Discriminative Accuracy of Procalcitonin and Traditional Biomarkers in Pediatric Acute Musculoskeletal Infection

McMichael, Brianna S.; Nickel, Amanda; Christensen, Eric; Frenn, Kristin A.; Truong, Walter H.; Laine, Jennifer C.; Kharbanda, Anupam B.

doi:10.1097/pec.0000000000001978

Cited by 9 publications

(13 citation statements)

References 31 publications

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“… 17 Comparatively, CRP typically begins to elevate within 6 h of a stimulus and peak later than PCT, between 24 and 72 h. 17 McMichael et al reported that PCT, CRP, and erythrocyte sedimentation rate (ESR) performed reasonably well for the detection of MSKI, while WBC count was not predictive of MSKI. 18 Woo et al also confirmed that CRP and PCT had better predictive function for sepsis than WBC count. 19 In a multicenter trial, sepsis patients received either PCT-guided discontinuation of antimicrobials or standard of care.…”

Section: Discussionmentioning

confidence: 91%

Clinical Features and Etiology of Musculoskeletal Infection with or without Sepsis in the Emergency Department

Zhang

Huang

et al. 2021

IJGM

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Background: Musculoskeletal infection (MSKI) is a common reason to seek medical care in the emergency department (ED). We aimed to determine the clinical characteristics and etiology of patients with MSKI in our ED, the characteristics of MSKI with sepsis, and the predictors of death in sepsis patients. Methods: The study retrospectively analyzed patients with MSKI from April 1, 2017, to March 31, 2021. The patients were divided into non-sepsis and sepsis groups. Clinical data of these patients including their basic information, laboratory results, diagnostic results, and outcomes were collected. Statistical analysis was carried out using GraphPad Prism 5. Results: In all, 106 patients (70 male, 36 female) were enrolled in this study: 43 MSKI patients with sepsis and 63 MSKI patients without sepsis. Five patients with sepsis died. The patients' age and sex ratio were no significantly different between the sepsis and non-sepsis groups. In the sepsis group, the ratio of rheumatic diseases, diabetes, coronary heart disease, and deep vein thrombosis was significantly different than that in the non-sepsis group (all p<0.05). Fifty-six patients (54.37%) had positive etiology results. Staphylococcus, streptococcus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli were the most common bacteria found in both groups, but sepsis patients had more Candida albicans infections than non-sepsis patients (p=0.0331, p<0.05). The five patients who died in the sepsis group had higher serum levels of creatinine and procalcitonin (PCT). Multivariate logistic regression analyses showed that PCT (p=0.026; odds ratio, 1.038) was significantly related to mortality. Conclusion:In MSKI patients, rheumatic diseases, diabetes, coronary heart disease, and deep vein thrombosis are the risk factors for sepsis. Staphylococcus, streptococcus, K. pneumoniae, P. aeruginosa, and E. coli were the most common bacteria in MSKI patients, while MSKI patients with sepsis had more C. albicans infections. Elevated PCT was significantly related to death in sepsis patients.

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Section: Discussionmentioning

confidence: 91%

Clinical Features and Etiology of Musculoskeletal Infection with or without Sepsis in the Emergency Department

Zhang

Huang

et al. 2021

IJGM

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“…Another limitation is our retrospective classification of MSKI, which is why we used 2 physician raters to determine the diagnosis of patients included in the original study. 7 A strength of our study is that it is one of the first to evaluate the utility of the Kocher and Caird to detect MSKI in medium or large joints beyond the hip or knee joint. Although the Kocher and Caird are applied to all joints with monoarticular pain in clinical settings, there has been no evidence to support this application.…”

Section: Discussionmentioning

confidence: 99%

“…Methods of enrollment and outcome classification are described in greater detail in our original study. 7…”

Section: Outcomementioning

confidence: 99%

Novel Uses of Traditional Algorithms for Septic Arthritis

Nickel

Bretscher

Truong

et al. 2021

Journal of Pediatric Orthopaedics

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Background: Pediatric musculoskeletal infection (MSKI) is a bacterial infection of the bone, joint, and/or muscle that can be difficult to diagnose. The Kocher and Caird algorithms were developed to distinguish septic arthritis (SA) from transient synovitis (TS) in the hip. These algorithms have been applied to all patients presenting with painful, swollen monoarticular joints regardless of suspicion for SA. The aim of this analysis was to assess the test performance of Kocher and Caird to distinguish MSKI among all pediatric patients presenting with monoarticular joint pain. A secondary aim was to validate the original algorithms. Methods: We conducted a secondary analysis of a prospective cohort study evaluating the test performance of procalcitonin for suspected SA in a pediatric emergency department. Patients aged 0 to 16 years old who presented with a painful or swollen monoarticular joint were considered for enrollment. We compared the test performance of the traditional algorithms in an expanded population of MSKI versus alternate joint pain using sensitivity, specificity, and area under the curve (AUC). As a sensitivity analysis, missing data for predictors like temperature, erythrocyte sedimentation rate, C-reactive protein, and inability to bear weight were multiply imputed using the Stata program, mi impute, for changed equations. Results: The Caird algorithm had better test performance compared to the Kocher in all populations. Both algorithms were most discriminative in comparing SA to TS in all joints (AUC: 0.84 Caird and 0.75 Kocher). However, the Caird criteria performed almost as well discriminating MSKI from other causes of monoarticular joint pain in all joints (AUC: 0.79; 95% confidence interval: 0.72, 0.85) and nonhip joints (AUC: 0.80; 95% confidence interval: 0.71, 0.88). Conclusion:Based on the findings of this study, it is clinically reasonable to apply the Caird algorithm to pediatric patients presenting with monoarticular joint pain of medium and large joints such as the knee, ankle, shoulder, elbow, and wrist, in addition to the hip. Level of Evidence: Level III-retrospective study of novel applications of SA algorithms.

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“…If PCT normalizes faster than CRP, trending PCT instead of CRP could be cost saving in the long term because fewer tests would be needed. A recent study demonstrated that CRP outperformed PCT in diagnosing pediatric musculoskeletal infection, so measurement of PCT alone on initial evaluation may not be sufficient [14]. Another possible use for PCT is in reducing the duration of antibiotic courses for non-critical bacterial infections or facilitating earlier conversion from intravenous to oral antibiotics, although more research is needed on this topic before recommendations to support this clinical application can be made.…”

Section: Discussionmentioning

confidence: 99%

“…There are fewer data to support the use of PCT use in meningitis or in infectious complications of trauma, burns and pancreatitis [11]. Recent studies have evaluated the role of PCT in identifying bacterial infection in children with pneumonia, musculoskeletal infection, central line and fever and urinary tract infections, with varying utility of PCT to predict bacterial vs. non-bacterial infection [14][15][16][17][18].…”

Section: Introductionmentioning

confidence: 99%

Prospective Observational Study to Determine Kinetics of Procalcitonin in Hospitalized Children Receiving Antibiotic Therapy for Non-Critical Acute Bacterial Infections

et al. 2020

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Introduction: The kinetics of procalcitonin in pediatric patients with non-critical acute bacterial infections receiving appropriate antibiotic therapy are not well described. Methods: We performed a single-center, prospective observational pilot study of children admitted to a tertiary care children's hospital who were receiving antibiotics for treatment of a non-critical acute bacterial infection, and we prospectively measured serial procalcitonin levels daily for 4 days during hospitalization. Results: Among the 46 children with baseline procalcitonin levels enrolled in the study, procalcitonin kinetics followed a half-life of approximately 24 h in most patients. Procalcitonin declined faster than C-reactive protein over the first 48 h of appropriate antibiotic treatment. There was variation in biomarker levels among participants with the same infection type, especially in participants with bacteremia, musculoskeletal infection and skin/soft tissue infection. Conclusion: Utility of procalcitonin as a biomarker to follow every 24-48 h in non-critically ill children receiving antibiotic therapy for bacterial infections as an objective measure of clinical improvement is promising.

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Discriminative Accuracy of Procalcitonin and Traditional Biomarkers in Pediatric Acute Musculoskeletal Infection

Cited by 9 publications

References 31 publications

Clinical Features and Etiology of Musculoskeletal Infection with or without Sepsis in the Emergency Department

Clinical Features and Etiology of Musculoskeletal Infection with or without Sepsis in the Emergency Department

Novel Uses of Traditional Algorithms for Septic Arthritis

Prospective Observational Study to Determine Kinetics of Procalcitonin in Hospitalized Children Receiving Antibiotic Therapy for Non-Critical Acute Bacterial Infections

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