Association of procalcitonin values and bacterial infections in pediatric patients receiving extracorporeal membrane oxygenation

Abstract

Objective:

There is increasing data in pediatrics demonstrating procalcitonin (PCT) is more sensitive and specific than other biomarkers in the setting of bacterial infections. However, the use of PCT in neonatal and pediatric extracorporeal membrane oxygenation (ECMO) is not well described. Therefore, the purpose of this study was to describe the clinical utility of PCT in determining the absence or presence of bacterial infections in neonatal and pediatric patients on ECMO.

Methods:

This was a retrospective electronic medical record (EMR) review of data between January 1, 2010 to June 30, 2016 at a single, free-standing, children’s hospital. All patients on ECMO with ≥1 PCT level obtained while receiving ECMO support were eligible for inclusion. The EMR was searched for chest radiographs (CXR) and bacterial culture results (urine, blood, cerebrospinal fluid (CSF), bronchoalveolar lavage (BAL) and respiratory cultures). All bacterial and viral cultures obtained within 5 days of PCT levels being obtained were analyzed. PCT levels of 0.5, 0.9, 1.0, 1.4 and 2.0 were used as the initial cut-off values for the analysis. The sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV) and likelihood ratios were calculated for each of the PCT levels.

Results:

Twenty-seven patients met the inclusion criteria and contributed 193 PCT values for the analysis. The median age was 8 months (range 0 days to 18 years). Linear regression analysis demonstrated that a PCT cut-off of 0.5, 0.9 and 1.4 predicted the presence of a bacterial infection. The PCT value with the most utility was 0.5, with a sensitivity of 92%, a specificity of 43%, a positive predictive value of 60% and a negative predictive value (NPV) of 86%.

Conclusion:

This is the largest data set evaluating PCT in neonatal and pediatric patients on ECMO. A PCT value of 0.5 ng/mL had the most utility for determining the absence or presence of a bacterial infection in the setting of ECMO with a high sensitivity and NPV.

Keywords

procalcitonin pediatric neonatal extracorporeal life support ECMO ECLS

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References

Gibbon

Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med 1954; 37: 171–185; passim.

Baffes

Fridman

Bicoff

et al . Extracorporeal circulation for support of palliative cardiac surgery in infants. Ann Thorac Surg 1970; 10: 354–363.

Bartlett

Gazzaniga

Jefferies

et al . Extracor-poreal membrane oxygenation (ECMO) cardiopulmonary support in infancy. Trans Am Soc Artif Intern Organs 1976; 22: 80–93.

Extracorporeal Life Support Organization. ELSO International Registry. https://www.elso.org/Registry/Statistics/InternationalSummary.aspx (March 2016, accessed March 28, 2016.

Simon

Saint-Louis

Amre

et al . Procalcitonin and C-reactive protein as markers of bacterial infection in critically ill children at onset of systemic inflammatory response syndrome. Pediatr Crit Care Med 2008; 9: 407–413.

Rungatscher

Merlini

De Rita

et al ., Diagnosis of infection in paediatric veno-arterial cardiac extracorporeal membrane oxygenation: role of procalcitonin and C-reactive protein. Eur J Cardiothorac Surg 2013; 43: 1043–1049.

Agarwal

Akba

Soundar

et al ., Validation of the procalcitonin (PCT) assay: experience in a pediatric hospital. Clin Biochem 2015; 48: 886–890.

Anand

Das

Bhargava

et al ., Procalcitonin as a rapid diagnostic biomarker to differentiate between culture-negative bacterial sepsis and systemic inflammatory response syndrome: a prospective, observational, cohort study. J Crit Care 2015; 30: 218.e7–12.

Becker

Nylen

White

et al . Clinical review 167: procalcitonin and the calcitonin gene family of peptides in inflammation, infection, and sepsis: a journey from calcitonin back to its precursors. J Clin Endocrinol Metab 2004; 89: 1512–1525.

10.

Bizzarro

Conrad

Kaufman

et al . Infections acquired during extracorporeal membrane oxygenation in neonates, children, and adults. Pediatr Crit Care Med 2011; 12: 277–281.

11.

Meyer

Jessen

Eberhart

RC.

Neonatal extracoporeal membrane oxygenation complicated by sepsis. Ann Thorac Surg 1995; 59: 975–980.

12.

Leclerc

Cremer

Noizet

Procalcitonin as a diagnostic and prognostic biomarker of sepsis in critically ill children. Pediatr Crit Care Med 2003; 4: 264–266.

13.

Meisner

Pathobiochemistry and clinical use of procalcitonin. Clin Chim Acta 2002; 323: 17–29.

14.

Cies

Chopra

Procalcitonin use in a pediatric intensive care unit. Pediatr Infect Dis J 2014; 33: 984–986.

15.

Pieri

Greco

De Bonis

et al . Diagnosis of infection in patients undergoing extracorporeal membrane oxygenation: a case-control study. J Thorac Cardiovasc Surg 2012; 143: 1411–1416.

16.

Tanaka

Pitcher

Cavarocchi

et al . Can procalcitonin differentiate infection from systemic inflammatory reaction in patients on extracorporeal membrane oxygenation? J Heart Lung Transplant 2014; 33: 1186–1188.