Abstract
Background
Procalcitonin (PCT) is regarded as a specific indicator of bacterial infection. Infectious complications in patients after colorectal surgery are a common cause of morbidity and mortality. The aim of this study was to investigate (a) whether PCT could serve as a negative predictive marker for postoperative complications and (b) whether, in patients with elevated PCT levels, a pre-emptive treatment with the third-generation cephalosporin ceftriaxone is superior to an antibiotic treatment starting later on the appearance of clinical signs and symptoms of infection.
Patients and methods
By screening 250 patients with colorectal surgery, we identified 20 patients with PCT serum levels more than 1.5 ng/ml on at least 2 of the first 3 postoperative days. The remaining 230 patients were followed-up for the occurrence of infectious complications. The 20 patients with elevated PCT were included in a prospective randomised pilot study comparing pre-emptive antibiotic treatment with ceftriaxone vs standard treatment.
Results
The negative predictive value of PCT for systemic infectious complications was 98.3%. In patients receiving pre-emptive antibiotic treatment (ceftriaxone), both the incidence and the severity of postoperative systemic infections were significantly lower compared to those in a control group (Pearson’s χ 2 test; p=0.001 and p=0.007, respectively). Major differences were also observed with respect to duration of antibiotic treatment and length of hospital stay.
Conclusions
PCT is an early marker for systemic infectious complications after colorectal surgery with a high negative predictive value. A significant reduction in the rate of postoperative infections in patients with elevated PCT serum concentrations was achieved by means of pre-emptive antibiotic treatment.
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References
Fowler CL, Pattisapu R, Johnson LM, Assimacopoulos C, Halverson K (1988) Complications of colorectal surgery. A review of factors affecting surgical complication in 411 colorectal procedures. S D J Med 41:19–23
Kingston RD, Jeacock J, Walsh S, Keeling F (1995) The outcome of surgery for colorectal cancer in the elderly: a 12-year review from the Trafford Database. Eur J Surg Oncol 21:514–516
Urbach DR, Kennedy ED, Cohen MM (1999) Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis. Ann Surg 229:174–180
Daly JM, DeCosse JJ (1983) Complications in surgery of the colon and rectum. Surg Clin North Am 63:1215–1231
Song F, Glenny AM (1998) Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials. Br J Surg 85:1232–1241
Zanella E, Rulli F (2000) A multicenter randomized trial of prophylaxis with intravenous cefepime + metronidazole or ceftriaxone + metronidazole in colorectal surgery. The 230 Study Group. J Chemother 12:63–71
Woodfield JC, Van Rij AM, Pettigrew RA, van der Linden AJ, Solomon C, Bolt D (2003) A comparison of the prophylactic efficacy of ceftriaxone and cefotaxime in abdominal surgery. Am J Surg 185:45–49
Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR, Reid CR (1993) Nosocomial infections in surgical patients in the United States, January 1986–June 1992. National Nosocomial Infections Surveillance (NNIS) System. Infect Control Hosp Epidemiol 14:73–80
Arozullah AM, Khuri SF, Henderson WG, Daley J (2001) Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med 135:847–857
Johnson CC, Baldessarre J, Levison ME (1997) Peritonitis: update on pathophysiology, clinical manifestations, and management. Clin Infect Dis 24:1035–1045; quiz 1046–1037
Grant SW, Hopkins J, Wilson SE (1995) Operative site bacteriology as an indicator of postoperative infectious complications in elective colorectal surgery. Am Surg 61:856–861
The Norwegian Study Group for Colorectal Surgery (1985) Should antimicrobial prophylaxis in colorectal surgery include agents effective against both anaerobic and aerobic microorganisms? A double-blind, multicenter study. Surgery 97:402–408
Mittelkotter U (2001) Antimicrobial prophylaxis for abdominal surgery: is there a need for metronidazole? J Chemother 13(Spec No 1):27–34
Rau HG, Mittelkotter U, Zimmermann A, Lachmann A, Kohler L, Kullmann KH (2000) Perioperative infection prophylaxis and risk factor impact in colon surgery. Chemotherapy 46:353–363
Bone RC (1996) Immunologic dissonance: a continuing evolution in our understanding of the Systemic Inflammatory Response Syndrome (SIRS) and the Multiple Organ Dysfunction Syndrome (MODS). Ann Intern Med 125:680–687
Al-Nawas B, Krammer I, Shah PM (1996) Procalcitonin in diagnosis of severe infections. Eur J Med Res 1:331–333
Al-Nawas B, Shah P (1997) Procalcitonin in acute malaria. Eur J Med Res 2:206–208
Snider RH Jr, Nylen ES, Becker KL (1997) Procalcitonin and its component peptides in systemic inflammation: immunochemical characterization. J Investig Med 45:552–560
Gendrel D, Raymond J, Assicot M, Moulin F, Iniguez JL, Lebon P, Bohuon C (1997) Measurement of procalcitonin levels in children with bacterial or viral meningitis. Clin Infect Dis 24:1240–1242
Viallon A, Zeni F, Lambert C, Pozzetto B, Tardy B, Venet C, Bertrand JC (1999) High sensitivity and specificity of serum procalcitonin levels in adults with bacterial meningitis. Clin Infect Dis 28:1313–1316
Zeni F, Viallon A, Assicot M (1994) Procalcitonin serum concentration and severity of sepsis. Clin Intensive Care 5:89–98
Assicot M, Gendrel D, Carsin H, Raymond J, Guilbaud J, Bohuon C (1993) High serum procalcitonin concentrations in patients with sepsis and infection. Lancet 341:515–518
Muller B, Becker KL, Schachinger H, Rickenbacher PR, Huber PR, Zimmerli W, Ritz R (2000) Calcitonin precursors are reliable markers of sepsis in a medical intensive care unit. Crit Care Med 28:977–983
Wanner GA, Keel M, Steckholzer U, Beier W, Stocker R, Ertel W (2000) Relationship between procalcitonin plasma levels and severity of injury, sepsis, organ failure, and mortality in injured patients. Crit Care Med 28:950–957
Moulin F, Raymond J, Lorrot M, Marc E, Coste J, Iniguez JL, Kalifa G, Bohuon C, Gendrel D (2001) Procalcitonin in children admitted to hospital with community acquired pneumonia. Arch Dis Child 84:332–336
Nylen ES, Snider RH Jr, Thompson KA, Rohatgi P, Becker KL (1996) Pneumonitis-associated hyperprocalcitoninemia. Am J Med Sci 312:12–18
Bernard L, Ferriere F, Casassus P, Malas F, Leveque S, Guillevin L, Lortholary O (1998) Procalcitonin as an early marker of bacterial infection in severely neutropenic febrile adults. Clin Infect Dis 27:914–915
Rau B, Kruger CM, Schilling MK (2004) Procalcitonin: improved biochemical severity stratification and postoperative monitoring in severe abdominal inflammation and sepsis. Langenbecks Arch Surg 389:134–144
Reith HB, Mittelkotter U, Wagner R, Thiede A (2000) Procalcitonin (PCT) in patients with abdominal sepsis. Intensive Care Med 26:165–169
Reith HB, Mittelkotter U, Debus ES, Kussner C, Thiede A (1998) Procalcitonin in early detection of postoperative complications. Dig Surg 15:260–265
American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference (1992) definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874
Carrol ED, Thomson AP, Hart CA (2002) Procalcitonin as a marker of sepsis. Int J Antimicrob Agents 20:1–9
Al-Nawas B, Shah PM (1996) Procalcitonin in patients with and without immunosuppression and sepsis. Infection 24:434–436
Engel A, Steinbach G, Kern P, Kern WV (1999) Diagnostic value of procalcitonin serum levels in neutropenic patients with fever: comparison with interleukin-8. Scand J Infect Dis 31:185–189
Meisner M, Tschaikowsky K, Hutzler A, Schick C, Schuttler J (1998) Postoperative plasma concentrations of procalcitonin after different types of surgery. Intensive Care Med 24:680–684
Molter GP, Soltesz S, Kottke R, Wilhelm W, Biedler A, Silomon M (2003) Procalcitonin plasma concentrations and systemic inflammatory response following different types of surgery. Anaesthesist 52:210–217
Di Filippo A, Lombardi A, Ognibene A, Messeri G, Tonelli F (2002) Procalcitonin as an early marker of postoperative infectious complications. Minerva Chir 57:59–62
Schwenk W, Haase O, Raue W, Neudecker J, Muller JM (2004) Establishing “fast-track”-colonic surgery in the clinical routine. Zentralbl Chir 129:502–509
Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH (2001) ‘Fast track’ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 88:1533–1538
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Chromik, A.M., Endter, F., Uhl, W. et al. Pre-emptive antibiotic treatment vs ‘standard’ treatment in patients with elevated serum procalcitonin levels after elective colorectal surgery: a prospective randomised pilot study. Langenbecks Arch Surg 391, 187–194 (2006). https://doi.org/10.1007/s00423-005-0009-1
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DOI: https://doi.org/10.1007/s00423-005-0009-1