Abstract
Background: The incidence and mortality from sepsis has been on a rising trend worldwide. Early diagnosis and intervention are key to reducing morbidity and mortality from sepsis. Biomarkers are gaining prominence in this regard. Of these, procalcitonin (PCT) which is elaborated by the tissues in response to the inflammatory response of sepsis, has high sensitivity and specificity to diagnose sepsis.
Aims and Objectives: The study was done with the aim to assess the prevalence of elevated serum procalcitonin levels in patients with sepsis, and to evaluate for correlation of procalcitonin levels with severity of sepsis, clinical course, prognosis (assessed by prognostication scores like qSOFA, SOFA, APACHE II scores) and treatment outcome of sepsis.
Methods: 40 patients admitted with sepsis in the medical ICU of Rajah Muthiah Medical College Hospital during the period from September 2018 to August 2020 were studied. Demographic characteristics, history and physical examination details of the patients were entered in a case proforma. qSOFA score was calculated from GCS, respiratory rate and systolic BP. Shock index was calculated from heart rate and systolic BP. A venous sample for procalcitonin estimation was obtained in first 12 hours. Investigations from workup of the patient and clinical status were used to calculate SOFA and APACHE II score. The clinical course and treatment of the patients were followed up. Statistical analysis of the above data was performed.
Results: Among the 40 sepsis patients studied, 20% had sepsis (n=8), 40% each severe sepsis and septic shock (n=16 in each category). The overall mortality was 25% (n=10), with highest mortality in patients with septic shock. The mean PCT of study subjects was 5.64 ± 15.05 ng/ml. PCT may be used to predict mortality as survivors had mean PCT of 2.75 ± 4.10 ng/ml compared to 14.29 ± 28.57 ng/ml in non-survivors (p < 0.05). Greater PCT values were associated with need for ventilatory support (mean 8.86 ± 21.78 ng/ml, p <0.05). PCT levels were greater with greater severity of sepsis: the mean PCT was 1.77 ± 2.66 ng/ml in sepsis, compared to 3.05 ± 4.29 ng/ml in severe sepsis, and 10.16 ± 22.90 ng/ml in septic shock. qSOFA score and CRP were good independent predictors of mortality (p < 0.05 and p < 0.0001 respectively) and showed positive correlation with PCT.
Conclusion: Serum PCT may be used to diagnose sepsis at an early stage. In addition, it is useful to categorize severity of sepsis, predict mortality and need for ventilatory support in patients with sepsis.
Keywords: Sepsis, procalcitonin, biomarkers, septic shock, CRP, SOFA, APACHE II score, shock index, prognostic indicator.
References
- Na S, Kuan WS, Mahadevan M, Li CH, Shrikhande P, Ray S, et al. Implementation of early goal-directed therapy and the surviving sepsis campaign resuscitation bundle in Asia. Int J Qual Health Care. 2012; 24: 452–462. doi: 10.1093/intqhc/mzs045 PMID: 22899698
- Bone RC, Grodzin CJ, Balk RA. Sepsis: a new hypothesis for pathogenesis of the disease process. Chest 1997;112:235–43.
- Andersson U, Tracey KJ (2003) HMGB1 in sepsis. Scand J Infect Dis 35:577–584
- Hofer N, Zacharias E, Muller W, Resch B. An update on the use of C-reactive protein in early-onset neonatal sepsis: current insights and new tasks. Neonatology 2012;102:25–36.
- Müller B, White JC, Nylén ES, Snider RH, Becker KL, Habener JF (2001). Ubiquitous expression of the calcitonin gene in multiple tissues in response to sepsis. J ClinEndocrinol Metab 86: 396–404.
- Nylén ES, Snider RH, Thompson BS, Rohatgi P, Becker KL (1996). Pneumonitis-associated hyperprocalcitonemia. Am J Med Sci 312: 12–18.
- Whang KT, Vath SD, Becker KL, Snider RH, Nylen ES, Muller B et al. (2000). Procalcitonin and pro-inflammatory cytokine interactions in sepsis. Shock 14: 73–78.
- Jensen JU, Heslet L, Hartvig T, Espersen K, Steffensen P, Tvede M (2006). Procalcitonin increase in early identification of critically ill patients at high risk of mortality. Crit Care Med 34: 2596–2602.
- Maki DG, Kluger DM, Crnich CJ (2006). The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo ClinProc 81: 1159–1171
- Becker KL, Snider RH, Nylén ES (2007). Procalcitonin assay in systemic inflammation infection, and sepsis: clinical utility and limitations. Crit Care Med 36: 941–952.
- Harbarth S, Holeckova K, Froidevaux C, et al (2001) Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis. Am J Respir Crit Care Med 164:396–340
- Suprin E, Camus C, Gacouin A, et al. Procalcitonin: a valuable indicator of infection in a medical ICU? Intensive Care Med 2000; 26: 1232–8.
- Schuetz P, Birkhahn R, Sherwin R, et al. Serial procalcitonin predicts mortality in severe sepsis patients: results from the Multicenter Procalcitonin Monitoring SEpsis (MOSES) Study. Crit Care Med 2017; 45: 781–89.
- Brunkhorst FM, Wegschneider K, Forycki ZF, Brunkhorst R. Procalcitonin for early diagnosis and differentiation of SIRS, sepsis, severe sepsis, and septic shock. Intensive Care Med 2000;26:S148–S152.
- Brunkhorst FM, Al-Nawas B, Krummenauer F, et al. Procalcitonin, c-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia. ClinMicrobiol Infect 2002;8:93–100.
- Tang BMP, Eslick GD, Craig JC, McLean AS. Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systemic review and meta-analysis. Lancet Infect Dis 2007;7: 210–17.
- Martinez JM, Wagner KE, Snider RH, Nylen ES, Müller B, Sarani B et al. (2001). Late immunoneutralization of procalcitonin arrests the progression of lethal porcine sepsis. Surg Infect (Larchmt) 2: 193–201, discussion 202–203.
- Nylén ES, Whang KL, Steinwald PM, Snider RH, White JC, Becker KL(1998). Procalcitonin increases mortality and procalcitoninrecognizing antiserum improves mortalityin an experimental model of sepsis. Crit Care Med 26: 1001–1006. (See Editorial 26: 977–978).
- Stolz D, Christ-Crain M, Bingisser R, Leuppi J, Miedinger D, Müller C et al. (2007). Antibiotic treatment of exacerbations of COPD: a randomized, controlled trial comparing procalcitonin-guidance with standard therapy. Chest 131: 9–19.
Corresponding Author
Jyotsnaa M
Post Graduate, Department of Medicine, RMMCH, Chidambaram-608002, Tamilnadu
DOI: https://dx.doi.org/10.18535/jmscr/v8i11.33
