The Role of Serum Procalcitonin Levels in Predicting Ascitic Fluid Infection in Hospitalized Cirrhotic and Non-cirrhotic Patients

Abstract

Objective: To determine the role of serum procalcitonin levels in predicting ascites infection in hospitalized cirrhotic and non-cirrhotic patients.Methods: A total of 101 patients (mean age: 63.4±1.3, 66.3% were males) hospitalized due to cirrhosis (n=88) or malignancy related (n=13) ascites were included in this study. Spontaneous bacterial peritonitis (SBP, 19.8%), culture-negative SBP (38.6%), bacterascites (4.9%), sterile ascites (23.8%) and malign ascites (12.9%) groups were compared in terms of procalcitonin levels in predicting ascites infection. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of procalcitonin levels and predicting outcome of procalcitonin levels was compared with C-reactive protein (CRP).Results: Culture positivity was determined in 26.7% of overall population. Serum procalcitonin levels were determined to be significantly higher in patients with positive bacterial culture in ascitic fluid compared to patients without culture positivity (median (min-max): 4.1 (0.2-36.4) vs. 0.4 (0.04-15.8), p<0.001). Using ROC analysis, a serum procalcitonin level of <0.61 ng/mL in SBP (area under curve (AUC): 0.981, CI 95%: 0.000-1.000, p<0.001), <0.225 ng/mL in culture-negative SBP (AUC: 0.743, CI 95%: 0.619-0.867, p<0.001), <0.42 ng/mL in SBP and culture-negative SBP patients (AUC: 0.824, CI 95%: 0.732-0.916, p<0.001), and <1.12 ng/mL in bacterascites (AUC: 0.837, CI 95%: 0.000-1.000, p=0.019) were determined to accurately rule out the diagnosis of bacterial peritonitis. Predictive power of serum procalcitonin levels in SBP + culture-negative SBP group (AUCs: 0.824 vs 0.622, p=0.004, Fig 4), culture-positive SBP (AUCs: 0.981 vs 0.777, p=0.006, Fig 5) and (although less powerfull) in culture-negative SBP (AUCs: 0.743 vs 0.543, p=0.02, Fig 6) were found significantly higher than CRP.Conclusion: According to our findings determination of serum procalcitonin levels seems to provide satisfactory diagnostic accuracy in differentiating bacterial infections in hospitalized patients with liver cirrhosis related ascites.

The role of serum procalcitonin and C-reactive protein levelsin predicting spontaneous bacterial peritonitis in patients with advanced liver cirrhosis

“…Ascitic fluid culture examination is time consuming (24-48h) which delays the diagnosis and treatment. Therefore, the identification of clinical and laboratory parameters for the early diagnosis of SBP would be of special interest 5,6…”

Significance of serum procalcitonin as biomarker for detection of bacterial peritonitis: a systematic review and meta-analysis

“…Five of 18 included studies were prospective [17, 18, 22, 23, 25], and 13 studies were retrospective in design [19–21, 24, 26–34]. All studies had clearly defined inclusion and exclusion criteria.…”

“…Eleven studies [21–23, 25–27, 29–32, 34] had reported accuracy parameters on serum PCT in cirrhotic patients. The pooled sensitivity and specificity were 0.86 and 0.94 respectively, and the AUROC was 0.91 (95% CI: 0.89-0.94), indicating that serum PCT also had acceptable predictive performance in cirrhotic patients.…”

Markers of bacterial translocation in end-stage liver disease

“…As the liver is believed to be a key source of PCT, there were initially concerns that hepatic impairment may result in downregulated serum PCT levels. Although, this was not proven to be the case [84] , and early reports were encouraging about the use of PCT in the diagnosis of SBP, its potential role remains currently unclear as several studies provided conflicting results [85][86][87][88][89][90][91][92][93] . A solution has been proposed with the use of an ultra-sensitive PCT assay [87] , and possible explanations for the discrepancies noted between studies include higher baseline levels in patient with alcoholic [94] or specific viral-related [95] causes of cirrhosis and the presence of other bacterial infections [96] .…”