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• Rational Use of Procalcitonin in Neonatal Sepsis
  Jogender Kumar
  Published on: 19 September 2018

• Published on: 19 September 2018

  Rational Use of Procalcitonin in Neonatal Sepsis

  • Jogender Kumar, Neonatologist Post Graduate Institute of Medical education and Research, Chandigarh India 160012

  Dear Editor,
  We read with interest the article by Robinson et al on use of Procalcitonin (PCT) in the pediatric population.[1] This article meticulously narrates the importance as well as shortcomings of the PCT in pediatric population. Being a neonatologist, I read the neonatal part very carefully and found few points which are either contrary or extension to the above article.
  1. Authors stated that the number of patient used to generate nomogram for neonatal PCT were too low, to validate it and quotes an old study with 83 healthy subjects (1998) by Chiesa et al. However, the same group published another study in 2011 (not cited by authors) with 421 healthy participants, which provides largest normative data on PCT.[2] The nomograms are robust for term neonates but for preterms < 33 weeks the data is very small and needs further studies.
  2. Author stated that PCT is better marker for early-onset sepsis (EOS) than late sepsis, which is not true. This statement is based on extrapolation of an old meta-analysis by Yu et al[3] which included 22 studies. In this meta-analysis also they found that PCT has moderate diagnostic accuracy in early as well as late-onset sepsis. So, the basis of author’s statement that PCT is better marker for early-onset sepsis is not very clear. On the contrary, Vouloumanou et al[4] published a systematic review and meta-analysis of 29 studies and concluded that the diagnostic accuracy is higher for late-onset neonatal se...

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  Dear Editor,
  We read with interest the article by Robinson et al on use of Procalcitonin (PCT) in the pediatric population.[1] This article meticulously narrates the importance as well as shortcomings of the PCT in pediatric population. Being a neonatologist, I read the neonatal part very carefully and found few points which are either contrary or extension to the above article.
  1. Authors stated that the number of patient used to generate nomogram for neonatal PCT were too low, to validate it and quotes an old study with 83 healthy subjects (1998) by Chiesa et al. However, the same group published another study in 2011 (not cited by authors) with 421 healthy participants, which provides largest normative data on PCT.[2] The nomograms are robust for term neonates but for preterms < 33 weeks the data is very small and needs further studies.
  2. Author stated that PCT is better marker for early-onset sepsis (EOS) than late sepsis, which is not true. This statement is based on extrapolation of an old meta-analysis by Yu et al[3] which included 22 studies. In this meta-analysis also they found that PCT has moderate diagnostic accuracy in early as well as late-onset sepsis. So, the basis of author’s statement that PCT is better marker for early-onset sepsis is not very clear. On the contrary, Vouloumanou et al[4] published a systematic review and meta-analysis of 29 studies and concluded that the diagnostic accuracy is higher for late-onset neonatal sepsis than early-onset sepsis (AUC 0.95 vs 0.78 respectively). So, in the present article, the role of PCT in late-onset sepsis didn’t get due importance.
  3. Also, this is important to emphasize that we must follow the age and gestation based nomograms for interpretation of PCT values as variation may be as high as 1000 times. Similarly, for C reactive protein also there are age and gestation based nomograms which should be used rather than using a single cutoff value across all gestation and ages.
  4. The results of Neonatal Procalcitonin Intervention Study (NeoPInS) are encouraging for use of PCT in EOS. But at the same time we must keep in mind that these results cannot be extrapolated to preterm neonates and developing countries where the incidence of proven early-onset sepsis is high.
  5. Author stated that PCT should not be used as a ‘rule-out’ test for sepsis in febrile infants. But, being a screening test its role will be only in “ruling out” rather than “ruling in” sepsis. Although the negative likelihood ratio of PCT alone is not very impressive, so it should be used in conjunction with other inflammatory markers to rule out sepsis.
  In the era of emerging multidrug-resistant organisms, it is need of the hour to optimally use the pro-inflammatory markers for guiding the duration of the therapy and PCT seems promising one. There is urgent need of further studies to test whether PCT can be used as a decision-making tool for initiation of the therapy.

  References
  1 Robinson P, De SK. How to use… Procalcitonin. Arch Dis Child - Educ Pract Ed 2018;:edpract-2017- 313699. doi:10.1136/archdischild-2017-313699
  2 Chiesa C, Natale F, Pascone R, et al. C reactive protein and procalcitonin: reference intervals for preterm and term newborns during the early neonatal period. Clin Chim Acta Int J Clin Chem 2011;412:1053–9. doi:10.1016/j.cca.2011.02.020
  3 Yu Z, Liu J, Sun Q, et al. The accuracy of the procalcitonin test for the diagnosis of neonatal sepsis: A meta-analysis. Scand J Infect Dis 2010;42:723–33. doi:10.3109/00365548.2010.489906
  4 Vouloumanou EK, Plessa E, Karageorgopoulos DE, et al. Serum procalcitonin as a diagnostic marker for neonatal sepsis: a systematic review and meta-analysis. Intensive Care Med 2011;37:747–62. doi:10.1007/s00134-011-2174-8

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  Conflict of Interest:
  None declared.

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