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Procalcitonin to Detect Suspected Bacterial Infections in the PICU

Mandell, Iris M. MD1; Aghamohammadi, Sara MD1; Deakers, Timothy MD, PhD1,2; Khemani, Robinder G. MD, MsCI1,2

Pediatric Critical Care Medicine: January 2016 - Volume 17 - Issue 1 - p e4–e12
doi: 10.1097/PCC.0000000000000571
Online Clinical Investigations

Objectives: Nonspecific clinical symptoms frequently lead to suspicion of bacterial infection in critically ill children. Clinicians send bacterial cultures for suspected infection and begin an empiric course of antibiotics while microbiology results are pending. We investigated whether the biomarker procalcitonin could be useful to predict confirmed bacterial infection in critically ill children in the PICU, before culture results are available.

Design: Prospective, blinded single-center study.

Setting: Tertiary PICU and cardiothoracic ICU.

Patients: There were one hundred forty-four patients with suspected bacterial infections that had bacterial cultures sent by clinicians.

Interventions: Procalcitonin samples were obtained at three time intervals: as close to the time of the initial culture as possible (up to 12 hr after) and 24 and 72 hours after the initial culture. Patients were stratified into clinical outcome groups based on microbiology results and clinical symptoms using Centers for Disease Control and Prevention criteria. These assignments were blinded to procalcitonin levels. Primary outcome was the presence of culture-proven bacterial infection.

Measurements and Main Results: There was a statistically significant difference in initial and subsequent median procalcitonin values between patients with confirmed bacterial infections and patients with low suspicion of bacterial infection (p < 0.02). However, there was extremely high variability in procalcitonin values among all groups. Procalcitonin had only a fair ability to predict bacterial infection, with area under the curve of receiver operating characteristic plots ranging between 0.63 and 0.71. When using serial procalcitonin values to predict bacterial infection, positive likelihood ratios were near 1 and negative likelihood ratios were between 0.3 and 0.4.

Conclusions: Procalcitonin levels were higher in children with documented confirmed bacterial infection as compared with those with low suspicion of infection. However, neither single nor serial procalcitonin measurements were able to predict the presence or absence of confirmed bacterial infection with enough certainty to be clinically useful as to recommend initiating or withholding antibiotics.

1Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA.

2Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA.

This work was performed at Children’s Hospital Los Angeles.

Current address for Dr. Mandell: Department of Critical Care, St. Louis Children’s Hospital, 1 Children’s Place, St. Louis, MO 63110.

Dr. Khemani receives grant support (National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development 1K23HL103785) unrelated to this study. The remaining authors have disclosed that they do not have any conflicts of interest.

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©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies