Abstract
Infection and sepsis continue to be the leading cause of morbidity and death in burn injuries. Diagnosing sepsis in burns is challenging as signs and symptoms of sepsis are not specific and overlap with those related to the burn injury. While the use of procalcitonin (PCT) as a biomarker is recommended for diagnosing sepsis in burns, evidence for children with burns is scarce. In this study, we aimed to investigate the role of PCT in distinguishing sepsis in pediatric burns. A prospective observational study was conducted in a single pediatric burn unit. Children hospitalized with burns ≤ 30% of total body surface area were included while patients with chemical burn, inhalation injury, or concomitant chronic diseases were excluded. Patients were classified into three groups for sepsis, systemic inflammatory response syndrome (SIRS), or controls using the American Burn Association (ABA) criteria. The predictive role of C-reactive protein (CRP) and PCT was investigated for distinguishing sepsis. Seventy-two patients were included in the study. The median total body surface area (TBSA) size was 12% (2.0–28.5%), and the median abbreviated burn severity index (ABSI) score was 3 (2–7). The median length of burn unit stay was 9.5 days (1–59 days). Sepsis was diagnosed in 11 patients (15.2%), and SIRS was present in 23 patients (40.0%), whereas 38 patients (52.8%) had neither SIRS nor sepsis (control group). Receiver operating characteristic analysis revealed that CRP and PCT levels distinguished sepsis patients from non-sepsis patients while PCT had a higher positive predictive value (50.0% vs. 45.0%). Optimal cutoff values of CRP and PCT for distinguishing sepsis were 66.75 mg/L and 0.95 ng/mL.
Conclusions: PCT levels could distinguish sepsis in children with burn injuries, performing better than CRP levels. Confirmatory studies are needed to evaluate the development of sepsis and the role of PCT in diagnosing sepsis in pediatric burn patients.
What is Known: • Even though there are excellent criteria for the diagnosis of infection and sepsis in children and several clinical parameters and biomarkers are being studied, it's difficult to diagnose burn wound sepsis in children. | |
What is New: • Data from this study showed that procalcitonin levels performed better than CRP levels as a biomarker for distinguishing sepsis from systemic inflammatory response syndrome (SIRS) in children with burn injuries. |
Similar content being viewed by others
Availability of data and material
The data was generated at a central, large-scale facility and available upon request.
Code availability
Not applicable.
Abbreviations
- ABA:
-
American Burn Association
- ABSI:
-
Abbreviated burn severity index
- ACCP/SCCM:
-
American College of Chest Physicians/Society of Critical Care Medicine
- ANC:
-
Absolute neutrophil count
- CRP:
-
C-reactive protein
- PCT:
-
Procalcitonin
- ROC:
-
Receiver operating characteristic
- SD:
-
Standard deviation
- SIRS:
-
Systemic inflammatory response syndrome
- TBSA:
-
Total body surface area
- WBC:
-
White blood cell count
References
Krishnan P, Frew Q, Green A et al (2013) Cause of death and correlation with autopsy findings in burns patients. Burns 39:583–588. https://doi.org/10.1016/j.burns.2012.09.017
Appelgren P, Björnhagen V, Bragderyd K et al (2002) A prospective study of infections in burn patients. Burns 28:39–46. https://doi.org/10.1016/s0305-4179(01)00070-5
Kumar A, Roberts D, Wood KE et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 34:1589–1596. https://doi.org/10.1097/01.CCM.0000217961.75225.E9
Greenhalgh DG (2017) Sepsis in the burn patient: a different problem than sepsis in the general population. Burn Trauma 5:23. https://doi.org/10.1186/s41038-017-0089-5
Martinez R, Rode H (2018) Role of procalcitonin in paediatric burn wound sepsis. S Afr Med J 108:793–794
Greenhalgh DG, Saffle JR, Holmes JH et al (2007) American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res 28:776–790. https://doi.org/10.1097/BCR.0b013e3181599bc9
Hollén L, Hughes R, Dodds N et al (2019) Use of procalcitonin as a biomarker for sepsis in moderate to major paediatric burns. Trauma 21:192–200
Avni T, Levcovich A, Ad-El DD et al (2010) Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ 340:c241. https://doi.org/10.1136/bmj.c241
Wibbenmeyer L, Danks R, Faucher L et al (2006) Prospective analysis of nosocomial infection rates, antibiotic use, and patterns of resistance in a burn population. J Burn Care Res Off Publ Am Burn Assoc 27:152–160. https://doi.org/10.1097/01.BCR.0000203359.32756.F7
Zbyrak V, Reverón SL, Smoke S et al (2020) Antibiotic usage after procalcitonin-guided therapy algorithm implementation in a burn intensive care unit. Ann Burns Fire Disasters 33:317–321
Vijayan AL, Vanimaya RS et al (2017) Procalcitonin: a promising diagnostic marker for sepsis and antibiotic therapy. J Intensive Care 5:51. https://doi.org/10.1186/s40560-017-0246-8
Cabral L, Afreixo V, Almeida L, Paiva JA (2016) The use of procalcitonin (PCT) for diagnosis of sepsis in burn patients: a meta-analysis. PLoS One 11:e0168475. https://doi.org/10.1371/journal.pone.0168475
Tobiasen J, Hiebert JM, Edlich RF (1982) The abbreviated burn severity index. Ann Emerg Med 11:260–262. https://doi.org/10.1016/s0196-0644(82)80096-6
Goldstein B, Giroir B, Randolph A (2005) International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc 6:2–8. https://doi.org/10.1097/01.PCC.0000149131.72248.E6
Bone RC, Balk RA, Cerra FB et al (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101:1644–1655. https://doi.org/10.1378/chest.101.6.1644
Duke J, Wood F, Semmens J et al (2011) A study of burn hospitalizations for children younger than 5 years of age: 1983–2008. Pediatrics 127:e971–e977. https://doi.org/10.1542/peds.2010-3136
Geyik MF, Aldemir M, Hosoglu S, Tacyildiz HI (2003) Epidemiology of burn unit infections in children. Am J Infect Control 31:342–346. https://doi.org/10.1016/S0196-6553(02)48226-0
Santucci SG, Gobara S, Santos CR et al (2003) Infections in a burn intensive care unit: experience of seven years. J Hosp Infect 53:6–13. https://doi.org/10.1053/jhin.2002.1340
Ozkan GY, Yucel T (2007) Burn, introduction, epidemiology, etiology. In: Turkiye Klin J Surg Med Sci, 3rd ed. pp 1–3
Farina JAJ, Rosique MJ, Rosique RG (2013) Curbing inflammation in burn patients. Int J Inflam 2013:715645. https://doi.org/10.1155/2013/715645
Stanojcic M, Vinaik R, Jeschke MG (2018) Status and challenges of predicting and diagnosing sepsis in burn patients. Surg Infect (Larchmt) 19:168–175. https://doi.org/10.1089/sur.2017.288
Fitzwater J, Purdue GF, Hunt JL, O’Keefe GE (2003) The risk factors and time course of sepsis and organ dysfunction after burn trauma. J Trauma 54:959–966. https://doi.org/10.1097/01.TA.0000029382.26295.AB
Berndtson AE, Sen S, Greenhalgh DG, Palmieri TL (2013) Estimating severity of burn in children: Pediatric Risk of Mortality (PRISM) score versus Abbreviated Burn Severity Index (ABSI). Burns 39:1048–1053. https://doi.org/10.1016/j.burns.2013.05.001
Bozkurt M, Öztürk S, Külahçı Y et al (2005) The role of procalcitonin levels at early diagnosis and follow up period in septic burn patients. Turkish J Plast Surg 13:123–129
Murray CK, Hoffmaster RM, Schmit DR et al (2007) Evaluation of white blood cell count, neutrophil percentage, and elevated temperature as predictors of bloodstream infection in burn patients. Arch Surg 142:639–642. https://doi.org/10.1001/archsurg.142.7.639
Von Heimburg D, Stieghorst W, Khorram-Sefat R, Pallua N (1998) Procalcitonin - a sepsis parameter in severe burn injuries. Burns 24:745–750. https://doi.org/10.1016/S0305-4179(98)00109-0
Neely AN, Fowler LA, Kagan RJ, Warden GD (2004) Procalcitonin in pediatric burn patients: an early indicator of sepsis? J Burn Care Rehabil 25:76–80. https://doi.org/10.1097/01.BCR.0000105095.94766.89
Bargues L, Chancerelle Y, Catineau J et al (2007) Evaluation of serum procalcitonin concentration in the ICU following severe burn. Burns 33:860–864. https://doi.org/10.1016/j.burns.2006.10.401
Lavrentieva A, Kontakiotis T, Lazaridis L et al (2007) Inflammatory markers in patients with severe burn injury. What is the best indicator of sepsis? Burns 33:189–194. https://doi.org/10.1016/j.burns.2006.07.001
Barati M, Alinejad F, Bahar MA et al (2008) Comparison of WBC, ESR, CRP and PCT serum levels in septic and non-septic burn cases. Burns 34:770–774. https://doi.org/10.1016/j.burns.2008.01.014
Bognar Z, Foldi V, Rezman B et al (2010) Extravascular lung water index as a sign of developing sepsis in burns. Burns 36:1263–1270. https://doi.org/10.1016/j.burns.2010.04.006
Lavrentieva A, Papadopoulou S, Kioumis J et al (2012) PCT as a diagnostic and prognostic tool in burn patients. Whether time course has a role in monitoring sepsis treatment. Burns 38:356–363. https://doi.org/10.1016/j.burns.2011.08.021
Kim HS, Yang HT, Hur J et al (2012) Procalcitonin levels within 48 hours after burn injury as a prognostic factor. Ann Clin Lab Sci 42:57–64
Cakır Madenci Ö, Yakupoğlu S, Benzonana N et al (2014) Evaluation of soluble CD14 subtype (presepsin) in burn sepsis. Burns 40:664–669. https://doi.org/10.1016/j.burns.2013.08.024
Seoane L, Pértega S, Galeiras R et al (2014) Procalcitonin in the burn unit and the diagnosis of infection. Burns 40:223–229. https://doi.org/10.1016/j.burns.2013.11.018
Paratz JD, Lipman J, Boots RJ et al (2014) A new marker of sepsis post burn injury?*. Crit Care Med 42:2029–2036. https://doi.org/10.1097/CCM.0000000000000400
Mokline A, Garsallah L, Rahmani I et al (2015) Procalcitonin: a diagnostic and prognostic biomarker of sepsis in burned patients. Ann Burns Fire Disasters 28:116–120
Rosanova MT, Tramonti N, Taicz M et al (2015) Assessment of C-reactive protein and procalcitonin levels to predict infection and mortality in burn children. Arch Argent Pediatr 113:36–41. https://doi.org/10.5546/aap.2015.36
Kundes MF, Kement M (2019) Value of procalcitonin levels as a predictive biomarker for sepsis in pediatric patients with burn injuries. Niger J Clin Pract 22:881–884. https://doi.org/10.4103/njcp.njcp_311_18
Brink C, Isaacs Q, Scriba MF et al (2019) Infant burns: a single institution retrospective review. Burns 45:1518–1527. https://doi.org/10.1016/j.burns.2018.11.005
Author information
Authors and Affiliations
Contributions
Conceived and designed the experiments: UO and ND. Performed the experiments: CAK and MD. Analyzed the data: UO and PK. Wrote the paper: UO. Reviewed the paper: ND.
Corresponding author
Ethics declarations
Ethics approval
The study protocol was approved by the Sisli Etfal Training and Research Hospital Clinical Research Ethical Committee (approval number: 449/ 03032015).
Consent to participate
Written informed consent was obtained from the parents of all study participants.
Conflict of interest
The authors declare no competing interests.
Additional information
Communicated by Nicole Ritz.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Oncul, U., Dalgıç, N., Demir, M. et al. Use of procalcitonin as a biomarker for sepsis in pediatric burns. Eur J Pediatr 182, 1561–1567 (2023). https://doi.org/10.1007/s00431-023-04831-6
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00431-023-04831-6