|Year : 2022 | Volume
| Issue : 3 | Page : 575-578
Determination of serum procalcitonin and total antioxidant capacity in patients of sepsis before and after treatment, in a tertiary care hospital
Divya Anand Jain1, Ajit V Sontakke1, Vaishali S Pawar1, Ashutosh Jain2
1 Department of Biochemistry, KIMSDU Karad, Maharashtra, India
2 Department of Community Medicine, KIMSDU Karad, Maharashtra, India
|Date of Submission||15-Apr-2022|
|Date of Decision||03-Sep-2022|
|Date of Acceptance||05-Sep-2022|
|Date of Web Publication||2-Nov-2022|
Dr. Divya Anand Jain
Department of Biochemistry, KIMSDU, Karad, Maharashtra - 415 539
Source of Support: None, Conflict of Interest: None
Introduction: Sepsis is a medical emergency, occurring due to the body's systemic immunological response to an infection. It is among the most common reasons for intensive care unit admissions worldwide and is one of the top 10 leading causes of death worldwide. Procalcitonin (PCT) is the marker of sepsis, and total antioxidant capacity (TAC) is a marker of oxidative stress and gives a mirror image about patient's antioxidant status. The purpose of the study was to estimate serum PCT and TAC levels in sepsis patients, before and after treatment, and to find the correlation between them. Materials and Methods: In this observational follow-up study, 60 sepsis patients were recruited using purposive sampling method, and samples were taken before and after treatment. Separated serum was used to measure PCT and TAC. PCT was measured by a rapid quantitative test using a sandwich immunodetection method based on fluorescence immunoassay technology, on a Finecare FIA system. Values over 0.5 ng/ml were considered significant. TAC was measured using the ferric-reducing antioxidant power method based on reduction of a colorless Fe3+-TPTZ on interaction with a potential antioxidant, into an intense blue Fe2+-TPTZ complex. Results: The mean PCT in subjects before treatment was as high as 40.62 ± 12.02 ng/ml, and the difference between before and after treatment values was highly significant (P = 0.000). For TAC also, before treatment value was higher (485.64 ± 106.53 μm/l) than the after treatment (277.79 ± 74.17 μm/l) value with a significantly high difference (P = 0.000). Furthermore, a strong positive correlation between PCT and TAC (r = 0.754, P = 0.000) was observed. Conclusion: It was concluded that in sepsis, there is a concomitant existence of inflammation and oxidative stress. Since TAC values correlate with values of PCT, TAC could be a reliable prognostic marker and may be helpful in evaluating interventions on follow-up of patients.
Keywords: Inflammation, oxidative stress, procalcitonin, sepsis, total antioxidant capacity
|How to cite this article:|
Jain DA, Sontakke AV, Pawar VS, Jain A. Determination of serum procalcitonin and total antioxidant capacity in patients of sepsis before and after treatment, in a tertiary care hospital. J Datta Meghe Inst Med Sci Univ 2022;17:575-8
|How to cite this URL:|
Jain DA, Sontakke AV, Pawar VS, Jain A. Determination of serum procalcitonin and total antioxidant capacity in patients of sepsis before and after treatment, in a tertiary care hospital. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Feb 1];17:575-8. Available from: http://www.journaldmims.com/text.asp?2022/17/3/575/360180
| Introduction|| |
Sepsis is a life-threatening condition, amid the top 10 death causes, estimates globally 30 million patients, and 6 million deaths annually.,,, In India, mortality in an intensive care unit (ICU), hospital, and 28 days is 56%, 63.6%, and 62.8%, respectively.
Global tissue hypoperfusion and oxidative damage cause apoptosis, therefore, early identification is a need for timely therapeutic approach.,,
Procalcitonin (PCT), a polypeptide produced by the thyroid gland, has high sensitivity and specificity in diagnosing sepsis. Total antioxidant capacity (TAC) is the cumulative action of all antioxidants of plasma. The present study estimates serum PCT and TAC levels in sepsis patients, before and after treatment, and finds the correlation between them.
| Materials and Methods|| |
This observational follow-up study was executed in a tertiary care center in collaboration with the department of biochemistry from December 2019 to October 2021. In all, 67 patients (35 males and 25 females) were selected for the study with age ranging from 46 years to 75 years. Out of 67 patients, 7 patients did not survive sepsis. They expired and had to be removed from the total sample size. The patients who survived and were planned for discharge were the only participants who were enrolled in the study, and the after treatment, samples were collected when they were on the process of discharge. Purposive sampling method - based on physician's provisional diagnosis at the time of admission, was used for selecting the study subjects.
Patients who were suspected to have a bacterial infection and were having a score of 2 or more points from the baseline based on the Sequential Organ Failure Assessment, were diagnosed with sepsis by the physician.
The need and probable outcomes of the study were explained, and written informed consent was taken from all the participants, ethical grant for the study was obtained from the institutional committee of ethics.
All patients with sepsis between 46 and 75 years of age who gave written informed consent comprised the study subjects. Subjects with preexisting renal disease, heart disease, liver disease, HIV, cancer, and COVID-19 infection were not included in the study.
Samples of blood were taken on two occasions: first, on the admission of the patient to the ICU and second, when the patient was on recovery phase from sepsis. 5ml of blood was drawn from the peripheral vein of patients under all aseptic precautions and was collected in plain vacutainers. Serum was separated from the samples by centrifugation at 3000 rpm for 10 min after 30 min of standing and was used to measure PCT and TAC.
Tests and equipments
Finecare FIA system was used to measure PCT using the Finecare PCT kit. It is a rapid and quantitative test based on fluorescence immunoassay technology. It uses a sandwich immunodetection method. Values over 0.5 ng/ml were considered significant
Total antioxidant capacity
TAC was estimated by the ferric-reducing antioxidant power method.
This assay is based on the reduction of a colorless Fe3+-TPTZ on interaction with a potential antioxidant, into an intense blue Fe2+-TPTZ complex.
The absorbance units obtained were used to calculate the value of TAC using the formula:
The data collected were coded and entered in an Excel spreadsheet and further analyzed with SPSS 20.0 version statistical software (SPSS Inc, Chicago, Illinois, USA). Analysis of data was done using Pearson product moment correlation coefficient and students paired t-test. Statistically significant P ≤ 0.05.
| Ethical clearance|| |
The Institutional Ethics Committee of KIMSDU, Karad has approved the Research work proposed to be carried out at KIMSDU Karad, Maharashtra, india. Date : 30th Nov 2021 with Reference no KIMSDU/IC/2021-22/201.
| Results|| |
The most common cause of sepsis in these patients was the infection of the lungs, followed by infection of the abdomen or pelvis and urinary tract. A significant difference was not observed in the laboratory values of male and female participants. The laboratory findings notably differed on comparing pretreatment values with posttreatment values of the participants.
The mean value for the age of study subjects was 59.8 ± 10.06 years.
[Table 1] depicts a difference between the mean ± standard deviation (SD) values of serum PCT in patients of sepsis before treatment (40.62 ± 12.02 ng/ml) and after treatment (1.99 ± 1.092 ng/ml) with P = 0.000 which was highly significant. For S. TAC also, the difference between the mean ± SD values of serum TAC in patients of sepsis before treatment (485.64 ± 106.53 μm/l) and after treatment (277.79 ± 74.17 μm/l) was significantly high (P = 0.000).
|Table 1: Laboratory findings of serum procalcitonin and serum total antioxidant capacity in patients of sepsis before and after treatment and their comparison applying paired ‘t’ test|
Click here to view
[Table 2] illustrates Pearson's coefficient of correlation, carried out to find the association of serum PCT with S. TAC. A strong positive correlation was seen to exist between serum PCT and TAC (r = 0.754, P = 0.000).
|Table 2: Pearson's coefficient of correlation of procalcitonin with total antioxidant capacity|
Click here to view
| Discussion|| |
The purpose of the study was to measure and relate the levels of inflammation and oxidative stress in patients of sepsis before and after treatment.
The mean value of PCT in patients of sepsis before treatment in the present study was reported to be 40.62 ± 12.02 ng/ml and was considerably greater than the normal range (00.5 ng/ml). The mean PCT value after treatment was 1.705 ± 1.99 ng/ml. The difference in the values of PCT before treatment and after treatment was highly significant (P = 0.000).
High levels of PCT indicate flared-up inflammatory processes going on in the patients of sepsis in response to infection, which starts subsiding on appropriate treatment and the values reduce as patients start recovering. Serum PCT levels generally upsurge distinctly in sepsis, systemic infection, and severe inflammation attaining values ten times, to hundred times, and to thousand times that of normal levels.
A similar mean value of PCT before treatment (44.05 ± 31.6 ng/ml) was seen in a study done by Yerlikaya et al., but it was done in premature babies of 7–28 days of age. Such similarity in values of PCT in adults and premature babies might be because of the fact that the PCT values obtained were from the premature babies who were in late stages of sepsis where the disease process might have been more advanced and profound, whereas in the present study, the adult patients were enrolled and before treatment PCT values were obtained at the time of admission when the disease process might have just set in or was in the early stage. The above study enrolled 21 healthy controls for comparing the results and the difference was found to be highly significant (P < 0.001), whereas in the present study, the comparison was made between the before treatment and after treatment values (1.705 ± 1.99 ng/ml) for which the difference was also significantly high (P = 0.000).
In a study done by Jekarl et al., the mean value of PCT in the patients of sepsis was 10.2 ± 24.5 ng/mL and in those who survived sepsis, the mean and SD for PCT were 8.1 ± 19.5 ng/ml. The values observed were lower than that in the present study. The reason for this might also be the age of the subjects. In this study, patients of age >18 years have been enrolled which involves a significant young age group from 19 to 45 years, whereas in our study, the patients enrolled were between 45 and 76 years of age. In the above study, comparison was made between the sepsis and nonsepsis groups and also between the survivors and nonsurvivors of sepsis. The difference in the mean values of PCT between the sepsis and nonsepsis (3.2 ± 11.7 ng/ml) group was highly significant (p < 0.001) and between sepsis survivors and nonsurvivors (23.2 ± 43.2 ng/ml), it was significant (P = 0.005).
In a study by Naher et al. and Köksal et al., the values of PCT in patients with highly probable sepsis were 5.85 ± 1.39 ng/ml and 9.3 ± 9.9 ng/ml, respectively. In the group with probable sepsis, the mean values of PCT were 5.3636 ± 1.35 ng/ml and 1.8 ± 1.7 ng/ml, respectively. Both the studies show lower mean PCT values in comparison to the present study values. The probable reason for this might be the study population selected for these studies, i. e, newborn infants, whereas in our study, adult population was enrolled. In a study by Naher et al., the PCT values of both the groups were compared with that of patients not having sepsis and it was observed that the difference was significantly high (P = 0.001. In a study by Köksal et al. on comparing the PCT value of group 1 (9.3 ± 9.9 ng/ml) with that of group 4 (0.4 ± 0.3 ng/ml), the difference was observed to be significantly high (P = 0.000).
The mean value of TAC in the current study, in sepsis patients before treatment was 485.64 ± 106.53 μm/l and after treatment was 277.79 ± 74.17 μm/l with a significant high difference (P = 0.000) between the two.
The explanation to such high values can be the fact that the generation of reactive oxygen and nitrogen species contributes to the pathogenesis of sepsis, and to counterfeit the ill effects of excess generation of reactive oxygen species, there is excess production of antioxidants.
In a similar study done by Chuang et al., the values of TAC were considerably high in patients having severe sepsis and in healthy individuals (637.0 ± 290.9 μmol/l versus 355.2 ± 102.7 μmol/l) when compared to that of the current study. Furthermore, the difference between the cases and controls was significantly high (P < 0.001). There might be two possible reasons for such high values: the higher mean age of study subjects (65.9 ± 16.4 years) and the patients enrolled had severe sepsis, in contrast to our study, where patients had sepsis and not severe sepsis.
In the present study, correlation between PCT and TAC was strongly positive (r = 0.754, P = 0.000) in before treatment patients. None of the studies could be traced in the literature showing correlation between PCT and TAC.
| Conclusion|| |
From the results of our study, it can be said that in sepsis, inflammation and oxidative stress go hand in hand and thus inflammation alone does not contribute to the pathophysiology of the disease.
PCT is an established sensitive marker of inflammation and its upsurge in sepsis has been witnessed in several studies, therefore, elevation in the levels of other parameters along with PCT before treatment and their improving trend after the treatment, indicate that these changes occur solely due to sepsis in response to an infection and not due to any other cause.
Since it was observed in the study that values of TAC rise and decline with values of PCT, TAC can be used as a cost-effective tool to monitor the patients of sepsis admitted in ICU. The values of TAC could also be helpful in assessing the disease severity in patients of sepsis.
Very less studies have been done in this aspect, particularly in India, and therefore, this study will be helpful in understanding the importance of selected biomarkers in sepsis and would add to our knowledge about the same. Moreover, this study has been done in a rural area, and despite limited resources, it could be completed without hurdles.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Elewa A, Anber N, Zaki ME, El Deek AB. Evaluation of soluble E-selectin and total antioxidant capacity as prognostic biomarkers of sepsis in children. Int J Curr Microbiol Appl Sci 2015;4:665-73.
Ashok Kumar P, Anand U. Multiple biomarkers to assess the pathophysiological state in critically ill patients with sepsis. Indian J Clin Biochem 2016;31:310-4.
Prashanth AK, Anand U. Clinical significance of ischemia modified albumin in critically ill patients with sepsis. Indian J Clin Biochem 2015;30:194-7.
Sahoo S, Mukherjee B, Patra S. Comparative study between serum ischemia modified albumin, nitric oxide products and malondialdehyde in patients of sepsis. Int J Health Sci Res 2015;5:161-72.
Rohit YV, Raghu K, Shabnum M. Study of ischemia-modified albumin as a biomarker in critically ill patients with sepsis. Saudi Crit Care J 2019;3:104. [Full text]
Yin M, Liu X, Chen X, Li C, Qin W, Han H, et al.
Ischemia-modified albumin is a predictor of short-term mortality in patients with severe sepsis. J Crit Care 2017;37:7-12.
Lorente L, Martín MM, Abreu-González P, Domínguez-Rodriguez A, Labarta L, Díaz C, et al.
Sustained high serum malondialdehyde levels are associated with severity and mortality in septic patients. Crit Care 2013;17:R290.
Hu C, Zhou Y, Liu C, Kang Y. Pentraxin-3, procalcitonin and lactate as prognostic markers in patients with sepsis and septic shock. Oncotarget 2018;9:5125-36.
Jekarl DW, Lee S, Kim M, Kim Y, Woo SH, Lee WJ. Procalcitonin as a prognostic marker for sepsis based on SEPSIS-3. J Clin Lab Anal 2019;33:e22996.
Christ-Crain M, Jaccard-Stolz D, Bingisser R, Gencay MM, Huber PR, Tamm M, et al.
Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: Cluster-randomised, single-blinded intervention trial. Lancet 2004;363:600-7.
Spiegel M, Kapusta K, Kołodziejczyk W, Saloni J, Żbikowska B, Hill GA, et al.
Antioxidant activity of selected phenolic acids-ferric reducing antioxidant power assay and QSAR analysis of the structural features. Molecules 2020;25:3088.
Schober P, Boer C, Schwarte LA. Correlation coefficients: Appropriate use and interpretation. Anesth Analg 2018;126:1763-8.
Becker KL, Snider R, Nylen ES. Procalcitonin in sepsis and systemic inflammation: A harmful biomarker and a therapeutic target. Br J Pharmacol 2010;159:253-64.
Yerlikaya FH, Kurban S, Mehmetoglu I, Annagur A, Altunhan H, Erbay E, et al.
Serum ischemia-modified albumin levels at diagnosis and during treatment of late-onset neonatal sepsis. J Matern Fetal Neonatal Med 2014;27:1723-7.
Naher BS, Mannan MA, Noor K, Shahiddullah M. Role of serum procalcitonin and C-reactive protein in the diagnosis of neonatal sepsis. Bangladesh Med Res Counc Bull 2011;37:40-6.
Köksal N, Harmanci R, Cetinkaya M, Hacimustafaoğlu M. Role of procalcitonin and CRP in diagnosis and follow-up of neonatal sepsis. Turk J Pediatr 2007;49:21-9.
Chuang CC, Shiesh SC, Chi CH, Tu YF, Hor LI, Shieh CC, et al.
Serum total antioxidant capacity reflects severity of illness in patients with severe sepsis. Crit Care 2006;10:R36.
[Table 1], [Table 2]