Procalcitonin, C-Reactive Protein, Albumin, and Blood Cultures as Early Markers of Sepsis Diagnosis or Predictors of Outcome: A Prospective Analysis

A simple nomogram for predicting the mortality of PICU patients with sepsis-associated encephalopathy: a multicenter retrospective study

Background

As one of the serious complications of sepsis in children, sepsis-associated encephalopathy (SAE) is associated with significantly poor prognosis and increased mortality. However, predictors of outcomes for pediatric SAE patients have yet to be identified. The aim of this study was to develop nomograms to predict the 14-day and 90-day mortality of children with SAE, providing early warning to take effective measures to improve prognosis and reduce mortality.

Methods

In this multicenter, retrospective study, we screened 291 patients with SAE admitted to the PICU between January 2017 and September 2022 in Shandong Province. A least absolute shrinkage and selector operation (LASSO) method was used to identify the optimal prognostic factors predicting the outcomes in pediatric patients with SAE. Then, multivariable logistic regression analysis was performed based on these variables, and two nomograms were built for visualization. We used the area under the curve (AUC), calibration curves and decision curves to test the accuracy and discrimination of the nomograms in predicting outcomes.

Results

There were 129 patients with SAE in the training cohort, and there were 103 and 59 patients in the two independent validation cohorts, respectively. Vasopressor use, procalcitonin (PCT), lactate and pediatric critical illness score (PCIS) were independent predictive factors for 14-day mortality, and vasopressor use, PCT, lactate, PCIS and albumin were independent predictive factors for 90-day mortality. Based on the variables, we generated two nomograms for the early identification of 14-day mortality (AUC 0.853, 95% CI 0.787-0.919, sensitivity 72.4%, specificity 84.5%) and 90-day mortality (AUC 0.857, 95% CI 0.792-0.923, sensitivity 72.3%, specificity 90.6%), respectively. The calibration plots for nomograms showed excellent agreement of mortality probabilities between the observed and predicted values in both training and validation cohorts. Decision curve analyses (DCA) indicated that nomograms conferred high clinical net benefit.

Conclusion

The nomograms in this study revealed optimal prognostic factors for the mortality of pediatric patients with SAE, and individualized quantitative risk evaluation by the models would be practical for treatment management.

Prognostic Potential of Thrombocyte Indices, Acute Phase Proteins, Electrolytes and Acid-Base Markers in Canine Parvovirus Infected Dogs With Systemic Inflammatory Response Syndrome

Dogs with canine parvovirus enteritis (CPVE) that develop systemic inflammatory response syndrome (SIRS) frequently have a poor prognosis. The aim of the study was to assess the prognostic potential of thrombocyte indices, acute phase proteins, electrolytes, and acid-base markers in CPVE puppies with SIRS (CPVE-SIRS+) at admission. A case-controlled, prospective, and observational study was performed on 36 CPVE puppies. Mean concentrations of C-reactive protein (CRP), albumin, thrombocyte count, mean platelet volume (MPV), platelet distribution width (PDW), sodium (Na+), potassium (K+), chloride (Cl-) and ionized calcium (iCa) were measured and strong ion difference 3 (SID3), ATOT-albumin and ATOT-total protein were determined in CPVE-SIRS+ survivors and nonsurvivors. A prognostic cut-off value for predicting the disease outcome was determined by receiver operating characteristic (ROC) curve analysis. The mean values of MPV, PDW and CRP were significantly higher and the mean values of albumin, Cl- and ATOT-albumin were significantly lower in CPVE-SIRS+ nonsurvivor than CPVE-SIRS+ survivor puppies on the day of admission, but the thrombocyte count, Na+, K+, iCa, SID3 and ATOT- total protein values did not differ significantly. The positive predictive values (PPVs) for survival using cut-off value of MPV (≤15.08 fL), PDW (≤14.85%), CRP (≤180.7 mg/L), albumin (≥1.795 g/dL), Cl- (≥96.00 mmol/L), and ATOT-albumin (≥7.539) were determined as 100%, 100%, 100%, 80%, 100%, and 80%, respectively with better area under ROC curve and sensitivity. Based on sensitivity, specificity, and PPVs from ROC analysis, it is concluded that the determination of Cl- concentration and MPV at admission followed by CRP will serve as the most appropriate biomarkers in predicting the disease outcome of CPVE puppies that develop SIRS.

Albumin Infusion May Improve the Prognosis of Critical COVID-19 Patients with Hypoalbuminemia in the Intensive Care Unit: A Retrospective Cohort Study

Background

The coronavirus disease 2019 (COVID-19) pandemic has caused enormous mortality worldwide. Low albumin level is a risk factor for increasing mortality among patients in the intensive care unit (ICU). This study investigated the effect of albumin infusion on critical COVID-19 patients with hypoalbuminemia.

Methods

A total of 114 COVID-19 ICU patients with hypoalbuminemia were recruited from Wuhan Leishenshan Hospital and Zhongnan Hospital of Wuhan University. Clinical features and laboratory variables were collected through electronic medical records. The cohorts were divided into two groups: albumin infusion and non-albumin infusion. Propensity-matched analysis was used to compare patients who received albumin to controls. Statistical analyses were used to investigate the survival time and inflammation-related blood biomarkers between groups.

Results

Lactate dehydrogenase, interleukin (IL)-6, IL-2 receptor, and IL-8 levels were significantly downregulated in the albumin infusion group. Significant upregulations of lymphocyte counts and IL-10 were found in the albumin infusion group. There was a negative association between albumin level and D-dimer or procalcitonin levels after treatment. The albumin infusion group had a significantly longer survival time and shorter hospitalization time than control patients. Notably, a 1g increase in albumin level reduced the risk of death by approximately 7.3% after adjusting for age and sex. Patients with increased albumin levels after treatment had better prognoses than those without.

Conclusion

Albumin administration can regulate COVID-19-related biomarkers and reduce the risk of death in critical patients with hypoalbuminemia. Clinicians should pay more attention to these risk factors. Targeted clinical interventions should be implemented to minimize the negative impacts of hypoalbuminemia and improve disease outcomes.

The diagnostic utility of IL-10, IL-17, and PCT in patients with sepsis infection

Objective

The purpose of this study is to determine the diagnostic value and net clinical benefit of interleukin-10 (IL-10), interleukin-17 (IL-17), procalcitonin (PCT), and combination tests in patients with sepsis, which will serve as a standard for sepsis early detection.

Patients and methods

An investigation of 84 sepsis patients and 81 patients with local inflammatory diseases admitted to the ICU of Tongji University Hospital in 2021. In addition to comparing inter-group variability, indicators relevant to sepsis diagnosis and therapy were screened.

Results

LASSO regression was used to examine PCT, WBC, CRP, IL-10, IFN-, IL-12, and IL-17. Multivariate logistic regression linked IL-10, IL-17, and PCT to sepsis risk. The AUC values of IL-10, IL-17, PCT, and the combination of the three tests were much higher than those of standard laboratory infection indicators. The combined AUC was greater than the sum of IL-10, IL-17, and PCT (P < 0.05). A clinical decision curve analysis of IL-10, IL-17, PCT, and the three combined tests found that the three combined tests outperformed the individual tests in terms of total clinical benefit rate. To predict the risk of sepsis using IL-10, IL-17, and PCT had an AUC of 0.951, and the model's predicted probability was well matched. An examination of the nomogram model's clinical value demonstrated a considerable net therapeutic benefit between 3 and 87%.

Conclusion

The IL-10, IL-17, and PCT tests all have a high diagnostic value for patients with sepsis, and the combination of the three tests outperforms the individual tests in terms of diagnostic performance, while the combined tests have a higher overall clinical benefit rate.

The Association Between FT3 With the Outcome and Inflammation/Coagulopathy/Fibrinolysis of COVID-19

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has caused substantial threats to people's physical health and lives, claiming the lives of over 5 million people worldwide. It is imperative to identify the disease severity and intervene with effective therapy as early as possible. Previous studies have shown that low free triiodothyronine (FT3) may possess the predictive value on COVID-19 prognosis.

METHODS

In this retrospective cohort study, 15-day clinical and laboratory data of 186 hospitalized patients of COVID-19 after admission were analyzed. Groups were based on the disease severity of COVID-19, survival or non-survival, and presence or absence of euthyroid sick syndrome (ESS). Categorical variables were compared with the chi-square test or Fisher's exact test. Continuous variables were tested by Wilcoxon rank-sum test for the non-normal distribution. Spearman correlations were used to assess the correlations between FT3 with clinic parameters of multiple time points.

RESULTS

The non-survival patients had significant lower levels of FT3 (3.24 ± 0.42 vs. 4.19 ± 0.08 pmol/L, p < 0.05) and thyroid-stimulating hormone (TSH) (0.69 ± 0.19 vs. 2.32 ± 0.2 uIU/ml, p < 0.05), and the FT3 of severe patients was significantly lower than that of non-severe patients (3.67 ± 0.14 vs. 4.33 ± 0.09 pmol/L, p < 0.05). Fifty-nine cases of COVID-19 patients were diagnosed with ESS. Compared with non-ESS patients, those with ESS were older and had higher proportions of fever, shortness of breath, hypertension, diabetes, severe disease, and mortality. In addition, the correlation analysis between FT3 and clinical parameters showed that FT3 were positively related to the lymphocyte count and albumin and negatively correlated with C-reactive protein, erythrocyte sedimentation rate, and D-dimer at all time points in the first 15 days after admission.

CONCLUSION

Low FT3 had a significant predictive value on the prognosis of COVID-19 patients, and FT3 was significantly related with clinic parameters of inflammation/coagulopathy/fibrinolysis.

Diagnostic Value of sIL-2R, TNF-α and PCT for Sepsis Infection in Patients With Closed Abdominal Injury Complicated With Severe Multiple Abdominal Injuries

Objective

We aimed to evaluate the diagnostic value of soluble interleukin-2 receptor (sIL-2R), tumor necrosis factor-α (TNF-α), procalcitonin (PCT), and combined detection for sepsis infection in patients with closed abdominal injury complicated with severe multiple abdominal injuries.

Patients and Methods

One hundred forty patients with closed abdominal injury complicated with severe multiple abdominal injuries who were diagnosed and treated from 2015 to 2020 were divided into a sepsis group (n = 70) and an infection group (n = 70).

Results

The levels of sIL-2R, TNF-α, and PCT in the sepsis group were higher than those in the infection group (p < 0.05). The receiver operating characteristic (ROC) curve showed that the areas under the ROC curve (AUCs) of sIL-2R, TNF-α, PCT and sIL-2R+TNF-a+PCT were 0.827, 0.781, 0.821, and 0.846, respectively, which were higher than those of white blood cells (WBC, 0.712), C-reactive protein (CRP, 0.766), serum amyloid A (SAA, 0.666), and IL-6 (0.735). The AUC of the three combined tests was higher than that of TNF-α, and the difference was statistically significant (p < 0.05). There was no significant difference in the AUCs of sIL-2R and TNF-α, sIL-2R and PCT, TNF-α and PCT, the three combined tests and sIL-2R, and the three combined tests and PCT (p > 0.05). When the median was used as the cut point, the corrected sIL-2R, TNF-α, and PCT of the high-level group were not better than those of the low-level group (p > 0.05). When the four groups were classified by using quantile as the cut point, the OR risk values of high levels of TNF-α and PCT (Q4) and the low level of PCT (Q1) after correction were 7.991 and 21.76, respectively, with statistical significance (p < 0.05).

Conclusions

The detection of sIL-2R, TNF-α, and PCT has good value in the diagnosis of sepsis infection in patients with closed abdominal injury complicated with severe multiple abdominal injuries. The high concentrations of PCT and TNF-α can be used as predictors of the risk of septic infection.

Procalcitonin as a biomarker of bacterial infection in critically ill patients admitted with suspected Sepsis in Intensive Care Unit of a tertiary care hospital

OBJECTIVE

To compare the diagnostic accuracy of procalcitonin (PCT), C- reactive protein (CRP), total leukocyte count (TLC) and lactate in critically ill patients admitted with suspicion of sepsis.

METHODS

It was a cross sectional study conducted at the department of Chemical Pathology and Endocrinology AFIP, Rawalpindi, in collaboration with Medical and surgical intensive care units (ICU) of CMH Rawalpindi from January 2019 to December 2019. A total of 126 patients of both genders with age above 18 years and fulfilling the inclusion criteria of systemic inflammatory response syndrome (SIRS) were inducted in the study.

RESULTS

Out of 126 patients 82 (65%) patients have positive blood culture results. Male predominance was noted in patients with positive blood culture. Out of 82 patients with positive blood culture results 69(84%) patients have positive PCT results as well whereas 13(15%) patients with positive blood culture results have negative PCT values. 57(69%) patients had Gram negative bacterial infection and 25(30%) patients had Gram positive bacterial infection. Significant difference was noted between the medians of PCT in blood culture positive and blood culture negative group (p value< 0.05) whereas no significant difference was found between medians of CRP, TLC and lactate between blood culture positive and blood culture negative patients (p value > 0.05). ROC curve analysis of PCT, CRP and TLC were done, keeping blood culture as reference standard, PCT showed largest area under the curve (AUC) and clearly outperformed TLC and CRP. PCT showed AUC of 0.781 as compared to CRP and TLC, which was 0.568 and 0.617 respectively. PCT showed sensitivity of 93.9%, specificity of 47.7%, positive predictive value (PPV) of 77% and negative predictive value (NPV) of 80.8%.

CONCLUSION

Higher NPV makes it a reliable marker for screening out sepsis in suspected cases.

Microbiological findings in emergency department patients with sepsis identified by the Sepsis-3 criteria: a single-center prospective population-based cohort study

Background

Studies comparing the microbiological profiles among sepsis patients identified with either Sequential Organ Failure Assessment (SOFA) score or systemic inflammatory response syndrome (SIRS) criteria are limited. The aim was to examine if there are differences in the microbiological findings among septic patients identified by Sepsis-3 criteria compared to patients identified by the previous sepsis criteria, SIRS, and without organ failure. A secondary purpose was to examine if we could identify microbiological characteristics with increased risk of 28-day mortality.

Methods

Prospective cohort study of all adult (≥ 18 years) patients admitted with sepsis to the Emergency Department of Slagelse Hospital, Denmark from 1st October 2017 to 31st March 2018. Information regarding microbiological findings was obtained via linkage between a sepsis database and the local microbiological laboratory data system. Data regarding 28-day mortality were obtained from the Danish Civil Registration System. We used logistic regression to estimate the association between specific microbiological characteristics and 28-day mortality.

Results

A total of 1616 patients were included; 466 (28.8%; 95% CI 26.6%-31.1%) met SOFA criteria, 398 (24.6%; 95% CI 22.5–26.8%) met SIRS criteria. A total of 127 patients (14.7%; 95% CI 12.4–17.2%) had at least one positive blood culture. SOFA patients had more often positive blood cultures compared to SIRS (13.9% vs. 9.5%; 95 CI on difference 0.1–8.7%). Likewise, Gram-positive bacteria (8.6% vs. 2.8%; 95 CI on difference 2.8–8.8%), infections of respiratory origin (64.8% vs. 57.3%; 95 CI on difference 1.0–14%), Streptococcus pneumoniae (3.2% vs. 1.0%; 95% CI on difference 0.3–4.1) and polymicrobial infections (2.6% vs. 0.3% 95 CI on difference 0.8–3.8%) were more common among SOFA patients. Polymicrobial infections (OR 3.70; 95% CI 1.02–13.40), Staphylococcus aureus (OR 6.30; 95% CI 1.33–29.80) and a pool of “other” microorganisms (OR 3.88; 95% CI 1.34–9.79) in blood cultures were independently associated with mortality.

Conclusion

Patients identified with sepsis by SOFA score were more often blood culture-positive. Gram-positive pathogens, pulmonary tract infections, Streptococcus pneumoniae, and polymicrobial infections were also more common among SOFA patients. Polymicrobial infection, Staphylococcus aureus, and a group of other organisms were independently associated with an increased risk of death.

Circulating Complement C3-Alpha Chain Levels Predict Survival of Septic Shock Patients

BACKGROUND

Circulating complement C3 fragments released during septic shock might contribute to the development of complications such as profound hypotension and disseminated intravascular coagulation. The role of C3 in the course of septic shock varies in the literature, possibly because circulating C3 exists in different forms indistinguishable via traditional ELISA-based methods. We sought to test the relationship between C3 forms, measured by Western blotting with its associated protein size differentiation feature, and clinical outcomes.

METHODS

Secondary analysis of two prospective cohorts of patients with septic shock: a discovery cohort of 24 patents and a validation cohort of 181 patients. C3 levels were measured by Western blotting in both cohorts using blood obtained at enrollment. Differences between survivors and non-survivors were compared, and the independent prognostic values of C3 forms were assessed.

RESULTS

In both cohorts there were significantly lower levels of the C3-alpha chain in non-survivors than in survivors, and persisted after controlling for sequential organ failure assessment score. Area under the receiver operating characteristics to predict survival was 0.65 (95% confidence interval: 0.56-0.75). At a best cutoff value (Youden) of 970.6 μg/mL, the test demonstrated a sensitivity of 68.5% and specificity of 61.5%. At this cutoff point, Kaplan-Meier survival analysis showed that patients with lower levels of C3-alpha chain had significantly lower survival than those with higher levels (P < 0.001).

CONCLUSION

Circulating C3-alpha chain levels is a significant independent predictor of survival in septic shock patients.

Acute kidney injury adversely affects the clinical course of acute myeloid leukemia patients undergoing induction chemotherapy

Acute kidney injury (AKI) complicates the clinical course of hospitalized patients by increasing need for intensive care treatment and mortality. There is only little data about its impact on AML patients undergoing intensive induction chemotherapy. In this study, we analyzed the incidence as well as risk factors for AKI development and its impact on the clinical course of AML patients undergoing induction chemotherapy. We retrospectively analyzed data from 401 AML patients undergoing induction chemotherapy between 2007 and 2019. AKI was defined and stratified according to KIDGO criteria by referring to a defined baseline serum creatinine measured on day 1 of induction chemotherapy. Seventy-two of 401 (18%) AML patients suffered from AKI during induction chemotherapy. AML patients with AKI had more days with fever (7 vs. 5, p = 0.028) and were more often treated on intensive care unit (45.8% vs. 10.6%, p < 0.001). AML patients with AKI had a significantly lower complete remission rate after induction chemotherapy and, with 402 days, a significantly shorter median overall survival (OS) (median OS for AML patients without AKI not reached). In this study, we demonstrate that the KIDGO classification allows mortality risk stratification for AML patients undergoing induction chemotherapy. Relatively mild AKI episodes have impact on the clinical course of these patients and can lead to chronic impairment of kidney function. Therefore, we recommend incorporating risk factors for AKI in decision-making considering nutrition, fluid management, as well as the choice of potentially nephrotoxic medication in order to decrease the incidence of AKI.

Usefulness of ischemia-modified albumin in the diagnosis of sepsis/septic shock in the emergency department

Objective

No studies have evaluated the diagnostic value of ischemia-modified albumin (IMA) for the early detection of sepsis/septic shock in patients presenting to the emergency department (ED). We aimed to assess the usefulness of IMA in diagnosing sepsis/septic shock in the ED.

Methods

This retrospective, observational study analyzed IMA, lactate, high sensitivity C-reactive protein, and procalcitonin levels measured within 1 hour of ED arrival. Patients with suspected infection meeting at least two systemic inflammatory response syndrome criteria were included and classified into the infection, sepsis, and septic shock groups using Sepsis-3 definitions. Areas under the receiver operating characteristic curves (AUCs) with 95% confidence intervals (CIs) and multivariate logistic regression were used to determine diagnostic performance.

Results

This study included 300 adult patients. The AUC (95% CI) of IMA levels (cut-off ≥85.5 U/mL vs. ≥87.5 U/mL) was higher for the diagnosis of sepsis than for that of septic shock (0.729 [0.667–0.791] vs. 0.681 [0.613–0.824]) and was higher than the AUC of procalcitonin levels (cut-off ≥1.58 ng/mL, 0.678 [0.613–0.742]) for the diagnosis of sepsis. When IMA and lactate levels were combined, the AUCs were 0.815 (0.762–0.867) and 0.806 (0.754–0.858) for the diagnosis of sepsis and septic shock, respectively. IMA levels independently predicted sepsis (odds ratio, 1.05; 95% CI, 1.00–1.09; P=0.029) and septic shock (odds ratio, 1.07; 95% CI, 1.02–1.11; P=0.002).

Conclusion

Our findings indicate that IMA levels are a useful biomarker for diagnosing sepsis/ septic shock early, and their combination with lactate levels can enhance the predictive power for early diagnosis of sepsis/septic shock in the ED.

The alveolar-arterial gradient, pneumonia severity scores and inflammatory markers to predict 30-day mortality in pneumonia

OBJECTIVE

The objective of this study was to evaluate the association of elevated alveolar-arterial oxygen (A-a O₂) gradient with risk of mortality in hospitalized patients with community-acquired pneumonia (CAP).

METHODS

This prospective study included 206 patients diagnosed with CAP admitted to the ED. Demographics, comorbidities, arterial blood gas, serum electrolytes, liver-renal functions, complete blood count, NLR, PLR, CRP, CAR, procalcitonin, A-a O₂ gradient, expected A-a O₂ and A-a O₂ difference were evaluated. PSI and CURB-65 scores were classified as follow: a) PSI low risk (I-III) and moderate-high risk (IV-V) groups; b) CURB-65; low risk (0-2) and high risk (3-5) groups.

RESULTS

The survival rates of the PSI class (I-III) were significantly higher than the ones of the PSI class (IV-V) (92.1% vs. 62.9%, respectively). The percentage of survivors of the CURB-65 score (0-2) group (81.9%) was higher than the survivors of CURB-65 score (3-5) group (27.8%). Creatinine, BUN, uric acid, phosphorus, RDW, CRP, CAR, procalcitonin, lactate, A-a 0₂ gradient, expected A-a 0₂ and A-a 0₂ difference were significantly higher and basophil was lower in non-survivors. A-a O₂ gradient (AUC 0.78), A-a O₂ difference (AUC 0.74) and albumin (AUC 0.80) showed highest 30-day mortality prediction. NLR (AUC 0.58) and PLR (AUC 0.55) showed lowest 30-day mortality estimation. Procalcitonin (AUC 0.65), PSI class (AUC 0.81) and PSI score (AUC 0.86) indicated statistically significant higher 30-day mortality prediction.

CONCLUSION

A-a O₂ gradient, A-a O₂ difference and albumin are potent predictors of 30-day mortality in CAP patients in the ED.