Diagnostic Value of Procalcitonin and Interleukin-6 on Early Postoperative Pneumonia after Adult Cardiac Surgery: A Prospective Observational Study
A Prospective Observational Study
DOI:
https://doi.org/10.1532/hsf.4297Keywords:
procalcitonin;, interleukin-6, cardiac surgery, postoperative pneumoniaAbstract
Background: Postoperative pneumonia (PP) is the most common primary infection after cardiac surgery, increasing the hospitalization expense and causing the consumption of healthcare resources. This study aimed to investigate the diagnostic value of procalcitonin (PCT) and interleukin-6 (IL-6) on early postoperative pneumonia after adult cardiac surgery.
Methods: In this prospective observational study, patients with pneumonia and age- and sex-matched cases in our center from October 10, 2020 to January 31, 2021 were included. Patients diagnosed with pneumonia in this study needed meet both clinical and microbiological diagnostic criteria. Blood samples were collected in all patients from postoperative day (POD) 1 to postoperative day 5 to detect PCT, IL-6, white blood cell count, and C-reactive protein. The diagnostic performance of different biomarkers was evaluated by the receiver operating characteristic curves and the area under the curves.
Results: Our study enrolled 272 patients, including 24 patients with postoperative pneumonia and 248 age- and sex-matched cases. From POD1 to POD5, the absolute value of PCT and PCT variations showed diagnostic significance for pneumonia (P < .05); the diagnostic value of the absolute value of IL-6 and IL-6 variations was not satisfying. White blood cell count showed no differences; C-reactive protein had no diagnostic value before POD4. Multivariable logistic regression showed that PCT variation and IL-6 variation from POD3 to POD1 were the strongest risk factors for postoperative pneumonia [OR:12.50, 95% CI: (3.40-45.5); OR:13.71, 95% CI: (1.11-168.47)]. According to the above results, we defined the PL Index. PL Index showed the best diagnostic value among those biomarkers in POD3 [AUC: 0.90, 95% CI: (0.79-0.95)]. Multivariable logistic regression showed PL Index POD3 has significant correlation with postoperative pneumonia [OR:1.23, 95% CI: (1.11-1.37), P = .041].
Conclusions: PCT variation and IL-6 were more accurate than C-reactive protein and white blood cell count to predict early postoperative pneumonia, but the diagnostic properties of PCT could not be observed during the first three postoperative days due to the inflammatory process. By combining the variations of PCT and IL-6, we defined the PL Index, which shows the best diagnostic ability on early postoperative pneumonia after adult cardiac surgery.
References
Abdollahi A, Shoar S, Nayyeri F, Shariat M. 2012. Diagnostic Value of Simultaneous Measurement of Procalcitonin, Interleukin-6 and hs-CRP in Prediction of Early-Onset Neonatal Sepsis. MEDITERR J HEMATOL I. 4(1):e2012028.
Ailawadi G, Chang HL, O'Gara PT, O'Sullivan K, Woo YJ, DeRose JJJ, et al. 2017. Pneumonia after cardiac surgery: Experience of the National Institutes of Health/Canadian Institutes of Health Research Cardiothoracic Surgical Trials Network. The Journal of thoracic and cardiovascular surgery. 153(6):1384-91.
Assicot M, Gendrel D, Carsin H, Raymond J, Guilbaud J, Bohuon C. 1993. High serum procalcitonin concentrations in patients with sepsis and infection. Lancet (London, England). 341(8844):515-8.
Baykut D, Schulte-Herbrüggen J, Krian A. 2000. The value of procalcitonin as an infection marker in cardiac surgery. EUR J MED RES. 5(12):530-6.
Becker KL, Snider R, Nylen ES. 2008. Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations. CRIT CARE MED. 36(3):941-52.
Calandra T, Cohen J. 2005. The international sepsis forum consensus conference on definitions of infection in the intensive care unit. p. 1538-48.
Chanderraj R, Dickson RP. 2018. Rethinking pneumonia: A paradigm shift with practical utility. Proc Natl Acad Sci U S A. [Journal Article; Research Support, N.I.H., Extramural; Comment]. 12-26;115(52):13148-50.
Christ-Crain M, Jaccard-Stolz D, Bingisser R, Gencay MM, Huber PR, Tamm M, et al. 2004. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. p. 600-7.
Dandona P, Nix D, Wilson MF, Aljada A, Love J, Assicot M, et al. 1994. Procalcitonin increase after endotoxin injection in normal subjects. The Journal of clinical endocrinology and metabolism. 79(6):1605-8.
Dörge H, Schöndube FA, Dörge P, Seipelt R, Voss M, Messmer BJ. 2003. Procalcitonin is a valuable prognostic marker in cardiac surgery but not specific for infection. The Thoracic and cardiovascular surgeon. 51(6):322-6.
Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. 2006. The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part I: Duration. The Annals of thoracic surgery. 81(1):397-404.
Engelman R, Shahian D, Shemin R, Guy TS, Bratzler D, Edwards F, et al. 2007. The Society of Thoracic Surgeons practice guideline series: Antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice. The Annals of thoracic surgery. 83(4):1569-76.
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. 2005. p. 388-416.
Haghi AR, Kasraianfard A, Monsef A, Kazemi AS, Rahimi S, Javadi SMR. 2018. The diagnostic values of procalcitonin and interleukin 6 in acute appendicitis. Turkish journal of surgery. 35(1):1-3.
He S, Chen B, Li W, Yan J, Chen L, Wang X, et al. 2014. Ventilator-associated pneumonia after cardiac surgery: a meta-analysis and systematic review. The Journal of thoracic and cardiovascular surgery. 148(6):3148-55.
Hulzebos EHJ, Helders PJM, Favié NJ, De Bie RA, Brutel de la Riviere A, Van Meeteren NLU. 2006. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA. 296(15):1851-7.
Jebali MA, Hausfater P, Abbes Z, Aouni Z, Riou B, Ferjani M. 2007. Assessment of the accuracy of procalcitonin to diagnose postoperative infection after cardiac surgery. p. 232-8.
Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. 2016. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 63(5):e61-111.
Kin H, Kawazoe K, Nakajima T, Niinuma H, Kataoka T, Endo S, et al. 2003. Perioperative serum procalcitonin concentrations in patients with acute aortic dissection. EUR SURG RES. [Journal Article]. 35(5):451-4.
Kinlin LM, Kirchner C, Zhang H, Daley J, Fisman DN. 2010. Derivation and validation of a clinical prediction rule for nosocomial pneumonia after coronary artery bypass graft surgery. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 50(4):493-501.
Klingele M, Bomberg H, Schuster S, Schäfers H, Groesdonk HV. 2016. Prognostic value of procalcitonin in patients after elective cardiac surgery: a prospective cohort study. ANN INTENSIVE CARE. 6(1):116.
Le Moine O, Deviere J, Devaster JM, Crusiaux A, Durand F, Bernuau J, et al. 1994. Interleukin-6: an early marker of bacterial infection in decompensated cirrhosis. J HEPATOL. [Clinical Trial; Controlled Clinical Trial; Journal Article; Research Support, Non-U.S. Gov't]. 06-01;20(6):819-24.
Li X, Wang X, Li S, Yan J, Li D. 2017. Diagnostic Value of Procalcitonin on Early Postoperative Infection After Pediatric Cardiac Surgery. p. 420-8.
Ma L, Zhang H, Yin Y, Guo W, Ma Y, Wang Y, et al. 2016. Role of interleukin-6 to differentiate sepsis from non-infectious systemic inflammatory response syndrome. CYTOKINE. 88:126-35.
Macrina F, Tritapepe L, Pompei F, Sciangula A, Evangelista E, Toscano F, et al. 2005. Procalcitonin is useful whereas C-reactive protein is not, to predict complications following coronary artery bypass surgery. Perfusion. 20(3):169-75.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. 2001. Early goal-directed therapy in the treatment of severe sepsis and septic shock. p. 1368-77.
Steinmetz HT, Herbertz A, Bertram M, Diehl V. 1995. Increase in interleukin-6 serum level preceding fever in granulocytopenia and correlation with death from sepsis. The Journal of infectious diseases. 171(1):225-8.
Tanaka T, Narazaki M, Kishimoto T. 2014. IL-6 in inflammation, immunity, and disease. CSH PERSPECT BIOL. 6(10):a16295.
van Rossum AMC, Wulkan RW, Oudesluys-Murphy AM. 2004. Procalcitonin as an early marker of infection in neonates and children. The Lancet. Infectious diseases. 4(10):620-30.
Vos RJ, Van Putte BP, Kloppenburg GTL. 2018. Prevention of deep sternal wound infection in cardiac surgery: a literature review. The Journal of hospital infection. 100(4):411-20.
Wacker C, Prkno A, Brunkhorst FM, Schlattmann P. 2013. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. The Lancet. Infectious diseases. 13(5):426-35.
Wan S, LeClerc JL, Vincent JL. 1997. Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies. CHEST. 112(3):676-92.
Youden WJ. 1950. Index for rating diagnostic tests. CANCER-AM CANCER SOC. 3(1):32-5.