Diagnostic Value of Procalcitonin and Interleukin-6 on Early Postoperative Pneumonia after Adult Cardiac Surgery: A Prospective Observational Study
A Prospective Observational Study
Keywords:procalcitonin；, interleukin-6, cardiac surgery, postoperative pneumonia
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.
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.
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).