Use of procalcitonin as a biomarker for sepsis in moderate to major paediatric burns

Abstract

Introduction

Accurate and early detection of sepsis poses a significant challenge in burn populations. Our objective was to assess whether procalcitonin is a marker of blood culture positive sepsis in moderate to severe paediatric burns.

Methods

We analysed procalcitonin levels in 27 children admitted with burns of 15–65% total body surface area. Procalcitonin was measured at admission (baseline), 24 and 48 h post-admission and during periods of suspected sepsis (diagnosed against pre-defined criteria). Patients were categorised into controls with no episodes of suspected sepsis (n = 10) and those with episodes of suspected sepsis (n = 17). The latter were split into two groups based on blood culture results: culture positive (bacteraemia) and culture negative patients.

Results

Baseline procalcitonin levels increased with burn size (odds ratio (95% confidence interval): 1.15 (1.02–1.29)). Suspected sepsis patients had larger burns than controls (median 31 vs. 20%; p = 0.003). Only 5/23 suspected sepsis episodes were blood culture positive. Procalcitonin levels were similar in culture positive and culture negative patients (p = 0.43). Sensitivity for predicting positive blood culture was 100% (95% confidence interval: 47.8–100.0%) but specificity was only 22.2% (95% confidence interval: 6.4–47.6%). Area under the curve was poor at 0.62 (95% confidence interval: 0.33–0.90). There was no significant change in procalcitonin levels from baseline to septic episode in either group (positive: p = 0.35; negative: p = 0.95).

Conclusion

We conclude that evidence for the use of procalcitonin to diagnose bacteraemia in this population is poor, with burn size playing a significant role implying a correlation with systemic inflammation rather than sepsis.

Keywords

Procalcitonin sepsis burn injury children C-reactive protein

Get full access to this article

View all access options for this article.

References

Dellinger

Levy

Rhodes

et al.

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41: 580–637.

Krishnan

Frew

Green

et al.

Cause of death and correlation with autopsy findings in burns patients. Burns 2013; 39: 583–588.

Chipp

Milner

Blackburn

. Sepsis in burns: a review of current practice and future therapies. Ann Plast Surg 2010; 65: 228–236.

Mann

Braun

Meininger

et al.

Comparison of mortality associated with sepsis in the burn, trauma, and general intensive care unit patient. Shock 2012; 37: 4–16.

Murray

Hoffmaster

Schmit

et al.

Evaluation of white blood cell count, neutrophil percentage, and elevated temperature as predictors of bloodstream infection in burn patients. Arch Surg 2007; 142: 639–642.

Sun

Zhang

Fang

et al.

Spectrum and drug resistance of pathogens from patients with burns. Burns 2012; 38: 1124–1130.

Lilly

Lowbury

. Antibiotic resistance of Staphylococcus aureus in a burns unit after stopping routine prophylaxis with erythromycin. J Antimicrob Chemother 1978; 4: 545–550.

Tang

Eslick

Craig

et al.

Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis 2007; 7: 210–217.

Schuetz

Christ-Crain

Thomann

et al.

Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA 2009; 302: 1059–1066.

10.

Schuetz

Müller

Christ-Crain

et al.

Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev 2012; 9: CD007498.

11.

Kopterides

Siempos

Tsangaris

et al.

Procalcitonin-guided algorithms of antibiotic therapy in the intensive care unit: a systematic review and meta-analysis of randomized controlled trials. Crit Care Med 2010; 38: 2229–2241.

12.

Bouadma

Luyt

Tubach

et al.

Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010; 375: 463–474.

13.

Hohn

Schroeder

Gehrt

et al.

Procalcitonin-guided algorithm to reduce length of antibiotic therapy in patients with severe sepsis and septic shock. BMC Infec Dis 2013; 13: 158.

14.

Wacker

Prkno

Brunkhorst

et al.

Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. Lancet Infect Dis 2013; 13: 426–435.

15.

Von Heimburg

Stieghorst

Khorram-Sefat

et al.

Procalcitonin – a sepsis parameter in severe burn injuries. Burns 1998; 24: 745–750.

16.

Sachse

Machens

Felmerer

et al.

Procalcitonin as a marker for the early diagnosis of severe infection after thermal injury. J Burn Care Rehabil 1999; 20: 354–360.

17.

Lavrentieva

Kontakiotis

Lazaridis

et al.

Inflammatory markers in patients with severe burn injury. What is the best indicator of sepsis?. Burns 2007; 33: 189–194.

18.

Barati

Alinejad

Bahar

et al.

Comparison of WBC, ESR, CRP and PCT serum levels in septic and non-septic burn cases. Burns 2008; 34: 770–774.

19.

Mann

Wood

Wade

. Use of procalcitonin for the detection of sepsis in the critically ill burn patient: a systematic review of the literature. Burns 2011; 37: 549–558.

20.

Lavrentieva

Papadopoulou

Kioumis

et al.

PCT as a diagnostic and prognostic tool in burn patients. Whether time course has a role in monitoring sepsis treatment. Burns 2012; 38: 356–363.

21.

Ren

Han

et al.

Serum procalcitonin as a diagnostic biomarker for sepsis in burned patients: a meta-analysis. Burns 2015; 41: 502–509.

22.

Cabral

Afreixo

Almeida

et al.

The use of procalcitonin (PCT) for diagnosis of sepsis in burn patients: a meta-analysis. PLoS ONE 2016; 11: e0168475. https://doi.org/10.1371/journal.pone.0168475 .

23.

Cabral

Afreixo

Santos

et al.

Procalcitonin for the early diagnosis of sepsis in burn patients: a retrospective study. Burns 2017; 43: 1427–1434.

24.

Simon

Gauvin

Amre

et al.

Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis 2004; 39: 206–217.

25.

Meisner

. Update on procalcitonin measurements. Ann Lab Med 2014; 34: 263–273.

26.

BalcI

Sungurtekin

Gürses

et al.

Usefulness of procalcitonin for diagnosis of sepsis in the intensive care unit. Crit Care 2003; 7: 85–90.

27.

Seoane

Pértega

Galeiras

et al.

Procalcitonin in the burn unit and the diagnosis of infection. Burns 2014; 40: 223–229.

28.

Neely

Fowler

Kagan

et al.

Procalcitonin in pediatric burn patients: an early indicator of sepsis?. J Burn Care Rehabil 2004; 25: 76–80.

29.

Rosanova

Tramonti

Taicz

et al.

Assessment of C-reactive protein and procalcitonin levels to predict infection and mortality in burn children. Arch Argent Pediatr 2015; 113: 36–41.

30.

Greenhalgh

Saffle

Holmes

et al.

American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res 2007; 28: 776–790.

31.

StataCorp. Stata Statistical Software: Release 14, College Station, TX: StataCorp LP, 2015.

32.

Meisner

Tschaikowsky

Schnabel

et al.

Procalcitonin–influence of temperature, storage, anticoagulation and arterial or venous asservation of blood samples on procalcitonin concentrations. Eur J Clin Chem Clin Biochem 1997; 35: 597–601.

33.

Lee

Kang

Back

et al.

Cutoff value of serum procalcitonin as a diagnostic biomarker of infection in end-stage renal disease patients. Korean J Intern Med 2015; 30: 198–204.