Procalcitonin as an early indicator of outcome in sepsis: a prospective observational study

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Summary

This study explores the role of procalcitonin (PCT) in predicting the outcome of sepsis. In a prospective multicentre observational investigation, blood was sampled within 24 h of onset of sepsis in 1156 hospitalised patients; 234 were in the intensive care unit (ICU) at the point of presentation of sepsis while 922 were not. PCT was estimated in serum by the ultrasensitive Kryptor assay in a double-blinded fashion. Among patients outside the ICU, mortality was 8% in those with PCT ≤0.12 ng/mL but 19.9% in those with PCT >0.12 ng/mL [P < 0.0001, odds ratio (OR) for death: 2.606; 95% confidence interval (CI): 1.553–4.371]. Among patients whose sepsis presented in ICU, mortality was 25.6% in those with PCT ≤0.85 ng/mL but 45.3% in those with PCT >0.85 ng/mL (P = 0.002; OR for death: 2.404; 95% CI: 1.385–4.171). It is concluded that PCT cut-off concentrations can contribute to predicting the outcome of sepsis and might be of particular value in identifying patients who would benefit from ICU admission.

Introduction

The incidence of sepsis has increased over the last decade. This has been attributed to various factors including the increased incidence of diabetes mellitus, increasing numbers of long-stay intensive care unit (ICU) patients, increasing use of immunosuppressive therapies and increasing antimicrobial resistance.1 Numerous studies have attempted to define the role of procalcitonin (PCT) as a diagnostic biomarker in sepsis.2, 3, 4 Although levels of PCT in serum are generally greater among patients with sepsis than among those with non-infectious systemic inflammatory response, meta-analyses have failed to determine a threshold above which PCT can safely discriminate sepsis.5 A serious limitation of all these studies is the limited number of enrolled patients and the heterogeneity of PCT assays used, although there is evidence that serial PCT measurement might be of value in determining the prognosis of the septic patient.3, 6

More recently, the role of PCT in sepsis has been explored in a series of prospective trials.7, 8, 9, 10 For instance, using an ultrasensitive assay, PCT has been shown to be useful in the decision to initiate empiric antibiotics in patients with lower respiratory tract infection.

In an attempt to study the problem of sepsis in Greece, the Hellenic Sepsis Study Group was convened in May 2006 with the participation of various ICUs, departments of internal medicine and departments of surgery across the country. Twenty-six of these departments participated in the present study. The aim of the study was to define thresholds of PCT that can safely discriminate risk of death separately for patients presenting with sepsis outside an ICU and for those developing sepsis after ICU admission.

Section snippets

Study design

This prospective multicentre study was conducted in 26 departments across Greece from January 2007 to September 2008. The participating departments were 11 ICUs, eight departments of internal medicine, one department of pulmonary medicine, five departments of surgery and one department of urology. Some are university departments and some are departments of the Greek national health system. The aim of the study was to define PCT thresholds that can safely discriminate the prognosis of sepsis.

Patient population

A total of 1550 patients were eligible for the study, of whom 1156 were enrolled: 922 were hospitalised outside the ICU and 234 presented with sepsis after ICU admission. Among patients with sepsis hospitalised outside the ICU, due to lack of beds none was transferred to an ICU. Demographic and clinical characteristics are shown in Table I.

Lack of effect of underlying infection on outcome

PCT did not differ between different types of infection, either for survivors or non-survivors (data not shown). PCT concentrations of survivors and

Discussion

Early and reliable recognition of sepsis is essential for successful management, prompting great interest in the role of biomarkers. Although numerous studies have explored the role of PCT in early diagnosis, to our knowledge no study has investigated whether PCT can be predictive of outcome.

Our results suggest that PCT can be useful in the early prediction of patients at risk of death. The PCT cut-off estimated within the first 24 h of onset of sepsis differed according to the type of nursing

Conflict of interest statement

None declared.

Funding source

This study was supported by an unrestricted educational grant by Brahms GmbH, Germany. The funding source had no role in the collection and analysis of data nor in writing the manuscript.

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