Research code: IR.ArakLU.rec.1398.060
Ethics code: IR.ArakLU.rec.1398.060
Clinical trials code: 0
, fatemeh_dorre@yahoo.com
Abstract: (325 Views)
Background
Fever is one of the most common reasons for patients to visit health centers. Often fever is accompanied by other symptoms that make the diagnosis more likely (1). Asymptomatic localized fever in children less than 36 months old is a common diagnostic problem (1). Etiology and evaluations required in children with fever without localized symptoms are different depending on the age of the children. Unimmunized or incompletely immunized young children are at the highest risk of hidden bacteremia due to pneumococcus .(1)and are more at risk. (1)
In the control and management of this disease, one of the most important issues is the presence of high-value diagnostic tests. The existence of these diagnostic tests is of great value in timely treatment and prevention of the complications of these infections in children. Of course, another way is to start experimental injectable antibiotics, which exposes the patient to unwanted side effects and negative consequences, such as increasing treatment costs, the risk of allergies, and drug side effects . (3)
Procalcitonin (PCT) (one of the most reliable indicators of sepsis is the precursor of calcitonin hormone (4). PCT is produced in the C cells of the thyroid gland and is converted to calcitonin before entering the blood circulation under normal conditions (5,6,7). In healthy individuals, the PCT level is usually less than 0.10 ng/ml (8). When a Bacterial infection occurs, significant production of PCT by non-thyroidal tissues occurs throughout the body (9). On the other hand, cytokines released in viral infections help to reduce its level (10). Procalcitonin is a biomarker that is used in some conditions, especially in the processes of bacterial infections, early diagnosis and monitoring of antimicrobial treatments . (2) The status and role of procalcitonin has been evaluated in different conditions such as respiratory system infections, neonatal infections, hemato-oncology infections, hospital infections, surgical procedures and traumas (3)..
Considering the importance of asymptomatic localized fever in children and the existence of many problems in the field of having a specific biomarker for this disease, as well as the increasing and widespread role of calcitonin biomarker in recent years, in the following study, we decided to evaluate the diagnostic value of procalcitonin in children. Patients with fever without localized symptoms should be evaluated.
Materials and methods
In this study, all children from 3 to 36 Months who were hospitalized due to fever without symptoms. After justifying the plan and obtaining written consent, the parents were included in the study. After confirming the fever, they underwent a detailed physical examination Children who had taken antibiotics in the last 48 hours were not included in the study. If there is no specific focus for these patients, in addition to CBC diff, ESR, CRP, U/C, U/A, B/C by BACTEC method, a blood clot sample to measure procalcitonin quantitatively was taken from patients. The laboratory colleagues did not know about the diagnosis of the disease. Also, a checklist containing the demographic information of the patients including age group, gender, history of contact with COVID 19 and vaccination history was completed for all patients and they were followed up during the entire hospitalization period. At the end of the research, the questionnaires were classified, extracted and measured sensitivity, specificity, Positive Predictive value (PPV) and negative predictive value (NPV) The procalcitonin test was determined and reported in relation to the culture.
Results
In this evaluation, 42 patients with the inclusion criteria for the study were considered as the study group and were investigated. The average age of the patients was 16.01 ± 9.30 months. 24 cases (57.14%) were male and 18 cases (42.86 (%were female. 17 patients had definite positive procalcitonin test and 25 had negative test. Blood culture by BACTEC method was positive in 3 (7.14%) patients. 40 cases (95.24%) of the covid patients were negative and the most common diagnosis was pyelonephritis which was recorded in 4 cases (36.36%) of the patients.
Table 1. Frequency distribution of final diagnosis
The 17 patients who tested positive for procalcitonin had 9 cases of leukocytosis (above 15,000), 10 cases of high ESR (>30), and 8 cases of both. All but one of them were CRP positive. Finally, from 17 patients who were positive for procalcitonin test, 4 cases of pyelonephritis, 2 cases of sepsis, 1 case of bacterial meningitis and 1 case of shigellosis were diagnosed. The 25 patients who tested negative for procalcitonin had 5 cases of leukocytosis (above 15,000), 2 cases of high ESR (>30), and 1 case of both. 8 cases were CRP positive. Finally, from of 25 patients, 2 cases were aseptic meningitis, 2 cases were covid 19 and 1 case was bacteremia. However, positive blood culture was reported with Staphylococcus lugdunensis. Other cases were considered viral infections.
Table2. Diagnostic value of procalcitonin
Discussion
The research showed the positive predictive value of procalcitonin in the diagnosis of bacterial infection in children with fever without focus at 47.05% and its negative predictive value is 96%. The results of a meta-analysis study conducted by Chia-Hung et al. PCT has been shown to be better than CRP for diagnosing serious bacterial infection in children with fever without a source (11).
In Galto et al.'s study to evaluate the value of bedside tests to predict the occurrence of severe bacterial infections (SBI) in children with non-focal fever 99 children aged 7 days to 36 months with fever above 38 degrees were evaluated, after comparing procalcitonin and CRP levels, they observed that PCT has the best sensitivity (93%) and negative predictive value (96%). but its positive predictive value was only38% Based on this, they have stated that PCT and CRP are better than interleukin 6 tests and white blood cell counts in predicting the occurrence of severe bacterial infections and are suitable tools in emergency. (12). In a study by Carnino et al., it was shown that PCT is significantly increased in bacterial infections compared to fungal infections, but not in response to other types of inflammation (9). A study by Gomes et al showed that the identification of patients with bacterial infection by PCT in young infants with FWS was better than CRP and seems to be the best indicator of IBI rejection. PCT has been the most accurate blood test in patients with normal urinalysis and fever (13).
Fever is one of the most common reasons for patients to visit health centers. Often fever is accompanied by other symptoms that make the diagnosis more likely (1). Asymptomatic localized fever in children less than 36 months old is a common diagnostic problem (1). Etiology and evaluations required in children with fever without localized symptoms are different depending on the age of the children. Unimmunized or incompletely immunized young children are at the highest risk of hidden bacteremia due to pneumococcus .(1)and are more at risk. (1)
In the control and management of this disease, one of the most important issues is the presence of high-value diagnostic tests. The existence of these diagnostic tests is of great value in timely treatment and prevention of the complications of these infections in children. Of course, another way is to start experimental injectable antibiotics, which exposes the patient to unwanted side effects and negative consequences, such as increasing treatment costs, the risk of allergies, and drug side effects . (3)
Procalcitonin (PCT) (one of the most reliable indicators of sepsis is the precursor of calcitonin hormone (4). PCT is produced in the C cells of the thyroid gland and is converted to calcitonin before entering the blood circulation under normal conditions (5,6,7). In healthy individuals, the PCT level is usually less than 0.10 ng/ml (8). When a Bacterial infection occurs, significant production of PCT by non-thyroidal tissues occurs throughout the body (9). On the other hand, cytokines released in viral infections help to reduce its level (10). Procalcitonin is a biomarker that is used in some conditions, especially in the processes of bacterial infections, early diagnosis and monitoring of antimicrobial treatments . (2) The status and role of procalcitonin has been evaluated in different conditions such as respiratory system infections, neonatal infections, hemato-oncology infections, hospital infections, surgical procedures and traumas (3)..
Considering the importance of asymptomatic localized fever in children and the existence of many problems in the field of having a specific biomarker for this disease, as well as the increasing and widespread role of calcitonin biomarker in recent years, in the following study, we decided to evaluate the diagnostic value of procalcitonin in children. Patients with fever without localized symptoms should be evaluated.
Materials and methods
In this study, all children from 3 to 36 Months who were hospitalized due to fever without symptoms. After justifying the plan and obtaining written consent, the parents were included in the study. After confirming the fever, they underwent a detailed physical examination Children who had taken antibiotics in the last 48 hours were not included in the study. If there is no specific focus for these patients, in addition to CBC diff, ESR, CRP, U/C, U/A, B/C by BACTEC method, a blood clot sample to measure procalcitonin quantitatively was taken from patients. The laboratory colleagues did not know about the diagnosis of the disease. Also, a checklist containing the demographic information of the patients including age group, gender, history of contact with COVID 19 and vaccination history was completed for all patients and they were followed up during the entire hospitalization period. At the end of the research, the questionnaires were classified, extracted and measured sensitivity, specificity, Positive Predictive value (PPV) and negative predictive value (NPV) The procalcitonin test was determined and reported in relation to the culture.
Results
In this evaluation, 42 patients with the inclusion criteria for the study were considered as the study group and were investigated. The average age of the patients was 16.01 ± 9.30 months. 24 cases (57.14%) were male and 18 cases (42.86 (%were female. 17 patients had definite positive procalcitonin test and 25 had negative test. Blood culture by BACTEC method was positive in 3 (7.14%) patients. 40 cases (95.24%) of the covid patients were negative and the most common diagnosis was pyelonephritis which was recorded in 4 cases (36.36%) of the patients.
Table 1. Frequency distribution of final diagnosis
| Diagnosis | Count (%) |
| Pyelonephritis | 4(9.52) |
| Sepsis | 3(7.1) |
| Shigellosis | 2(4.76) |
| COVID-19 | 2(4.76) |
| Aseptic meningitis | 2(4.76) |
| Bacterial meningitis | 1(2.38) |
| Unknown | 28(66.64) |
| Total | 42(100) |
The 17 patients who tested positive for procalcitonin had 9 cases of leukocytosis (above 15,000), 10 cases of high ESR (>30), and 8 cases of both. All but one of them were CRP positive. Finally, from 17 patients who were positive for procalcitonin test, 4 cases of pyelonephritis, 2 cases of sepsis, 1 case of bacterial meningitis and 1 case of shigellosis were diagnosed. The 25 patients who tested negative for procalcitonin had 5 cases of leukocytosis (above 15,000), 2 cases of high ESR (>30), and 1 case of both. 8 cases were CRP positive. Finally, from of 25 patients, 2 cases were aseptic meningitis, 2 cases were covid 19 and 1 case was bacteremia. However, positive blood culture was reported with Staphylococcus lugdunensis. Other cases were considered viral infections.
Table2. Diagnostic value of procalcitonin
| Sensitivity | 88.88 (51.75-99.71) |
| Specificity | 72.72 (54.47-86.70) |
| Positive predictive value | 47.05 (22.98-72.18) |
| Negative predictive value | 96 (79.64-99.89) |
Discussion
The research showed the positive predictive value of procalcitonin in the diagnosis of bacterial infection in children with fever without focus at 47.05% and its negative predictive value is 96%. The results of a meta-analysis study conducted by Chia-Hung et al. PCT has been shown to be better than CRP for diagnosing serious bacterial infection in children with fever without a source (11).
In Galto et al.'s study to evaluate the value of bedside tests to predict the occurrence of severe bacterial infections (SBI) in children with non-focal fever 99 children aged 7 days to 36 months with fever above 38 degrees were evaluated, after comparing procalcitonin and CRP levels, they observed that PCT has the best sensitivity (93%) and negative predictive value (96%). but its positive predictive value was only38% Based on this, they have stated that PCT and CRP are better than interleukin 6 tests and white blood cell counts in predicting the occurrence of severe bacterial infections and are suitable tools in emergency. (12). In a study by Carnino et al., it was shown that PCT is significantly increased in bacterial infections compared to fungal infections, but not in response to other types of inflammation (9). A study by Gomes et al showed that the identification of patients with bacterial infection by PCT in young infants with FWS was better than CRP and seems to be the best indicator of IBI rejection. PCT has been the most accurate blood test in patients with normal urinalysis and fever (13).
In the present study, the total number of positive blood cultures was 3 (7.14%), two of which were gram-negative bacteria. Procalcitonin levels were reported to be higher than 5 ng / ml. In another case with positive blood culture with Staphylococcus lugdunensis, the amount of procalcitonin was reported to be 0.1 ng/ml. Staph lugdunensis infections in humans range from harmless skin colonization to invasive infection. The majority of infections are related to skin and soft tissue, the bloodstream, and prosthetic devices. the patient was evaluated clinically and by other tests and re-cultured, and due to the appropriate general condition and lack of bacterial evidence in other tests, he did not receive antibiotics. She was discharged from the hospital after the fever stopped, but he was mentioned in the statistics of the study to comply with the trust.
one of the weaknesses of this study was the small number of positive samples in terms of culture. This can confuse being positive. Perhaps for this reason, the positive predictivity value (PPV)of the test was only 47.05%, while the negative predictive value (NPV) was 96%, which is an important and valuable aspect of this study.
Conclusion
Fever without localized signs in young children is still a complex diagnostic problem, especially in Iran, where pneumococcal vaccination is not yet routine, and clinical signs and symptoms are often unreliable predictors of severe bacterial infection, which requires rapid intervention with intravenous antibiotics, and by Improper use of antibiotics and its side effects are the other side of this problem. According to the results of our study, it is suggested that PCT be considered as a diagnostic test along with other clinical and paraclinical criteria in the early stages of the disease to facilitate the diagnosis and treatment of the disease in the early stages.
one of the weaknesses of this study was the small number of positive samples in terms of culture. This can confuse being positive. Perhaps for this reason, the positive predictivity value (PPV)of the test was only 47.05%, while the negative predictive value (NPV) was 96%, which is an important and valuable aspect of this study.
Conclusion
Fever without localized signs in young children is still a complex diagnostic problem, especially in Iran, where pneumococcal vaccination is not yet routine, and clinical signs and symptoms are often unreliable predictors of severe bacterial infection, which requires rapid intervention with intravenous antibiotics, and by Improper use of antibiotics and its side effects are the other side of this problem. According to the results of our study, it is suggested that PCT be considered as a diagnostic test along with other clinical and paraclinical criteria in the early stages of the disease to facilitate the diagnosis and treatment of the disease in the early stages.
Type of Study: Research |
Subject:
Neonatology
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