Procalcitonin level, neutrophil to lymphocyte count ratio, and mean platelet volume as predictors of organ dysfunction and mortality in children with sepsis

Saptadi Yuliarto; Kurniawan Taufiq Kadafi; Dian Maharani; Irene Ratridewi; Savitri Laksmi Winaputri

doi:10.14238/pi63.1sup.2023.14-20

Saptadi Yuliarto Faculty of Medicine, Universitas Brawijaya http://orcid.org/0000-0003-0824-2883
Kurniawan Taufiq Kadafi http://orcid.org/0000-0003-2328-079X
Dian Maharani Faculty of Medicine, Universitas Brawijaya Malang http://orcid.org/0000-0003-4049-6381
Irene Ratridewi Department of Child Health, Universitas Brawijaya Medical School/Dr. Saiful Anwar Hospital, Malang, East Java http://orcid.org/0000-0002-9716-1673
Savitri Laksmi Winaputri Department of Child Health, Universitas Brawijaya Medical School/Dr. Saiful Anwar Hospital, Malang, East Java https://orcid.org/0000-0001-6808-3090

DOI: https://doi.org/10.14238/pi63.1sup.2023.14-20

Keywords: sepsis, procalcitonin, qSOFA, neutrophil to lymphocyte count ratio, mean platelet volume

Abstract

Background Procalcitonin (PCT) level is one of known biomarker in septic diagnosis, but limited studies report its benefit in predicting the outcomes of children with sepsis. Neutrophil to lymphocyte (NLR) and mean platelet volume (MPV) are simple biomarkers of inflammation that can be measured in routine hematological examination which role in predicting organ dysfunction remain unclear.

Objective To understand the correlations between PCT level, NLR, and MPV, tested in the first day of admission with outcomes of septic children in intensive care unit.

Methods This retrospective cohort study obtained the data from medical record of pediatric patients admitted in PICU and HCU since January 2019. The inclusion criteria were children aged 1 months to 18 years with sepsis; whie exclusion criteria were patients with congenital heart disease, hematologic disease, malignancy, and length of care in intensive care unit less than 3 days or more than 28 days. The PCT, NLR, and MPV levels were assessed in the first day of admission. Organ dysfunction was identified using qSOFA score more than 2 points.

Results Sixty-nine septic children were reviewed. Procalcitonin level in the first day of admission correlated significantly with qSOFA score in the third day of admission (R= 0.639; P=0.000); as well as with mortality (R=0.747; P=0.000). Receiver operating characteristic (ROC) curve of PCT level in the first day of admission had area under curve (AUC) of 0.922 to predict organ dysfunction (cut off 3.425; sensitivity 95.8%; specificity 52.4%) and AUC of 0.952 to predict mortality (cut off 21.165; sensitivity 96.4%; specificity 78%).

Moreover, NLR in the first day of admission correlated significantly with qSOFA in the third day of admission (R=0.407; P=0.001), but did not correlate with mortality. The ROC of NLR to predict organ dysfunction was 0.829 (cut off 3.52; sensitivity 87.5%; specificity 66.7%). There was no correlation between MPV in the first day of admission with qSOFA score in the third day of admission neither with mortality.

Linear regression test showed that PCT level and NLR in the first day of admission simultaneously had correlated with qSOFA score in the third day of admission (R=0.696; P= 0.000) and mortality (R=0.748; P=0.000). Meanwhile, PCT and MPV simultaneously had correlation with qSOFA score in the third day of admission (R=0.688; P=0.000) and mortality (R=0.733; P=0.000). Moreover, NLR and MPV simultaneously had correlation with qSOFA score in the third day of admission (R=0.453; P=0.002). All three independent variables (PCT level, NLR, and MPV) simultaneously correlated with qSOFA score in the third day of admission (R= 0.744; P=0.000) and mortality (R=0.739; P=0.000).

Conclusion There are significant correlations between each, PCT level and NLR in the first day of admission with qSOFA score in the third day of admission as well as with mortality. There is no correlation between MPV in the first day of admission with qSOFA score in the third day of admission, neither with mortality. There are significant correlations between PCV level and NLR with or without MPV with qSOFA score in the third day of admission as well as with mortality.

References

1. Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HL, Inwald DP, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatric Critical Care Medicine. 2020;21:52-106. DOI: https://doi.org/10.1097/PCC.0000000000002198.
2. Boeddha NP, Schlapbach LJ, Driessen GJ, Herberg JA, Rivero-Calle I, Cebey-Lopez M, et al. Mortality and morbidity in community- acquired sepsis in European pediatric intensive care units : a prospective cohort study from the European Childhood Life-Threatening Infectious Disease Study ( EUCLIDS ). Crit Care. 2018;22: 1–14. DOI: https://doi.org/10.1186/s13054-018-2052-7.
3. Wang Y, Sun B, Yue H, Lin X, Li B, Yang X, et al. An Epidemiologic survey of pediatric sepsis in regional hospitals in China. Pediatr Crit Care Med. 2014;15:814-820. DOI: https://doi.org/10.1097/PCC.0000000000000247.
4. Schlapbach LJ, Straney L, Bellomo R, Maclaren G, Pilcher D. Prognostic accuracy of age adapted SOFA , SIRS , PELOD 2, and QSOFA for in hospital mortality among children with suspected infection admitted to the intensive care unit. Intensive Care Med. 2018;44:179-188. DOI: https://doi.org/10.1007/s00134-017-5021-8.
5. van Nassau SC, van Beek RH, Driessen GJ, Hazelzet JA, van Wering HM. Translating Sepsis-3 criteria in children: prognostic accuracy of age-adjusted quick SOFA score in children visiting emergency department with suspected bacterial infection. Front Pediatr. 2018;6:266. DOI: https://doi.org/10.3389/fped.2018.00266.
6. Goldstein B, Giroir B, Randolph A. International Pediatric Sepsis Consensus Conference: Definitions for Sepsis and Organ Dysfunction in Pediatrics. Pediatr Crit Care Med. 2005;6:1-8. DOI: 10.1097/01.PCC.0000149131.72248.E6.
7. Koutroulis I, Loscalzo SM, Kratimenos P, Singh S, Weiner E, Syriopoulou V, et al. Clinical applications of procalcitonin in pediatrics: an advanced biomarker for inflammation and infection — can it also be used in trauma. Int Sch Res Notices. 2014;2014:286493. DOI: https://doi.org/10.1155/2014/286493.
8. Rosanova MT, Tramonti N, Taicz M, Martiren S, Basillico H, Signorelli C, et al. Assessment of C-reactive protein and procalcitonin levels to predict infection and mortality in burn children. Arch Argent Pediatr. 2015;113:36-41. English, Spanish. DOI: https://doi.org/10.5546/aap.2015.eng.36.
9. Zurek J, Vavrina M. Procalcitonin biomarker kinetics to predict multiorgan dysfunction syndrome in children with sepsis and systemic inflammatory response syndrome. Iran J Pediatr. 2015;25:e324. DOI: https://doi.org/10.5812/ijp.324.
10. Arif SK, Bau A, Rukka S, Wahyuni S. Comparison of neutrophils-lymphocytes ratio and procalcitonin parameters in sepsis patient treated in Intensive Care Unit Dr. Wahidin Hospital, Makassar, Indonesia. Journal Medical Science. 2017;17:17-21. DOI: https://doi.org/10.3923/jms.2017.17.21.
11. Tekinalp A, Bektas O, Kasdogan ZEA, Kaymaz H. The Association between lymphocyte/neutrophil ratio and clinical course in intensive care patients. EJMI. 2018;2:156–60. DOI: https://doi.org/10.14744/ejmi.2018.60252.
12. Ni J, Wang H, Li Y, Shu Y, Liu Y. Neutrophil to lymphocyte ratio (NLR) as a prognostic marker for in-hospital mortality of patients with sepsis. Medicine (Baltimore). 2019;98:1-5. DOI: https://doi.org/10.1097/MD.0000000000018029.