Serum procalcitonin and C-reactive protein as indices of early sepsis and mortality in North Indian pediatric burn injuries: a prospective evaluation and literature review

BACKGROUND

Delays in diagnosing sepsis in children afflicted with thermal injuries can result in high morbidity and mortality. Our study evaluated the role of the biomarkers Procalcitonin (PCT) and C-reactive protein (CRP) as predictors of early sepsis and mortality, respectively, in this group of patients.

METHODS

This was a prospective evaluation of 90 pediatric burn cases treated at a tertiary care burn center in Northern India. Patients, aged 1-16 years, presenting within 24 hours of being burned, with >10% body surface area of burn injury were included in the study. Levels of PCT and CRP were measured on days 1, 3, 5, and 7. Patients were followed until discharge, 30th post-burn day, or death, whichever occurred first.

RESULTS

Sepsis was clinically present in 49 of 90 (54.4%) cases with a median 30% total body surface area (TBSA) of burns. Mortality was seen in 31 of 90 (34.4%) cases with a median of 35% TBSA burns. High PCT and CRP were seen in the sepsis group, particularly on days 3, 5, and 7. PCT was also significantly higher in the mortality group (days 1 and 3).

CONCLUSIONS

While PCT was a good early predictor of sepsis and mortality in children with burns, CRP was reliable as a predictor of sepsis only. Both markers, however, can serve as adjuncts to culture sensitivity reports for diagnosing early onset sepsis and initiation of antibiotic therapy in appropriate patients.

Use of procalcitonin as a biomarker for sepsis in pediatric burns

Infection and sepsis continue to be the leading cause of morbidity and death in burn injuries. Diagnosing sepsis in burns is challenging as signs and symptoms of sepsis are not specific and overlap with those related to the burn injury. While the use of procalcitonin (PCT) as a biomarker is recommended for diagnosing sepsis in burns, evidence for children with burns is scarce. In this study, we aimed to investigate the role of PCT in distinguishing sepsis in pediatric burns. A prospective observational study was conducted in a single pediatric burn unit. Children hospitalized with burns ≤ 30% of total body surface area were included while patients with chemical burn, inhalation injury, or concomitant chronic diseases were excluded. Patients were classified into three groups for sepsis, systemic inflammatory response syndrome (SIRS), or controls using the American Burn Association (ABA) criteria. The predictive role of C-reactive protein (CRP) and PCT was investigated for distinguishing sepsis. Seventy-two patients were included in the study. The median total body surface area (TBSA) size was 12% (2.0-28.5%), and the median abbreviated burn severity index (ABSI) score was 3 (2-7). The median length of burn unit stay was 9.5 days (1-59 days). Sepsis was diagnosed in 11 patients (15.2%), and SIRS was present in 23 patients (40.0%), whereas 38 patients (52.8%) had neither SIRS nor sepsis (control group). Receiver operating characteristic analysis revealed that CRP and PCT levels distinguished sepsis patients from non-sepsis patients while PCT had a higher positive predictive value (50.0% vs. 45.0%). Optimal cutoff values of CRP and PCT for distinguishing sepsis were 66.75 mg/L and 0.95 ng/mL.

CONCLUSIONS

PCT levels could distinguish sepsis in children with burn injuries, performing better than CRP levels. Confirmatory studies are needed to evaluate the development of sepsis and the role of PCT in diagnosing sepsis in pediatric burn patients.

WHAT IS KNOWN

• Even though there are excellent criteria for the diagnosis of infection and sepsis in children and several clinical parameters and biomarkers are being studied, it's difficult to diagnose burn wound sepsis in children.

WHAT IS NEW

• Data from this study showed that procalcitonin levels performed better than CRP levels as a biomarker for distinguishing sepsis from systemic inflammatory response syndrome (SIRS) in children with burn injuries.

Infections in Patients with Major Burns: A Retrospective Study of a Burn Intensive Care Unit

OBJECTIVES

Burn related infections are challenging conditions to manage and can cause several complications entailing a complicated treatment. In this study infection in burn patients hospitalized in burn intensive care unit (ICU) of a tertiary care hospital is investigated.

MATERIAL AND METHODS

This retrospective study was conducted between 1 January 2018 and 31 December 2020 in burn ICU of a tertiary care hospital. Patients with an ICU stay less than 48 hours and survival less than 72 hours were not included in the study. The demographic and clinical data as well as referral status, the type of infections and the isolated microorganisms, antibiotics used for prophylaxis, outcomes and the mortality rate are evaluated retrospectively from patient files and the hospital registries.

RESULTS

A total of 311 patients were included in our study cohort with a mean age of 22.11±20.9 years. The burned total body surface area was 28.07±17.1 and abbreviated burn severity index was 5.76±2.3. There were 155 patients with 283 infections and the infection rate was 45.8 per 1000 patient days. The most commonly isolated microorganisms were Candida species in blood-stream and urinary tract infections, Pseudomonas aeruginosa in burn wound infections. Most of the deaths (86.7%) occurred in patients with infections.

CONCLUSIONS

In major burns strict adherence to isolation procedures, avoiding delays in referrals, early excision and early wound closure are important measures to reduce infections. Each burn center should develop appropriate antibiotic strategies due to their culture results and prophylaxis with broad spectrum antibiotics should be avoided.

Multicentre, longitudinal, observational cohort study to examine the relationship between neutrophil function and sepsis in adults and children with severe thermal injuries: a protocol for the Scientific Investigation of the Biological Pathways Following Thermal Injury-2 (SIFTI-2) study

INTRODUCTION

Burn-induced changes in the phenotype and function of neutrophils, cells which provide front-line protection against rapidly dividing bacterial infections, are emerging as potential biomarkers for the early prediction of sepsis. In a longitudinal study of adult burns patients, we recently demonstrated that a combined measurement of neutrophil phagocytic capacity, immature granulocyte (IG) count and plasma cell-free DNA (cfDNA) levels on the day of injury gave good discriminatory power for the prediction of later sepsis development. However, limited by a small sample size, single-centre design and focus on adult burns patients, these biomarkers require prospective validation in a larger patient cohort. The Scientific Investigation of the Biological Pathways Following Thermal Injury-2 study aims to prospectively validate neutrophil phagocytic activity, IG count and plasma cfDNA levels as early prognostic biomarkers of sepsis in thermally injured adult and paediatric patients.

METHODS AND ANALYSIS

This multicentre, longitudinal, observational cohort study will enrol 245 paediatric and adult patients with moderate to severe burns within 24 hours of injury. Blood samples will be obtained at 19 postinjury time points (days 1-14, day 28, months 3, 6, 12 and 24) and analysed for neutrophil phagocytic activity, IG count and cfDNA levels. Patients will be screened daily for sepsis using the 2007 American Burn Association diagnostic criteria for sepsis. In addition, daily multiple organ dysfunction syndrome and Sequential Organ Failure Assessment Scores will be recorded relationships between neutrophil phagocytic activity, IG count and plasma cfDNA levels on day 1 of injury and the development of sepsis will be examined using logistic regression models.

ETHICS AND DISSEMINATION

This study received ethics approval from the West Midlands, Coventry and Warwickshire Research Ethics Committee (REC reference:16/WM/0217). Findings will be presented at national and international conferences, and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04693442.