Significance of serum procalcitonin as biomarker for detection of bacterial peritonitis: a systematic review and meta-analysis

Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics

How to cite this article: Khilnani GC, Tiwari P, Zirpe KG, Chaudhary D, Govil D, Dixit S, et al. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022;26(S2):S77-S94.

Particularities of diagnosis in an elderly patient with neglected peritonitis: a case report

Acute peritonitis accounts for 1% of inpatient surgical emergencies and is the second leading cause of sepsis in patients in intensive care departments. Diagnosis through laboratory analysis in bacterial peritonitis focuses mainly on the biomarkers, procalcitonin and C-reactive protein. A 73-year-old male patient presented with meteorism, diarrhea, vomiting, fever, and hypotension. Laboratory investigations showed very high procalcitonin and C-reactive protein values, and abdominal radiography revealed paraumbilical hydroaerial levels, which suggested septic shock of intra-abdominal origin. Emergency laparotomy was performed, which revealed agglutinated intestinal loops in the right iliac fossa with false membranes, purulent fluid, overdistended jejunum and ileum with an occlusive appearance, acute gangrenous appendicitis with perforation, and suppurative omentitis. The intraoperative diagnosis was acute neglected peritonitis in the occlusive phase owing to acute gangrenous appendicitis with perforation and suppurative omentitis. Laboratory analysis in conjunction with imaging provides important information in the early diagnosis of infectious pathology in elderly patients, even if these methods do not accurately identify the cause. The combination of procalcitonin and C-reactive protein biomarker levels successfully contributed to the diagnosis in this case. Notably, the patient’s white blood cell counts were inconsistent with the severity of the infection.

Biomarkers of sepsis in pigs, horses and cattle: from acute phase proteins to procalcitonin

Sepsis is a complex clinical syndrome triggered by an inflammatory host response to an infection. It is usually complicated to detect and diagnose, and has severe consequences in human and veterinary health, especially when treatment is not started early. Therefore, efforts to detect sepsis accurately are needed. In addition, its proper diagnosis could reduce the misuse of antibiotics, which is essential fighting against antimicrobial resistance. This case is a particular issue in farm animals, as antibiotics have been traditionally given massively, but now they are becoming increasingly restricted. When sepsis is suspected in animals, the most frequently used biomarkers are acute phase proteins such as C-reactive protein, serum amyloid A and haptoglobin, but their concentrations can increase in other inflammatory conditions. In human patients, the most promising biomarkers to detect sepsis are currently procalcitonin and presepsin, and there is a wide range of other biomarkers under study. However, there is little information on the application of these biomarkers in veterinary species. This review aims to describe the general concepts of sepsis and the current knowledge about the biomarkers of sepsis in pigs, horses, and cattle and to discuss possible advances in the field.

Procalcitonin is one of the predictive factors of dehiscence of the colorectal anastomosis

Background/Aim: Dehiscence of the colorectal anastomosis is one of the most serious complications in digestive surgery that is still present in a large percentage today, which significantly increases the cost of treatment and can lead to death. Due to all the above, early detection of anastomotic dehiscence is very important, as well as the decision on surgical treatment. Procalcitonin (PCT) is thought to be an important marker of inflammation and sepsis. Aim of this paper was to confirm PCT as a marker of great sensitivity in early diagnosis of anastomotic leakage. Methods: The study included patients who underwent surgery for colorectal cancer in the period from 2016 to 2020. Patients were operated according to an elective protocol and with an open surgical approach. In patients, PCT values were measured on the 2nd and 4th postoperative day (POD) to determine the association between elevated PCT values and the onset of dehiscence of the colorectal anastomosis. Results: A study was conducted in 118 patients in whom a stapler colorectal anastomosis was created. Colorectal anastomosis dehiscence occurred in 10 patients. In 4 patients with dehiscence, no re-surgical intervention was required, but they were taken care of by conservative methods. Repeated surgery was performed in 6 patients. In all patients with dehiscence, there was a multiple increase in the value of PCT above normal. Conclusion: PCT has high sensitivity and specificity (85 and 74 % respectively) as a marker in dehiscence of colorectal anastomosis. In this study it was found that PCT values were significantly correlated with the dehiscence of anastomo-sis 2nd POD and especially 4th POD.

D, Hassan AS, Zahran FE, Abdelghany RS, Siddik RI, Abdel-Hamed AR. The Role of MicroRNAs (miRNA 155, miRNA-146b) and Procalcitonin as Novel Markers for the Diagnosis of Spontaneous Bacterial Peritonitis

Background:

MircoRNAs are endogenous, small non-coding RNA molecules that have been recognized as important modulators of gene expression. MicroRNA is considered one of the potential biomarkers of infection and inflammation. Our study aims to identify the potential role of miRNA-155, miRNA-146b, and Procalcitonin (PCT) in the early detection of spontaneous bacterial peritonitis in cirrhotic liver patients. miRNA-155 and 146b are molecular biomarkers , while procalcitonin is a serum marker in ascites patients complicated with Spontaneous Bacterial Peritonitis (SBP) .

Methods:

This study was conducted on 199 patients, 101 of them have ascites complicated with spontaneous bacterial peritonitis, and 98 patients without spontaneous bacterial peritonitis (control group). Ascitic fluid samples were collected from patients with SBP undergoing paracentesis at National Hepatology Institute in Egypt. MicroRNAs were determined in the serum using qPCR (quantitative polymerase chain reaction), while procalcitonin has been assessed in serum samples using ELISA (Enzyme-linked immune assay) technique.

Results:

Serum levels of miRNA-146b & miRNA-155 were significantly higher (p<0.001) in spontaneous bacterial peritonitis patients (79.2% and 97.0% respectively) than ascites patients (17.3% and 7.1%, respectively). Furthermore, the serum level of procalcitonin was significantly higher (p<0.001) in spontaneous bacterial peritonitis patients than that in ascites patients (68.3% and 27.6%, respectively).

Conclusion:

miRNA-155, miRNA-146b and procalcitonin can be used as early markers for the detection of SBP in hepatic patients with ascites.

Ascitic calprotectin for the diagnosis of spontaneous bacterial peritonitis: a systematic review and meta-analysis

Calprotectin is a promising diagnostic biomarker for spontaneous bacterial peritonitis (SBP) among cirrhotic patients, but published studies report a wide variation of its diagnostic accuracy. We systematically searched six databases for eligible studies (i.e., all original studies that reported ascitic calprotectin as a diagnostic marker for SBP in cirrhotic patients), and assessed their quality with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We calculated the pooled sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), and diagnostic odds ratio (DOR) using the bivariate mixed-effect model. We constructed the summary receiver operating characteristic and determined the area under the curve (AUC). We registered the study protocol in PROSPERO (CRD42019125476). Our search retrieved 102 studies, of which 10 were included in the analysis. The overall risk of bias of these studies ranged from low to moderate. There was no heterogeneity from the threshold effect (Spearman correlation coefficient = 0.100, P value = 0.770). The pooled estimates [95% confidence intervals (CIs)] for ascitic calprotectin were as follows: sensitivity 0.91 (95% CI: 0.88-0.94), specificity 0.87 (95% CI: 0.68-0.96), PLR 7.18 (95% CI: 2.52-20.43), NLR 0.10 (95% CI: 0.07-0.15), DOR 71.91 (95% CI: 19.42-266.34), and AUC 0.92 (95% CI: 0.90-0.94). The sensitivity analysis did not detect outliers, and the model had a robust goodness of fit. There was no significant publication bias detected (Deeks test of asymmetry, P value = 0.79). Ascitic calprotectin is a promising diagnostic biomarker for SBP in cirrhotic patients.

A modern multidisciplinary approach to the treatment of enterocutaneous fistulas in Crohn's disease patients

INTRODUCTION

Enterocutaneous fistulas (ECFs) is a manifestation of penetrating Crohn's disease (CD) that is challenging to treat and has considerable morbidity and mortality rates.

AREAS COVERED

This review aims to explore the practical and updated principles for the optimal treatment of ECFs in CD patients.

EXPERT OPINION

Optimal ECF management requires a multidisciplinary approach. Treatment first includes fluid resuscitation and electrolyte rebalancing with control of sepsis by means of antibiotics and, when indicated, drainage of infected collections. Subsequent therapeutic steps include nutritional support, control of the fistula output and treatment of peristomal skin. Anti-TNF-α therapy seems to have limited utility only after sepsis is resolved and intestinal stenosis excluded. However, ECFs heal in only approximately one-third of cases without surgical intervention. Thus, correct surgical timing combined with adequate nutritional support, sepsis resolution and skin care is considered the appropriate preoperative setting.

A novel serum index for accurate diagnosis of spontaneous bacterial peritonitis in cirrhotic patients without other infections

Background

The accurate non-invasive diagnosis of spontaneous bacterial peritonitis (SBP) in patients with decompensated liver cirrhosis has not been achieved yet. The aim of the study was to obtain an unmistakable diagnosis of SBP using a new simple serum bioscore, made by combined measurement of procalcitonin (PCT), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which we called the PEC index. This cross-sectional analytic study comprised 178 cirrhotic patients with ascites (60 patients with SBP and 118 patients with sterile ascites), after excluding non-SBP infection, during the period from March 2019 until September 2019. In all participants, serum levels of PCT, ESR, and CRP were measured, and PEC index was calculated [PEC index = PCT × (ESR + CRP)].

Results

Patients with SBP (n = 60) had significantly higher serum PEC index than those with sterile ascites (n = 118) (41.0/31.2–93.0 vs. 9.9/5.9–15.0, P < 0.001). PEC index distinguished culture positive cases significantly (P < 0.001). Using receiver operating characteristic (ROC) statistics, the sensitivity and specificity of PCT, at a cutoff value of 0.590 ng/mL, for SBP diagnosis, were 81.67% and 93.33%, respectively (area under the curve [AUC] = 0.879; 95% confidence interval [CI] 0.809–0.948). The sensitivity and specificity of ESR, at a cutoff value of 27.0 mm/hour, were 73.33% and 61.67%, respectively (AUC = 0.679; 95% CI 0.581–0.776). The sensitivity and specificity of CRP, at a cutoff value of 21.0 mg/L, were 93.33% and 51.67%, respectively (AUC = 0.736; 95% CI 0.639–0.833). While, the sensitivity and specificity of PEC index, at a cutoff value of 20, were highest (98.33% and 96.67%, respectively, AUC = 0.977; 95% CI 0.940–0.996).

Conclusion

Serum PEC index makes an accurate noninvasive diagnosis of SBP, after excluding other infections.

Serum procalcitonin as an independent diagnostic markers of bacteremia in febrile patients with hematologic malignancies

Background

Serum procalcitonin (PCT) and C-reactive protein (CRP) are biomarkers of infection. In patients with hematologic disorders with or without hematopoietic stem cell transplantation (HSCT), it is difficult to distinguish bloodstream infections from aseptic causes of febrile episodes. The objective of this study was to investigate diagnostic values of PCT and CRP in predicting systemic bacterial infection in patients with hematologic malignancies.

Methods

Clinical and laboratory data of 614 febrile episode cases from 511 patients were analyzed. Febrile episodes were classified into four groups: (1) culture-positive bacterial infection by Gram-positive cocci (GPC), (2) culture-positive bacterial infection by Gram-negative bacilli (GNB), (3) fungal infection, and (4) viral infection or a noninfectious etiology.

Results

Of 614 febrile cases, systemic bacterial infections were confirmed in 99 (16.1%) febrile episodes, including 38 (6.2%) GPC and 61 (9.9%) GNB infections. PCT levels were significantly higher in GNB infectious episodes than those in febrile episodes caused by fungal infection (0.58 ng/mL (95% CI: 0.26–1.61) vs. 0.22 ng/mL (0.16–0.38), P = 0.047). Bacterial infectious episodes showed higher PCT and CRP levels than non-bacterial events (PCT: 0.49 (0.26–0.93) ng/mL vs. 0.20 (0.18–0.22) ng/mL, P < 0.001; CRP: 76.6 (50.5–92.8) mg/L vs. 58.0 (51.1–66.5) mg/L, P = 0.036). For non-neutropenic febrile episodes, both PCT and CRP discriminated bacteremia from non-bacteremia. However, in neutropenic febrile episodes, PCT only distinguished bacteremia from non-bacteremia. In non-neutropenic episode, both PCT and CRP showed good diagnostic accuracy (AUC: 0.757 vs. 0.763). In febrile neutropenia, only PCT discriminated bacteremia from non-bacterial infection (AUC: 0.624) whereas CRP could not detect bacteremia (AUC: 0.500, 95% CI: 0.439–0.561, P > 0.05).

Conclusions

In this single-center observational study, PCT was more valuable than CRP for discriminating between bacteremia and non-bacteremia independent of neutropenia or HSCT.

Human beta-defensin-1 is a highly predictive marker of mortality in patients with acute-on-chronic liver failure

BACKGROUND & AIM

Human beta-defensin-1 (hBD-1) is a natural antimicrobial peptide expressed in the epithelia of multiple tissues including the digestive tract. In the current study, hBD-1 levels were determined in different subsets of patients with decompensated cirrhosis including acute-on-chronic liver failure (ACLF). In addition, the association with mortality of hBD-1, C-reactive protein (CRP) and procalcitonin (PCT) was assessed.

METHODS

A total of 125 patients were divided into three groups: 39 with ACLF (derivation cohort), 46 with acute decompensation without ACLF (AD) and 40 with decompensated cirrhosis without an acute event (DC). The data from 24 different ACLF patients were used for validation and 15 healthy individuals as control group.

RESULTS

Serum hBD-1, CRP and PCT levels were higher in ACLF compared to both AD and DC groups (P < 0.001). Healthy controls demonstrated similar hBD-1 and PCT values compared to DC group. In ROC curve, the performance of hBD-1 to predict 60-day mortality in ACLF group was similar in derivation and validation cohorts (c-statistic 0.834 and 0.879, respectively). CRP was a poor predictor of mortality. In ACLF group, patients with high hBD-1 (>36.625 ng/mL) had a poor prognosis at 60 days compared to those with lower values (log-rank P = 0.001). In Cox multivariate regression analysis, only hBD-1 (HR 1.020, 95%CI 1.006-1.035, P = 0.006) emerged as an independent predictor of death in ACLF group. In AD group, neither hBD-1 nor PCT or CRP variables were associated with mortality.

CONCLUSIONS

High hBD-1 was detected at presentation in patients with ACLF who died during follow-up period. hBD-1 is an accurate predictor of short-term mortality in patients with ACLF.

Procalcitonin Monitoring as a Guide for Antimicrobial Therapy: A Review of Current Literature

Effective antimicrobial stewardship practices are increasingly essential to best utilize the current arsenal of antimicrobials for the shortest necessary duration to minimize the development of antimicrobial resistance, secondary infections, and health care costs. Monitoring of serum procalcitonin (PCT) levels represents an effective antimicrobial stewardship strategy to differentiate bacterial infections from viral infections and noninfectious inflammatory conditions. Current literature illustrates the merits of PCT monitoring in reducing duration of antibiotic therapy without detrimental effects on mortality or infection relapses. However, the interpretation of PCT levels can be challenging, especially in light of comorbid disease states that can elevate PCT levels. This review sheds light on the utility of PCT monitoring, as well as providing insight into the practical interpretation of PCT levels. Much of the current literature surrounding PCT monitoring consists of use among patients with lower respiratory tract infections or in the critically ill. Overall, studies have demonstrated shorter antibiotic therapy durations when PCT monitoring is utilized. No studies to date have found increased rates of mortality or infection relapses, suggesting that PCT monitoring is not only effective, but also safe when used as a guide for antimicrobial therapy. Nonetheless, many conditions were shown to elevate PCT serum concentrations, even in the absence of bacterial infections, which can make interpretation of PCT concentrations challenging. Two common conditions that affect the accurate interpretation of PCT levels are renal dysfunction and congestive heart failure. Limited studies have been performed in these populations, but current available data propose the need for higher PCT thresholds in those with renal dysfunction or congestive heart failure and support utilizing PCT trends to monitor clinical improvement from bacterial infections. Evidence also suggests that PCT monitoring is cost-effective, as long as the test is ordered judiciously. In summary, PCT monitoring represents a promising antimicrobial stewardship strategy to limit exposure to unnecessary antimicrobial therapy.

2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability.

Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.

The role of procalcitonin in the diagnosis of bacterial infection after major abdominal surgery: Advantage from daily measurement

Postsurgical infections represent an important cause of morbidity after abdominal surgery. The microbiological diagnosis is not achieved in at least 30% of culture with consequent worsening of patient outcome. In this study, procalcitonin measurement, during the first 3 days after abdominal surgery, has been evaluated for the early diagnosis of postsurgical infection.Ninety consecutive patients subjected to major abdominal surgery at the University Campus Bio-Medico of Rome, have been included. PCT concentrations were measured by time-resolved amplified cryptate emission (TRACE) assay at admission and at the first, second, and third day after surgery. PCT levels were compared using the Mann-Whitney test and by ANOVA test for variance analysis. Receiver operating characteristic (ROC) analysis was performed to define the diagnostic ability of PCT in case of postsurgical infections.PCT values resulted significantly different between patients developing or not developing postsurgical infections. PCT >1.0 ng/mL at first or second day after surgery and >0.5 ng/mL at third day resulted diagnostic for infectious complication, whereas a value <0.5 ng/mL at the fifth day after surgery was useful for early and safety discharge of patients.In conclusion, PCT daily measurement could represent a useful diagnostic tool improving health care in the postsurgical period following major abdominal surgery and should be recommended.

Bowel injury following gynecological laparoscopic surgery

Background

Bowel injury remains a serious complication of gynecological laparoscopic surgery. We aimed to review the literature on this topic, combined with personal experiences, so as to give recommendations on how to avoid and manage this complication.

Methods

We performed a narrative review on bowel injury following gynecological laparoscopic surgery using PubMed covering prevention, diagnosis, and management. Search terms used were laparoscopy, gynaecology, injury, bowel, prevention, treatment.

Results

Important principles of prevention include proper pre-operative evaluation and increased laparoscopic surgical skills and knowledge. High clinical suspicion is crucial for early diagnosis. Diagnostic workup of suspected cases includes serial abdominal examination, measuring inflammatory markers, and performing imaging studies including abdominal ultrasound and CT scan. When bowel injury is recognized during the first laparoscopic procedure then laparoscopic primary suturing could be tried although laparotomy may be needed. When diagnosis is delayed, then laparotomy is the treatment of choice. The role of robotic surgery and three-dimensional laparoscopic gynecological surgery on bowel injury needs to be further assessed.

Conclusion

Early recognition of bowel injury is crucial for a favorable clinical outcome. A combined collaboration between gynecologists and general surgeons is important for timely and proper decisions to be made.

Serum Level of HMGB1 Protein and Inflammatory Markers in Patients with Secondary Peritonitis: Time Course and the Association with Clinical Status

Background

Intra-abdominal infection in secondary peritonitis drives as excessive production of inflammatory mediators and the development of systemic inflammatory response syndrome (SIRS) or sepsis. Finding a specific marker to distinguish SIRS from sepsis would be of immense clinical importance for the therapeutic approach. It is assumed that high-mobility group box 1 protein (HMGB1) could be such a marker. In this study, we examined the time course changes in the blood levels of HMGB1, C-reactive protein (CRP), procalcitonin (PCT) and serum amyloid A (SAA) in patients with secondary peritonitis who developed SIRS or sepsis.

Methods

In our study, we evaluated 100 patients with diffuse secondary peritonitis who developed SIRS or sepsis (SIRS and SEPSIS group) and 30 patients with inguinal hernia as a control group. Serum levels of HMGB1, CRP, PCT, and SAA were determined on admission in all the patients, and monitored daily in patients with peritonitis until discharge from hospital.

Results

Preoperative HMGB1, CRP, PCT and SAA levels were statistically highly significantly increased in patients with peritonitis compared to patients with inguinal hernia, and significantly higher in patients with sepsis compared to those with SIRS. All four inflammatory markers changed significantly during the follow-up. It is interesting that the patterns of change of HMGB1 and SAA over time were distinctive for SIRS and SEPSIS groups.

Conclusions

HMGB1 and SAA temporal patterns might be useful in distinguishing sepsis from noninfectious SIRS in secondary peritonitis.

Procalcitonin Reveals Early Dehiscence in Colorectal Surgery: The PREDICS Study

OBJECTIVES

We designed a multicentric, observational study to test if Procalcitonin (PCT) might be an early and reliable marker of anastomotic leak (AL) after colorectal surgery (ClinicalTrials.govIdentifier:NCT01817647).

BACKGROUND

Procalcitonin is a biomarker used to monitor bacterial infections and guide antibiotic therapy. Anastomotic leak after colorectal surgery is a severe complication associated with relevant short and long-term sequelae.

METHODS

Between January 2013 and September 2014, 504 patients underwent colorectal surgery, for malignant colorectal diseases, in elective setting. White blood count (WBC), C-reactive protein (CRP) and PCT levels were measured in 3rd and 5th postoperative day (POD). AL and all postoperative complications were recorded.

RESULTS

We registered 28 (5.6%) anastomotic leaks. Specificity and negative predictive value for AL with PCT less than 2.7 and 2.3 ng/mL were, respectively, 91.7% and 96.9% in 3rd POD and 93% and 98.3% in 5th POD. Receiver operating characteristic curve for biomarkers shows that in 3rd POD, PCT and CRP have similar area under the curve (AUC) (0.775 vs 0.772), both better than WBC (0.601); in 5th POD, PCT has a better AUC than CRP and WBC (0.862 vs 0.806 vs 0.611). Measuring together PCT and CRP significantly improves AL diagnosis in 5th POD (AUC: 0.901).

CONCLUSIONS

PCT and CRP demonstrated to have a good negative predictive value for AL, both in 3rd and in 5th POD. Low levels of PCT, together with low CRP values, seem to be early and reliable markers of AL after colorectal surgery. These biomarkers might be safely added as additional criteria of discharge protocols after colorectal surgery.

Development and Validation of a Disease Severity Scoring Model for Pediatric Sepsis

BACKGROUND

Multiple severity scoring systems have been devised and evaluated in adult sepsis, but a simplified scoring model for pediatric sepsis has not yet been developed. This study aimed to develop and validate a new scoring model to stratify the severity of pediatric sepsis, thus assisting the treatment of sepsis in children.

METHODS

Data from 634 consecutive patients who presented with sepsis at Children's hospital of Hunan province in China in 2011-2013 were analyzed, with 476 patients placed in training group and 158 patients in validation group. Stepwise discriminant analysis was used to develop the accurate discriminate model. A simplified scoring model was generated using weightings defined by the discriminate coefficients. The discriminant ability of the model was tested by receiver operating characteristic curves (ROC).

RESULTS

The discriminant analysis showed that prothrombin time, D-dimer, total bilirubin, serum total protein, uric acid, PaO2/FiO2 ratio, myoglobin were associated with severity of sepsis. These seven variables were assigned with values of 4, 3, 3, 4, 3, 3, 3 respectively based on the standardized discriminant coefficients. Patients with higher scores had higher risk of severe sepsis. The areas under ROC (AROC) were 0.836 for accurate discriminate model, and 0.825 for simplified scoring model in validation group.

CONCLUSIONS

The proposed disease severity scoring model for pediatric sepsis showed adequate discriminatory capacity and sufficient accuracy, which has important clinical significance in evaluating the severity of pediatric sepsis and predicting its progress.

Utility of blood procalcitonin concentration in the management of cancer patients with infections

Diagnosis of infections in cancer patients is usually problematic since differentiating between infection and fever of unknown origin is often a considerable clinical challenge. In general, increase concentration of blood procalcitonin (PCT) is associated with severe bacterial infection. PCT with an optimal cutoff level of 0.5 ng/mL seems to be the most helpful biochemical parameter in detecting severe infections, mainly bloodstream infection, in patients with hematological cancers. In all clinical situations, the elevated level of PCT should be carefully analyzed, always with a thorough physical examination and an appropriate microbiological assessment.

Diagnostic Accuracy of Serum Procalcitonin for Spontaneous Bacterial Peritonitis Due to End-stage Liver Disease: A Meta-analysis

Early diagnosis and prompt treatment of spontaneous bacterial peritonitis (SBP) due to end-stage liver disease is vital to shorten hospital stays and reduce mortality. Many studies have explored the potential usefulness of serum procalcitonin (PCT) in predicting SBP. The aim of this study is to evaluate the overall diagnostic accuracy of PCT levels for identifying SBP due to end-stage liver disease.After performing a systematic search of the Medline, Embase, and Cochrane databases for studies that evaluated the diagnostic role of PCT for SBP, sensitivity, specificity, and other measures of accuracy of PCT concentrations in serum for SBP diagnosis were pooled using random-effects models. A summary receiver operating characteristic curve was used to summarize overall test performance.Seven publications met the inclusion criteria covering 742 episodes of suspected SBP along with 339 confirmed cases. The summary estimates for serum PCT in the diagnosis of SBP attributable to end-stage liver disease were: sensitivity 0.82 (95% CI 0.79-0.87), specificity 0.86 (95% CI 0.82-0.89), positive likelihood ratio 4.94 (95% CI 2.28-10.70), negative likelihood ratio 0.22 (95% CI 0.10-0.52), and diagnostic OR 22.55 (95% CI 7.01-108.30). The area under the curve was 0.92. There was evidence of significant heterogeneity but no evidence of publication bias.Serum PCT is a relatively sensitive and specific test for the identification of SBP. However, due to the limited high-quality studies available, medical decisions should be carefully made in the context of both PCT test results and other clinical findings.

Significance of Serum Pepsinogens as a Biomarker for Gastric Cancer and Atrophic Gastritis Screening: A Systematic Review and Meta-Analysis

BACKGROUND

Human pepsinogens are considered promising serological biomarkers for the screening of atrophic gastritis (AG) and gastric cancer (GC). However, there has been controversy in the literature with respect to the validity of serum pepsinogen (SPG) for the detection of GC and AG. Consequently, we conducted a systematic review and meta-analysis to assess the diagnostic accuracy of SPG in GC and AG detection.

METHODS

We searched PubMed, Embase, and the Chinese National Knowledge Infrastructure (CNKI) for correlative original studies published up to September 30, 2014. The summary sensitivity, specificity, positive diagnostic likelihood ratio (DLR+), negative diagnostic likelihood ratio (DLR-), area under the summary receiver operating characteristic curve (AUC) and diagnostic odds ratio (DOR) were used to evaluate SPG in GC and AG screening based on bivariate random effects models. The inter-study heterogeneity was evaluated by the I2 statistics and publication bias was assessed using Begg and Mazumdar's test. Meta-regression and subgroup analyses were performed to explore study heterogeneity.

RESULTS

In total, 31 studies involving 1,520 GC patients and 2,265 AG patients were included in the meta-analysis. The summary sensitivity, specificity, DLR+, DLR-, AUC and DOR for GC screening using SPG were 0.69 (95% CI: 0.60-0.76), 0.73 (95% CI: 0.62-0.82), 2.57 (95% CI: 1.82-3.62), and 0.43 (95% CI: 0.34-0.54), 0.76 (95% CI: 0.72-0.80) and 6.01 (95% CI: 3.69-9.79), respectively. For AG screening, the summary sensitivity, specificity, DLR+, DLR-, AUC and DOR were 0.69 (95% CI: 0.55-0.80), 0.88 (95% CI: 0.77-0.94), 5.80 (95% CI: 3.06-10.99), and 0.35 (95% CI: 0.24-0.51), 0.85 (95% CI: 0.82-0.88) and 16.50 (95% CI: 8.18-33.28), respectively. In subgroup analysis, the use of combination of concentration of PGI and the ratio of PGI:PGII as measurement of SPG for GC screening yielded sensitivity of 0.70 (95% CI: 0.66-0.75), specificity of 0.79 (95% CI: 0.79-0.80), DOR of 6.92 (95% CI: 4.36-11.00), and AUC of 0.78 (95% CI: 0.72-0.81), while the use of concentration of PGI yielded sensitivity of 0.55 (95% CI: 0.51-0.60), specificity of 0.79 (95% CI: 0.76-0.82), DOR of 6.88 (95% CI: 2.30-20.60), and AUC of 0.77 (95% CI: 0.73-0.92). For AG screening, the use of ratio of PGI:PGII as measurement of SPG yielded sensitivity of 0.69 (95% CI: 0.52-0.83), specificity of 0.84 (95% CI: 0.68-0.93), DOR of 11.51 (95% CI: 6.14-21.56), and AUC of 0.83 (95% CI: 0.80-0.86), the use of combination of concentration of PGI and the ratio of PGI:PGII yield sensitivity of 0.79 (95% CI: 0.72-0.85), specificity of 0.89 (95% CI: 0.85-0.93), DOR of 24.64 (95% CI: 6.95-87.37), and AUC of 0.87 (95% CI: 0.81-0.92), concurrently, the use of concentration of PGI yield sensitivity of 0.46 (95% CI: 0.38-0.54), specificity of 0.93 (95% CI: 0.91-0.95), DOR of 19.86 (95% CI: 0.86-456.91), and AUC of 0.86 (95% CI: 0.52-1.00).

CONCLUSION

SPG has great potential as a noninvasive, population-based screening tool in GC and AG screening. In addition, given the potential publication bias and high heterogeneity of the included studies, further high quality studies are required in the future.

Prediction of mortality in patients with colorectal perforation based on routinely available parameters: a retrospective study

INTRODUCTION

Even after surgery and intensive postoperative management, the mortality rate associated with colorectal perforation is high. Identification of mortality markers using routinely available preoperative parameters is important.

METHODS

We enrolled consecutive patients with colorectal perforation who underwent operations from January 2010 to January 2015. We divided them into a mortality and survivor group and compared clinical characteristics between the two groups. Additionally, we compared the mortality rate between different etiologies: malignant versus benign and diverticular versus nondiverticular. We used the χ (2) and Mann-Whitney U tests and a logistic regression model to identify factors associated with mortality.

RESULTS

We enrolled 108 patients, and 52 (48 %) were male. The mean age at surgery was 71 ± 13 years. The postoperative mortality rate was 12 % (13 patients). Multivariate logistic regression analysis showed that a high patient age (odds ratio [OR], 1.09; 95 % confidence interval [CI], 1.020-1.181) and low preoperative systolic blood pressure (OR, 0.98; 95 % CI, 0.953-0.999) were independent risk factors for mortality in patients with colorectal perforation. In the subgroup analysis, there was no significant difference between the malignant and benign group (11.8 % vs. 23.9 %, respectively; p = 0.970), while the diverticular group had a significantly lower mortality rate than the nondiverticular group (2.6 % vs. 17.1 %, respectively; p = 0.027).

CONCLUSIONS

Older patients and patients with low preoperative blood pressure had a high risk of mortality associated with colorectal perforation. For such patients, operations and postoperative management should be performed carefully.

[Usefulness of procalcitonin for diagnosing infection in critically ill patients with liver cirrhosis]

OBJECTIVE

To evaluate the usefulness of procalcitonin (PCT) for diagnosing infection in patients with liver cirrhosis admitted to an Intensive Care Unit.

DESIGN

A retrospective study was carried out.

SCOPE

Intensive Care Unit. Versatile, twenty-four beds. Participants Patients with liver cirrhosis admitted to our Intensive Care Unit in the last four years with suspected infection and measurement of PCT.

RESULTS

Among the 255 patients with cirrhosis admitted to our unit, PCT was determined for the differential diagnosis of infection in 69 cases (27%). Three patients were excluded from analysis due to a lack of clinical data. The average stay was 10.6 ± 9.2 days, with a mortality rate of 65%. The origin of cirrhosis was mainly viral (57%) or alcoholic (37%). The Child-Pugh and MELD scores were 9.5 ± 2 and 23 ± 8, respectively. Infection was diagnosed in 54 patients (82%). The most common infection was pneumonia (72%), followed by intraabdominal infections (18%) and bacteremia (5%). In patients without infection, the median PCT concentration was 0.57 ng/ml (range 0.28 to 1.14) versus 2.99 (1.31 to 9.4) in those with infection (p<.001). Diagnostic capacity was maintained in patients with intraabdominal infections. The diagnostic cutoff point was set at 0.8 ng/ml (sensitivity 83%, specificity 75%, AUC 0.82 [0.702-0.93]).

CONCLUSIONS

In patients with liver cirrhosis, PCT is useful for identifying bacterial infections, including intraabdominal processes.