negative predictive value 63.16%, LR+ 5.64 and LR- 0.23. Mortality was higher in patients with sepsis (52.78% vs. 21.43%) (P=.039). Mean PCT ± SD upon admission among survivors and deceased patients with sepsis was 18.7 ± 6.7 and 19.5 ± 7.5 ng/ml, respectively (P=.934). CONCLUSIONS PCT upon admission to the ICU is useful for the diagnosis of sepsis, and is more effective than PCR in this respect. However, it is of no help in estimating the short-term prognosis.
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Affiliation(s)
- D Moretti
- Unidad de Terapia Intensiva, Hospital Escuela Eva Perón, Granadero Baigorria (Gran Rosario), Santa Fe, Argentina.
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Jabłoński S, Kozakiewicz M. Proposal for a recovery prediction method for patients affected by acute mediastinitis. World J Emerg Surg 2012; 7:11. [PMID: 22574625 PMCID: PMC3518827 DOI: 10.1186/1749-7922-7-11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 05/10/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An attempt to find a prediction method of death risk in patients affected by acute mediastinitis. There is not such a tool described in available literature for that serious disease. METHODS The study comprised 44 consecutive cases of acute mediastinitis. General anamnesis and biochemical data were included. Factor analysis was used to extract the risk characteristic for the patients. The most valuable results were obtained for 8 parameters which were selected for further statistical analysis (all collected during few hours after admission). Three factors reached Eigenvalue >1. Clinical explanations of these combined statistical factors are: Factor1 - proteinic status (serum total protein, albumin, and hemoglobin level), Factor2 - inflammatory status (white blood cells, CRP, procalcitonin), and Factor3 - general risk (age, number of coexisting diseases). Threshold values of prediction factors were estimated by means of statistical analysis (factor analysis, Statgraphics Centurion XVI). RESULTS The final prediction result for the patients is constructed as simultaneous evaluation of all factor scores. High probability of death should be predicted if factor 1 value decreases with simultaneous increase of factors 2 and 3. The diagnostic power of the proposed method was revealed to be high [sensitivity =90%, specificity =64%], for Factor1 [SNC = 87%, SPC = 79%]; for Factor2 [SNC = 87%, SPC = 50%] and for Factor3 [SNC = 73%, SPC = 71%]. CONCLUSION The proposed prediction method seems a useful emergency signal during acute mediastinitis control in affected patients.
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Affiliation(s)
- Sławomir Jabłoński
- Department of Thoracic Surgery, General and Oncological Surgery, Medical University of Lodz, 113 Żeromskiego St,, 90-547, Łódź, Poland.
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Procalcitonin is more useful than C-reactive protein in differentiation of fever in patients with sickle cell disease. J Pediatr Hematol Oncol 2012; 34:85-9. [PMID: 22367384 DOI: 10.1097/mph.0b013e3182495573] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study aimed at evaluating the value of C-reactive protein (CRP) and procalcitonin (PCT) levels in the differential diagnosis of fever in patients with sickle cell disease (SCD). The study included 86 children with SCD (group 1) and 49 controls (group 2). During the study, the patients had 114 acute episodes or routine visits to the units. They were classified as having vasoocclusive crisis with fever (group 1A), vasoocclusive crisis without fever (group 1B), and no crisis or fever (steady state, group 1C). Only patients with crises were admitted to the hospital. Patients admitted to the hospital with various clinical signs and symptoms each and every time were included in groups 1A, 1B, and 1C. Thus, a total of 114 clinical episodes were analyzed. The mean CRP levels in the 3 patient groups were significantly higher than that in the group 2, and among the patient groups, the mean CRP was significantly higher in group 1A than the other groups. The mean CRP level in group 1A and group 1B was significantly higher than that in group 1C. There were no significant differences among the 3 SCD groups in terms of the median serum PCT level; however, the median PCT level in group 1A, group 1B, and group 1C patients was significantly higher than that in group 2 patients. These data indicate that vasoocclusive disease with or without fever apparently does not significantly increase PCT levels in relation to the baseline status of children with SCD, which in turn are clearly more elevated than PCT levels of control children.
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Ruiz-Esteban R, Sarabia PR, Delgado EG, Aguado CB, Cuervo-Arango JA, Varela M. Procalcitonin and C-reactive protein levels as diagnostic tools in febrile patients admitted to a General Internal Medicine ward. Clin Biochem 2011; 45:22-5. [PMID: 22019953 DOI: 10.1016/j.clinbiochem.2011.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 08/31/2011] [Accepted: 09/28/2011] [Indexed: 01/21/2023]
Abstract
OBJECTIVE We study the extent to which procalcitonin (Pro-CT) and/or C-reactive protein (CRP) may be helpful in the early triage of febrile patients admitted to a general internal medicine ward. METHODS This is a prospective, observational study on 62 admitted patients in whom a temperature >38°C had been observed the day before inclusion. RESULTS Neither Pro-CT nor CRP was able to discriminate infectious (or bacterial) diseases from the other etiologies as a group, with an area under the ROC curve of 0.63 (95% CI 0.47-0.79, p=0.15) for Pro-CT and 0.61, (95CI 0.44-0.78, p=0.23) for CRP. Sensitivity and specificity for Pro-CT varied between 0.59 and 0.67 for a cut-off point of 0.2 ng/mL and 0.03 and 1 for a cut-off point of 10.0 ng/mL. However, in subgroup analysis, Pro-CT was able to discriminate between infectious and inflammatory diseases (Welch two sample t-test t=2.39, df=44.3, p=0.021).
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Affiliation(s)
- Raul Ruiz-Esteban
- Department of Internal Medicine, Universitary Hospital of Mostoles, Madrid, Spain
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Alexandraki I, Palacio C. Gram-negative versus Gram-positive bacteremia: what is more alarmin(g)? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:161. [PMID: 20550728 PMCID: PMC2911716 DOI: 10.1186/cc9013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Gram-negative bacteremia has been associated with severe sepsis, although the exact mechanism and pathophysiological differences among bacterial species are not well understood. In the previous issue of Critical Care, Abe and colleagues report results of a retrospective study that show a significantly higher incidence of Gram-negative bacteremia among adult intensive care unit patients with septic shock than in those with sepsis or severe sepsis. In this study, C-reactive protein and IL-6 levels were significantly higher in Gram-negative bacteremia than in Gram-positive bacteremia. These observations suggest a distinct immunopathophysiologic behavior of sepsis in patients with Gram-negative bacteremia that may influence clinical outcomes. Future research exploring new biomarkers and danger signals and further characterizing differences in the virulence mechanisms between Gram-negative and Gram-positive bacteria appears promising and could lead to new therapeutics and to improved clinical outcomes.
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Affiliation(s)
- Irene Alexandraki
- Department of Medicine, University of Florida - College of Medicine, 653-1 West Eighth Street, Jacksonville, FL32209, USA.
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Baruti Gafurri Z, Pacarizi H, Zhubi B, Begolli L, Topciu V. The importance of determining procalcitonin and C reactive protein in different stages of sepsis. Bosn J Basic Med Sci 2010; 10:60-4. [PMID: 20192933 DOI: 10.17305/bjbms.2010.2737] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Rapid and early diagnosis of systemic infections is very important for acting on time with an adequate therapy. The aim of this study is to determine the diagnostic importance of procalcitonin (PCT) and C-reactive protein (CRP) of bacterial infections in different stages of sepsis.PCT and CRP have been determined in 45 newborns, 1-21 days of age, with different stages of sepsis, in the centre for prematurely born neonates. These parameters have also been determined for control group, in which there were 10 healthy newborns. Procalcitonin values were significantly increased in neonates with septic shock (92,5 ng/mL; 6,06-200 ng/mL) compared to the systemic inflammatory response syndrome- SIRS (41 ng/mL; 0,28-200 ng/mL), neonatal sepsis (10,26 ng/mL; 1,08-111,3 ng/mL), neonatal sepsis and purulent meningitis (9,80 ng/mL; 4,3-18,9 ng/mL). The control group values were lower than 0,5 ng/mL. CRP is increased without statistical differences in all stages of sepsis in newborns with septic shock (93,2 mg/L; 6,0-196 mg/L) in cases with SIRS (45,64 mg/L; 6,0-147 mg/L), neonatal sepsis (70,02 mg/L; 6-177 mg/L), neonatal sepsis and purulent meningitis (61,98 mg/L; 24-192 mg/L). The average values for the control group were 4,7 mg/L. Procalcitonin is increased in all stages of sepsis with higher values in the septic shock. The increase of PCT levels is related to the severity, course of infection and prognosis of disease.
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Affiliation(s)
- Zana Baruti Gafurri
- Institute of Biochemistry, Faculty of Medicine, University of Prishtina. Mother Theresa str., 10 000 Prishtina, Kosovo
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Procalcitonin as a prognostic and diagnostic tool for septic complications after major trauma. Crit Care Med 2009; 37:1845-9. [PMID: 19384224 DOI: 10.1097/ccm.0b013e31819ffd5b] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The primary aim of this study was to investigate the diagnostic value of procalcitonin (PCT) and C-reactive protein (CRP) in septic complications after major trauma. A secondary aim was to determine whether there was a prognostic value of PCT for severity of injury, organ dysfunction, and sepsis. DESIGN Prospective study. SETTING Medical/surgical intensive care unit (ICU). PATIENTS Ninety-four patients with consecutive trauma >or=16 years who were admitted to the ICU for an expected stay of >24 hours. INTERVENTIONS None. MEASUREMENTS PCT and CRP were collected at admission and every day thereafter. The American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definition was used to identify sepsis criteria. The Sequential Organ Failure Assessment score was used to describe the severity of organ dysfunction. We retrospectively analyzed the occurrence of systemic inflammatory response syndrome and sepsis using the collected variables (criteria fulfilled at least during three continuous days). MAIN RESULTS Patients with trauma presented an early and significant increase in PCT at the moment of septic complications compared with concentrations measured 1 day before the diagnosis of sepsis: 0.85 vs. 3.32 ng/mL for PCT (p < 0.001) and 135 vs. 175 mg/L for CRP (p = not significant). The areas under the respective curve at admission in the diagnosis of sepsis were 0.787 (p < 0.001) and 0.489 for PCT and CRP, respectively. CONCLUSION PCT plasma reinduction marks possible septic complication during systemic inflammatory response syndrome after major trauma. In addition, high PCT concentration at admission after trauma in ICU patients indicates an increased risk of septic complications.
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Abstract
Prompt diagnosis, intervention, and risk assessment are critical in caring for septic patient but remain difficult with currently available methods. Biomarkers may become useful adjuncts to clinicians and ultimately serve as targets for future therapeutic trials in sepsis. The most relevant markers are reviewed in this article, including interleukin-6, C-reactive protein, procalcitonin, triggering receptor expressed on myeloid cells-1, and biomarker panels.
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Affiliation(s)
- Corey E Ventetuolo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, College of Physicians and Surgeons, Columbia University, PH 8, Room 101, 622 W. 168th Street, New York City, NY 10032, USA
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Ruiz-Alvarez M, García-Valdecasas S, De Pablo R, Sanchez García M, Coca C, Groeneveld T, Roos A, Daha M, Arribas I. Diagnostic Efficacy and Prognostic Value of Serum Procalcitonin Concentration in Patients With Suspected Sepsis. J Intensive Care Med 2008; 24:63-71. [DOI: 10.1177/0885066608327095] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Procalcitonin is released in response to bacterial infection and it is not released in Inflammatory and viral diseases. Objective: To show the diagnostic efficacy and prognostic value of procalcitonin for sepsis. Methods: A consecutive series of 103 patients with suspected sepsis were admitted to the intensive care unit over a 2-year period. During the first 24 hours of the admission procalcitonin, C-reactive protein, and complement proteins were determined. The diagnostic efficacy was tested with predictive values, likelihood ratios, receiver operating characteristic curves, and multiple logistic regression. The association of procalcitonin with mortality was assessed by the Multivariate Cox proportional hazards model. Results: Procalcitonin had a better positive likelihood ratio than C-reactive protein —2.2 (95% confidence interval: 1.3-3.7) versus 1.1 (95% confidence interval: 0.9-1.2). Sequential Organ Failure Assessment yielded the highest discriminative value, with an area under the curve of 0.82 (95% confidence interval: 0.73-0.92), followed by procalcitonin (0.81; 95% confidence interval: 0.72-0.89). Multivariate regression analysis showed procalcitonin (adjusted odds ratio: 3.8; 95% confidence interval: 1.2-11.8) and Sequential Organ Failure Assessment score (adjusted odds ratio: 5.3; 95% confidence interval: 1.4-19.9) as the only variables independently associated with infection. Multivariate Cox regression analysis revealed that procalcitonin was not independently associated with mortality. Conclusions: The diagnostic accuracy of procalcitonin was higher than C-reactive protein and complement proteins. Procalcitonin in combination with Sequential Organ Failure Assessment was useful to diagnose infection. C-reactive protein, Sequential Organ Failure Assessment score, age, and gender showed to be helpful to improve the prediction of mortality risk, but not procalcitonin.
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Affiliation(s)
- M.J. Ruiz-Alvarez
- Laboratorio de Analisis Clínicos, Intensivos Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain,
| | - S. García-Valdecasas
- Laboratorio de Analisis Clínicos, Intensivos Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - R. De Pablo
- Unidad de Cuidados, Intensivos Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - M. Sanchez García
- Unidad de Cuidados Intensivos Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - C. Coca
- Laboratorio de Analisis Clínicos, Intensivos Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - T.W. Groeneveld
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - A. Roos
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - M.R. Daha
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - I. Arribas
- Laboratorio de Analisis Clínicos, Intensivos Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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Charney P. Nutrition Screening vs Nutrition Assessment: How Do They Differ? Nutr Clin Pract 2008; 23:366-72. [DOI: 10.1177/0884533608321131] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Ivancević N, Radenković D, Bumbasirević V, Karamarković A, Jeremić V, Kalezić N, Vodnik T, Beleslin B, Milić N, Gregorić P, Zarković M. Procalcitonin in preoperative diagnosis of abdominal sepsis. Langenbecks Arch Surg 2007; 393:397-403. [PMID: 17968584 DOI: 10.1007/s00423-007-0239-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 10/16/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The present study attempted to identify the diagnostic significance of procalcitonin (PCT) in acute abdominal conditions as well as the range of concentrations relating to diagnosis of abdominal sepsis. MATERIALS AND METHODS This was prospective clinical study. The study included 98 consecutive patients with acute abdominal conditions, divided in sepsis and systemic inflammatory response syndrome (SIRS) group. RESULTS PCT concentrations on admission were significantly higher in the sepsis group than in the SIRS group (median [interquartile range] 2.32 [7.41] vs 0.45 ng/ml [2.62]). A cutoff value of 1.1 ng/ml yielded 72.4% sensitivity and 62.5% specificity. In a group of patients with abdominal symptoms lasting for more than 24 h, a cut-off value of 1.1 ng/ml yielded higher sensitivity (82.9%) and higher specificity (77.3%). CONCLUSION Our results suggest that PCT measurements may be useful for early, preoperative diagnosis of abdominal sepsis.
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Affiliation(s)
- Nenad Ivancević
- Center of Emergency Surgery, Clinical Centre of Serbia, Belgrade, Serbia.
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Póvoa P, Coelho L, Almeida E, Fernandes A, Mealha R, Moreira P, Sabino H. Early identification of intensive care unit-acquired infections with daily monitoring of C-reactive protein: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R63. [PMID: 16635270 PMCID: PMC1550913 DOI: 10.1186/cc4892] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 02/21/2006] [Accepted: 03/14/2006] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Manifestations of sepsis are sensitive but are poorly specific of infection. Our aim was to assess the value of daily measurements of C-reactive protein (CRP), temperature and white cell count (WCC) in the early identification of intensive care unit (ICU)-acquired infections. METHODS We undertook a prospective observational cohort study (14 month). All patients admitted for > or =72 hours (n = 181) were divided into an infected (n = 35) and a noninfected group (n = 28). Infected patients had a documented ICU-acquired infection and were not receiving antibiotics for at least 5 days before diagnosis. Noninfected patients never received antibiotics and were discharged alive. The progression of CRP, temperature and WCC from day -5 to day 0 (day of infection diagnosis or of ICU discharge) was analyzed. Patients were divided into four patterns of CRP course according to a cutoff value for infection diagnosis of 8.7 mg/dl: pattern A, day 0 CRP >8.7 mg/dl and, in the previous days, at least once below the cutoff; pattern B, CRP always >8.7 mg/dl; pattern C, day 0 CRP < or =8.7 mg/dl and, in the previous days, at least once above the cutoff; and pattern D, CRP always < or =8.7 mg/dl. RESULTS CRP and the temperature time-course showed a significant increase in infected patients, whereas in noninfected it remained almost unchanged (P < 0.001 and P < 0.001, respectively). The area under the curve for the maximum daily CRP variation in infection prediction was 0.86 (95% confidence interval: 0.752-0.933). A maximum daily CRP variation >4.1 mg/dl was a good marker of infection prediction (sensitivity 92.1%, specificity 71.4%), and in combination with a CRP concentration >8.7 mg/dl the discriminative power increased even further (sensitivity 92.1%, specificity 82.1%). Infection was diagnosed in 92% and 90% of patients with patterns A and B, respectively, and in only two patients with patterns C and D (P < 0.001). CONCLUSION Daily CRP monitoring and the recognition of the CRP pattern could be useful in the prediction of ICU-acquired infections. Patients presenting maximum daily CRP variation >4.1 mg/dl plus a CRP level >8.7 mg/dl had an 88% risk of infection.
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Affiliation(s)
- Pedro Póvoa
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal.
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31
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Seller-Pérez G, Herrera-Gutiérrez ME, Lebrón-Gallardo M, de Toro-Peinado I, Martín-Hita L, Porras-Ballesteros JA. [Serum C-reactive protein as a marker of outcome and infection in critical care patients]. Med Clin (Barc) 2006; 125:761-5. [PMID: 16373024 DOI: 10.1016/s0025-7753(05)72184-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE C-reactive protein (CRP) has been considered a marker for infection and an aid for diagnosing sepsis. We analyze the relation of CRP to infection and outcome in intensive care units (ICU) patients. PATIENTS AND METHOD Prospective study on 77 ventilated patients. Expected short ICU stay or (suspected or confirmed) infection at admission were excluding criteria. 55 admissions after elective surgery were the controls. CRP measurement the first (CRP-1), third (CRP-3) and sixth (CRP-6) day of stay. APACHE II (Acute Physiology Score and Chronic Health Evaluation), SOFA (Sepsis-related Organ Failure Assessment), shock, respiratory or renal failure, leucocytes, platelets and albumin were registered. Follow-up until day 9 for infection and ICU discharge for outcome. RESULTS CRP-1 in controls was 5.3 (3.9) mg/l and cases 67.8 (77.4) (p < 0.001). Shock on admission was related to CRP-1: patients in shock had higher CRP-1 levels (118.6 [82.8] vs 62.8 [75.6]; p = 0.06). 40.25% of cases developed infection, and CRP-1 levels were higher in this patients (88.8 [93.9] vs 53.8 [60.9]; p < 0.05). ROC area under curve was 0.6 with a sensibility of 23% and a specificity of 89% for a level of CRP-1 > 100. Mortality was 23.4% in cases and 1.8% in controls. Age, shock, APACHE II and SOFA were related to mortality, but CRP-1 did not. ROC area under curve for CRP-1 as mortality predictor in all patients was 0.62 (0.76 for APACHE II and 0.77 for SOFA) but only in cases was of 0.49 (0.69 for APACHE II and 0.67 for SOFA). CONCLUSIONS CRP level on admission is an useful marker for early infection but not for outcome in critically ill patients admited to the ICU.
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Affiliation(s)
- Gemma Seller-Pérez
- Servicio de Cuidados Críticos y Urgencias, Complejo Hospitalario Carlos Haya, Málaga.
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Lin IY, Ma HP, Lin ACM, Chong CF, Lin CM, Wang TL. Low plasma vasopressin/norepinephrine ratio predicts septic shock. Am J Emerg Med 2005; 23:718-24. [PMID: 16182977 DOI: 10.1016/j.ajem.2005.02.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2004] [Accepted: 02/02/2005] [Indexed: 11/17/2022] Open
Abstract
To evaluate if low plasma vasopressin and high norepinephrine concentrations predict grave prognosis of sepsis, a prospective sample of consecutive patients visiting the emergency department of a university teaching hospital who met the American College of Chest Physicians criteria of sepsis or severe sepsis was enrolled. Besides septic workup, we measured serum vasopressin and norepinephrine concentrations to correlate the impending outcome. One hundred eighty-two patients aged 27 to 99 years met the inclusive criteria and were classified as those with septic shock (n = 72), severe sepsis (n = 56), and those with sepsis only (n = 54) according to the outcome within 6 hours. Thirty healthy subjects were included as control. The plasma vasopressin level at baseline was significantly lower for those who finally developed septic shock (septic shock group, 3.6 +/- 2.5 pg/mL; 95% confidence interval [CI], 3.0-4.2 pg/mL; severe sepsis group, 21.8 +/- 4.1 pg/mL, 95% CI, 20.7-22.9 pg/mL; sepsis group, 10.6 +/- 6.5 pg/mL, 95% CI, 8.8-12.4 pg/mL, P < .001), whereas the norepinephrine level was highest for the same group (septic shock group, 3650 +/- 980 pg/mL, 95% CI, 3420-3880 pg/mL; severe sepsis group, 3600 +/- 1000 pg/mL, 95% CI, 3330-3870 pg/mL; sepsis group, 1720 +/- 320 pg/mL, 95% CI, 1630-1810 pg/mL). The vasopressin/norepinephrine ratio was significantly lower for the patients with final diagnosis of septic shock (P < .001). The mean interval between the time of samples drawn and the time of the most severe occurring sequelae was 2.4 +/- 0.8 hours. Receiver operating characteristic analysis revealed that the vasopressin/norepinephrine ratio 1 x 10(-3) had a sensitivity of 97% (95% CI, 90%-99%) and a specificity of 85% (95% CI, 78%-91%) for detecting impending septic shock. Low serum vasopressin/norepinephrine ratio can predict impending septic shock.
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Affiliation(s)
- I-Yin Lin
- Department of Emergency Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
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Póvoa P, Coelho L, Almeida E, Fernandes A, Mealha R, Moreira P, Sabino H. C-reactive protein as a marker of infection in critically ill patients. Clin Microbiol Infect 2005; 11:101-8. [PMID: 15679483 DOI: 10.1111/j.1469-0691.2004.01044.x] [Citation(s) in RCA: 202] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A prospective, observational study was conducted in a medico-surgical intensive care unit to assess the value of C-reactive protein (CRP), temperature and white cell count (WCC) measurements for the diagnosis of infection in critically ill patients. CRP, temperature and WCC were monitored daily in 76 infected and 36 non-infected patients. Multiple receiver-operating characteristics (ROC) curves were used to compare each parameter for infection diagnosis. The area under the curve (AUC) of CRP was significantly higher than that of temperature (0.93 and 0.75, respectively; p < 0.001). A CRP concentration of >8.7 mg/dL and a temperature of >38.2 degrees C were associated with infection, with a sensitivity of 93.4% and 54.8%, and a specificity of 86.1% and 88.9%, respectively. The ROC curve of WCC showed a poor diagnostic performance. The combination of CRP and temperature increased the specificity for infection diagnosis to 100%. In the subgroup of patients with ventilator-associated pneumonia (n = 48), CRP measurements were more reliable than temperature (AUC 0.92 and 0.78, respectively; p 0.006). The CRP levels in infected patients with sepsis, severe sepsis and septic shock were 15.2 +/- 8.2, 20.3 +/- 10.9 and 23.3 +/- 8.7 mg/dL, respectively (p 0.044). It was concluded that CRP was a better marker of infection than temperature. However, the combination of CRP and temperature measurements further increased the specificity for infection diagnosis, even in the subgroup of patients with VAP.
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Affiliation(s)
- P Póvoa
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal.
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Simon L, Gauvin F, Amre DK, Saint-Louis P, Lacroix J. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis 2004; 39:206-17. [PMID: 15307030 DOI: 10.1086/421997] [Citation(s) in RCA: 1063] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2003] [Accepted: 03/12/2004] [Indexed: 12/11/2022] Open
Abstract
A meta-analysis was performed to evaluate the accuracy of determination of procalcitonin (PCT) and C-reactive protein (CRP) levels for the diagnosis of bacterial infection. The analysis included published studies that evaluated these markers for the diagnosis of bacterial infections in hospitalized patients. PCT level was more sensitive (88% [95% confidence interval [CI], 80%-93%] vs. 75% [95% CI, 62%-84%]) and more specific (81% [95% CI, 67%-90%] vs. 67% [95% CI, 56%-77%]) than CRP level for differentiating bacterial from noninfective causes of inflammation. The Q value for PCT markers was higher (0.82 vs. 0.73). The sensitivity for differentiating bacterial from viral infections was also higher for PCT markers (92% [95% CI, 86%-95%] vs. 86% [95% CI, 65%-95%]); the specificities were comparable (73% [95% CI, 42%-91%] vs. 70% [95% CI, 19%-96%]). The Q value was higher for PCT markers (0.89 vs. 0.83). PCT markers also had a higher positive likelihood ratio and lower negative likelihood ratio than did CRP markers in both groups. On the basis of this analysis, the diagnostic accuracy of PCT markers was higher than that of CRP markers among patients hospitalized for suspected bacterial infections.
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Affiliation(s)
- Liliana Simon
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8064, USA.
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Castelli GP, Pognani C, Meisner M, Stuani A, Bellomi D, Sgarbi L. Procalcitonin and C-reactive protein during systemic inflammatory response syndrome, sepsis and organ dysfunction. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 8:R234-42. [PMID: 15312223 PMCID: PMC522844 DOI: 10.1186/cc2877] [Citation(s) in RCA: 269] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2003] [Revised: 04/22/2004] [Accepted: 05/04/2004] [Indexed: 12/17/2022]
Abstract
Introduction Both C-reactive protein (CRP) and procalcitonin (PCT) are accepted sepsis markers. However, there is still some debate concerning the correlation between their serum concentrations and sepsis severity. We hypothesised that PCT and CRP concentrations are different in patients with infection or with no infection at a similar severity of organ dysfunction or of systemic inflammatory response. Patients and methods One hundred and fifty adult intensive care unit patients were observed consecutively over a period of 10 days. PCT, CRP and infection parameters were compared among the following groups: no systemic inflammatory response syndrome (SIRS) (n = 15), SIRS (n = 15), sepsis/SS (n = 71) (including sepsis, severe sepsis and septic shock [n = 34, n = 22 and n = 15]), and trauma patients (n = 49, no infection). Results PCT and CRP concentrations were higher in patients in whom infection was diagnosed at comparable levels of organ dysfunction (infected patients, regression of median [ng/ml] PCT = -0.848 + 1.526 sequential organ failure assessment [SOFA] score, median [mg/l] CRP = 105.58 + 0.72 SOFA score; non-infected patients, PCT = 0.27 + 0.02 SOFA score, P < 0.0001; CRP = 84.53 - 0.19 SOFA score, P < 0.005), although correlation with the SOFA score was weak (R = 0.254, P < 0.001 for PCT, and R = 0.292, P < 0.001 for CRP). CRP levels were near their maximum already during lower SOFA scores, whereas maximum PCT concentrations were found at higher score levels (SOFA score > 12). PCT and CRP concentrations were 1.58 ng/ml and 150 mg/l in patients with sepsis, 0.38 ng/ml and 51 mg/l in the SIRS patients (P < 0.05, Mann–Whitney U-test), and 0.14 ng/ml and 72 mg/l in the patients with no SIRS (P < 0.05). The kinetics of both parameters were also different, and PCT concentrations reacted more quickly than CRP. Conclusions PCT and CRP levels are related to the severity of organ dysfunction, but concentrations are still higher during infection. Different sensitivities and kinetics indicate a different clinical use for both parameters.
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Affiliation(s)
- Gian Paolo Castelli
- Intensive Care, Anesthesiology and Pain Relief Unit, 'C Poma' Hospital, Mantova, Italy
| | - Claudio Pognani
- Intensive Care, Anesthesiology and Pain Relief Unit, 'C Poma' Hospital, Mantova, Italy
| | - Michael Meisner
- Department of Anaesthesiology and Intensive Care Therapy, University of Jena, Germany
| | - Antonio Stuani
- Intensive Care, Anesthesiology and Pain Relief Unit, 'C Poma' Hospital, Mantova, Italy
| | - Daniela Bellomi
- Clinical Pathology Laboratory, 'C Poma' Hospital, Mantova, Italy
| | - Laura Sgarbi
- Intensive Care, Anesthesiology and Pain Relief Unit, 'C Poma' Hospital, Mantova, Italy
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Chan YL, Tseng CP, Tsay PK, Chang SS, Chiu TF, Chen JC. Procalcitonin as a marker of bacterial infection in the emergency department: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2003; 8:R12-20. [PMID: 14975050 PMCID: PMC420058 DOI: 10.1186/cc2396] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2003] [Accepted: 10/16/2003] [Indexed: 11/24/2022]
Abstract
Introduction Procalcitonin (PCT) has been proposed as a marker of infection in critically ill patients; its level is related to the severity of infection. We evaluated the value of PCT as a marker of bacterial infection for emergency department patients. Methods This prospective observational study consecutively enrolled 120 adult atraumatic patients admitted through the emergency department of a 3000-bed tertiary university hospital in May 2001. Fifty-eight patients were infected and 49 patients were not infected. The white blood cell counts, the serum C-reactive protein (CRP) level (mg/l), and the PCT level (ng/ml) were compared between the infected and noninfected groups of patients. Results A white blood cell count >12,000/mm3 or <4000/mm3 was present in 36.2% of the infected patients and in 18.4% of the noninfected patients. The best cut-off serum levels for PCT and CRP, identified using the Youden's Index, were 0.6 ng/ml and 60 mg/l, respectively. Compared with CRP, PCT had a comparable sensitivity (69.5% versus 67.2%), a lower specificity (64.6% versus 93.9%), and a lower area under the receiver operating characteristic curve (0.689 versus 0.879). PCT levels, but not CRP levels, were significantly higher in bacteremic and septic shock patients. Multivariate logistic regression identified that a PCT level ≥ 2.6 ng/ml was independently associated with the development of septic shock (odds ratio, 38.3; 95% confidence interval, 5.6–263.5; P < 0.001). Conclusions PCT is not a better marker of bacterial infection than CRP for adult emergency department patients, but it is a useful marker of the severity of infection.
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Affiliation(s)
- Yi-Ling Chan
- Attending Physician, Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
| | - Ching-Ping Tseng
- Associated Professor, The School of Medical Technology, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Kuei Tsay
- Assistant Professor, Center of Biostatistics, Chang Gung University, Taoyuan, Taiwan
| | - Shy-Shin Chang
- Attending Physician, Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
| | - Te-Fa Chiu
- Attending Physician, Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
| | - Jih-Chang Chen
- Chief, Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou Medical Center, Taoyuan, Taiwan
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Tugrul S, Esen F, Celebi S, Ozcan PE, Akinci O, Cakar N, Telci L. Reliability of procalcitonin as a severity marker in critically ill patients with inflammatory response. Anaesth Intensive Care 2002; 30:747-54. [PMID: 12500512 DOI: 10.1177/0310057x0203000605] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Procalcitonin (PCT) is increasingly recognised as an important diagnostic parameter in clinical evaluation of the critically ill. This prospective study was designed to investigate PCT as a diagnostic marker of infection in critically ill patients with sepsis. Eighty-five adult ICU patients were studied. Four groups were defined on the basis of clinical, laboratory and bacteriologic findings as systemic inflammatory response syndrome (SIRS) (n = 10), sepsis (n = 16), severe sepsis (n = 18) and septic shock (n = 41). Data were collected including C-reactive protein (CRP), PCT levels and Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II scores on each ICU day. PCT levels were significantly higher in patients with severe sepsis and septic shock (19.25 +/- 43.08 and 37.15 +/- 61.39 ng/ml) than patients with SIRS (0.73 +/- 1.37 ng/ml) (P < 0.05 for each comparison). As compared with SIRS patients, plasma PCT levels were significantly higher in infected patients (21.9 +/- 47.8 ng/ml), regardless of the degree of sepsis (P < 0.001). PCT showed a higher sensitivity (73% versus 35%) and specificity (83% versus 42%) compared to CRP in identifying infection as a cause of the inflammatory response. Best cut-off levels were 1.31 ng/ml for PCT and 13.9 mg/dl for CRP. We suggest that PCT is a more reliable marker than CRP in defining infection as a cause of systemic inflammatory response.
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Affiliation(s)
- S Tugrul
- Department of Anesthesiology and Intensive Care, Medical Faculty of Istanbul, Istanbul University, Istanbul, Turkey
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Reny JL, Vuagnat A, Ract C, Benoit MO, Safar M, Fagon JY. Diagnosis and follow-up of infections in intensive care patients: value of C-reactive protein compared with other clinical and biological variables. Crit Care Med 2002; 30:529-35. [PMID: 11990910 DOI: 10.1097/00003246-200203000-00006] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate diagnostic and prognostic values of C-reactive protein (CRP) dosage in critically ill patients. DESIGN Prospective, observational study. SETTING Medical intensive care unit (ICU) in a university hospital. PATIENTS A consecutive series of 74 patients admitted to the ICU. INTERVENTION CRP measurements at admission and every 4 days thereafter. MEASUREMENTS AND MAIN RESULTS At admission, 28 patients (38%) had microbiologically proven infections. Compared with uninfected patients, their mean +/- SD CRP level was 191 +/- 123 vs. 83 +/- 91 mg/L (p < .0001), respectively, white blood cell count was 15.3 +/- 7.5 vs. 11.4 +/- 5.3 G/L (p = .01), and the systemic inflammatory response syndrome (SIRS) was present for 96% vs. 67% (p = .008). No threshold value could be identified to discriminate between these two populations. Multivariate analysis retained CRP and SIRS as the only variables independently associated with the presence of an infection. The combination of CRP > or = 50 mg/L with SIRS was identified as the best model to diagnose infection at admission. This multivariate model performed better than temperature, CRP alone, and white blood cell count. Among the 28 infected patients, 10 recovered; CRP values decreased significantly in this population as compared with patients with persistent infection (-130 +/- 110 vs. 12 +/- 97 mg/L, respectively; p = .004). A CRP decrease > or = 50 mg/L between admission and day 4 was the best cutoff value to diagnose recovery (sensitivity 89%, specificity 79%). CONCLUSION CRP in combination with SIRS was useful to diagnose infection in ICU patients; a CRP decrease > or = 50 mg/L between admission and day 4 was the best predictor of recovery.
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Affiliation(s)
- Jean-Luc Reny
- Service de Réanimation Médicale, Hôpital Broussais, Paris, France
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Ugarte H, Silva E, Mercan D, De Mendonça A, Vincent JL. Procalcitonin used as a marker of infection in the intensive care unit. Crit Care Med 1999; 27:498-504. [PMID: 10199528 DOI: 10.1097/00003246-199903000-00024] [Citation(s) in RCA: 292] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine the value of procalcitonin (ProCT) as a marker of infection in critically ill patients. DESIGN Prospective, observational study. SETTING Medicosurgical department of intensive care (31 beds). PATIENTS One hundred eleven infected and 79 noninfected patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS ProCT and C-reactive protein (CRP) concentrations were monitored daily. The best cutoff values for ProCT and CRP were 0.6 ng/mL and 7.9 mg/dL, respectively. Compared with CRP, ProCT had a lower sensitivity (67.6 vs. 71.8), specificity (61.3 vs. 66.6), and area under the receiver operating characteristic curve (0.66 vs. 0.78, p < .05). The combination of ProCT and CRP increased the specificity for infection to 82.3%. In the infected patients, plasma ProCT, but not CRP, values were higher in nonsurvivors than in survivors. Infected patients with bacteremia had higher ProCT concentrations than those without bacteremia, but similar CRP concentrations. ProCT levels were particularly high in septic shock patients. CONCLUSIONS ProCT is not a better marker of infection than CRP in critically ill patients, but it can represent a useful adjunctive parameter to identify infection and is a useful marker of the severity of infection.
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Affiliation(s)
- H Ugarte
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium
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Abstract
Fungal infection in critically ill patients is an increasingly prevalent problem. Candida spp. cause the majority of these infections in ICU. They occur most commonly in patients with severe underlying illness, multiple courses of antibiotics and intravascular catheters. Clinical diagnosis is difficult due to nonspecific signs and the frequent occurrence of widespread superficial colonization with Candida spp. in ventilated patients. Most patients are diagnosed using inferential evidence of infection, such as persistent pyrexia despite antibiotics, raised serum C-reactive protein and the presence of individual risk factors. Amphotericin B and fluconazole are the most commonly used anti-fungals dependent on the identity of the fungus. Most of these infections are endogenous; however, a proportion may be caused via the hands of healthcare staff or contaminated medical equipment.
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Affiliation(s)
- P G Flanagan
- Department of Medical Microbiology, University of Wales College of Medicine, Cardiff, UK
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Yentis SM, Soni N, Sheldon J. C-reactive protein as an indicator of resolution of sepsis in the intensive care unit. Intensive Care Med 1995; 21:602-5. [PMID: 7593905 DOI: 10.1007/bf01700168] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To investigate the value of decreasing plasma C-reactive protein (CRP) concentrations as an indicator or resolution of microbiologically-proven sepsis. DESIGN Retrospective analysis of CRP concentrations measured during episodes of microbiologically-proven sepsis. A receiver-operating characteristic (ROC) curve was used to assess the usefulness of CRP as a test for resolution of sepsis. SETTING The intensive care unit (ICU) of a teaching hospital. PATIENTS AND PARTICIPANTS 32 episodes of microbiologically-proven sepsis occurring in 18 patients were followed from diagnosis until resolution. MEASUREMENTS AND RESULTS Daily routine observations and blood testing were performed prospectively. The daily presence or absence of systemic inflammatory response syndrome (SIRS) was prospectively determined according to standard definitions. Concentrations of CRP were analysed retrospectively once the patients had left the ICU. A decrease in CRP by 25% or more from the previous day's level was a good indicator of resolution of sepsis, with a sensitivity of 97%, specificity of 95% and predictive value of 97%. In 13 cases (46%), a decrease in CRP preceded clinical resolution of sepsis; this was more likely to occur in patients with less severe sepsis than in those with severe sepsis or septic shock. CONCLUSION Daily measurement of CRP is useful for monitoring the course of microbiologically-proven sepsis in ICU patients, and may be used to indicate successful treatment.
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Affiliation(s)
- S M Yentis
- Magill Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
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Yentis SM, Rowbottom AW, Riches PG. Detection of cytoplasmic IL-1 beta in peripheral blood mononuclear cells from intensive care unit (ICU) patients. Clin Exp Immunol 1995; 100:330-5. [PMID: 7743673 PMCID: PMC1534328 DOI: 10.1111/j.1365-2249.1995.tb03673.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Cytokines including IL-1 beta have been implicated in the pathophysiology of sepsis and the systemic inflammatory response. It is believed that certain critically ill patients may be 'primed' with respect to cytokine production, and that subsequent 'triggers' may cause exaggerated cytokine production in these patients with exacerbation of their clinical condition; however, no means of identifying 'primed' patients has been described. The presence of cytoplasmic IL-1 beta within peripheral blood mononuclear cells (PBMC) from patients in the ICU was investigated as a means of identifying 'primed' patients, using fluorescent antibody labelling and flow cytometry. The study revealed that PBMC from ICU patients had a different staining pattern for IL-1 beta than those from healthy subjects, and that PBMC from certain ICU patients did indeed stain strongly for IL-1 beta; however, the presence of these strongly staining cells was not associated with clinical condition or outcome. It is concluded that whilst it might be possible to identify 'primed' patients in the ICU using this technique, this is of no clinical value as a predictor of clinical course.
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Affiliation(s)
- S M Yentis
- Magill Department of Anaesthetics, Charing Cross & Westminster Medical School, Chelsea & Westminster Hospital, London, UK
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Iwagaki H, Hizuta A, Tanaka N, Orita K. Plasma neopterin/C-reactive protein ratio as an adjunct to the assessment of infection and cancer cachexia. Immunol Invest 1995; 24:479-87. [PMID: 7790044 DOI: 10.3109/08820139509066844] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Neopterin (NPT), a pteridine intermediate metabolite in the biopterine synthetic pathway, is synthesized and secreted by monocytes/macrophages upon stimulation, mainly by gamma-interferon produced by activated T cells. C-reactive protein (CRP) is one of the major acute-phase reactants and its release is thought to be mediated by interleukin-6. Plasma concentrations of NPT and CRP were synchronously analyzed in 25 determinations of 5 patients with severe infectious complications and 50 determinations of 10 cancer-burden patients representing cachexia. The mean value of NPT (pmol/ml) was 201.6 in the infection group and 16.5 in the cancer cachexia group. The mean value of CRP (mg/dl) was 12.5 in the infection group and 3.4 in the cancer cachexia group. The number of samples in which NPT alone exceeded the cut-off level were 0/25 (0%) in the infection group and 38/50 (76.0%) in the cancer cachexia group. The number of samples in which both NPT and CRP exceeded the cut-off level was 25/25 (100%) in the infection group and 12/50 (24.0%) in the cancer cachexia group. The mean ratio of NPT to CRP was 11.3 in the infection group and 30.7 in the cancer cachexia group, respectively. These results suggest that gamma-interferon could play the principal role in the pathogenesis of cancer cachexia and that interleukin-6 modified the disease status. Interleukin-6 would be the critical mediator of host responses in infectious complications.
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Affiliation(s)
- H Iwagaki
- First Department of Surgery, Okayama University Medical School, Japan
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