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SEPSIS MARKERS IN

CLINICAL USE

Methee Chayakulkeeree, MD, PhD Division of Infectious Diseases and Tropical Medicine

Department of Medicine

Faculty of Medicine Siriraj Hospital

Mahidol University

Systemic Inflammatory Response Syndrome

(SIRS)

Criteria

• Two or more of the following are required

Body temperature > 38 °C or < 36 °C

Heart rate > 90 beats/min

Respiratory rate > 20 breaths/min (or arterial pCO2 < 32 mmHg, indicating hyperventilation)

White blood cell count > 12.0 x109/L or < 4.0 x109/L (or > 10% immature forms)

• Sepsis = Infection + SIRS

• Severe sepsis = Sepsis + evidence of organ dysfunction

Crit Care Med 1992;20:864-74., Crit Care Med 2003;31:1250-6.

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Diagnostic Criteria for Sepsis

General variables

• Fever (> 38.3°C)

• Hypothermia (core temperature < 36°C)

• HR > 90/min or > 2 SD above normal value for age

• Tachypnea

• Altered mental status

• Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)

• Hyperglycemia (plasma glucose > 140 mg/dL or 7.7

mmol/L) in the absence of diabetes

Inflammatory variables

• Leukocytosis (WBC count > 12,000 /μL)

• Leukopenia (WBC count < 4000 /μL)

• Normal WBC count with > 10% immature forms

• Plasma C-reactive protein > 2 SD above normal value

• Plasma procalcitonin > 2 SD above the normal value

Hemodynamic variables

• Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm

Hg, or an SBP decrease > 40 mm Hg in adults or < 2 SD below normal for age)

Organ dysfunction variables

• Arterial hypoxemia (Pao2/Fio2 < 300)

• Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)

• Creatinine increase > 0.5 mg/dL or 44.2 μmol/L

• Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)

• Ileus (absent bowel sounds)

• Thrombocytopenia (platelet count < 100,000 /μL)

• Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 μmol/L)

Tissue perfusion variables

• Hyperlactatemia (> 1 mmol/L)

• Decreased capillary refill or mottling

Infection, documented or suspected, and some of the following:

Surviving Sepsis Campaign Guidelines. Crit Care Med. 2013;41:580-637.

Severe sepsis = sepsis-induced tissue

hypoperfusion or organ dysfunction

• Sepsis-induced hypotension

• Lactate above upper limits laboratory normal

• Urine output < 0.5 mL/kg/hr for > 2 hrs despite adequate fluid resuscitation

• Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source

• Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as

infection source

• Creatinine > 2.0 mg/dL (176.8 μmol/L)

• Bilirubin > 2 mg/dL (34.2 μmol/L)

• Platelet count < 100,000 μL

• Coagulopathy (international normalized ratio > 1.5)

Surviving Sepsis Campaign Guidelines. Crit Care Med. 2013;41:580-637.

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Two phases of sepsis: Sequential Model

Hyper-inflammatory phase: SIRS

Immunosuppressed phase: Compensatory anti-inflammatory response syndrome

(CARS)

Contrib Microbiol 2011;17:1–11., Chest 1997;112:235–43.

Pro-inflammatory cytokines: TNF, IL-1β, IL-6, CRP, PCT

Anti-inflammatory cytokines: IL-10

Two phases of sepsis: Concurrent Model

Infect Dis Clin North Am 1999;13:413–26.

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Sepsis Biomarkers • Acute phase proteins

CRP

Procalcitonin (PCT)

Pentraxin3 (PTX3)

Lipopolysaccharide binding protein (LBP)

• Cytokines & chemokines IL-1RA, IL-1b, IL-2, IL-6, MCP-1

TNF-a, TNFR1/2

HMGBP1

• Cell surface markers Soluble CD14 (presepsin)

Neutrophil CD64 index (CD64in)

mHLA-DR (monocyte HLA-DR levels)

CD-163

• Receptor markers VEGF

Soluble VEGF-receptor 1 (sFLT)

Soluble urokinase plasminogen activator

(suPAR)

sTREM-1

RAGE (soluble receptor for advanced

glycationend products)

• Coagulation Activated partial thromboplastin time (aPTT)

waveform analysis

Protein C receptor

Thrombomodulin

• Endothelial damage Heparin binding protein

E-selectin

Neopterin

ICAM-1, VCAM-1

Angiopoietin-1 and -2

Syndecan-1 and -2

• Vasodilation Copeptin (AVP precursor)

• Cell damage MicroRNA

Microparticles

• Cell repair Procollagen III amino propeptide

inflammation

coagulation

Tissue damage

and repair

Pro-inflammatory cytokines during

hyper-inflammatory phase of sepsis

PAMPs = Pathogen Associated Molecular Patterns

DAMPs = Damage Associated Molecular Patterns

Crit Rev Clin Lab Sci, 2013; 50: 23–36

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Interleukin-6 (IL-6)

• A pro-inflammatory cytokine

• More reliably measurable in plasma than TNF and IL-1β

• Not specific for sepsis (like TNF and IL-1β)

• Autoimmune rheumatic disorders

• Major role as a biomarker of sepsis appears to be

prognostic, not diagnostic

• Elevated levels of IL-6 in septic patients are associated

with an increase in mortality

Br J Surg 1994;81:1306–8., Intensive Care Med 2002;28:1220–5., Crit Care Med 2004;32:2173–82.

C- reactive protein (CRP)

• One of a group of acute phase reactants

• A well-established biomarker of infection and inflammation

• Inflammatory or infectious disease

• Atherosclerosis

• Cardiovascular disease

• High sensitivity, low specificity

• Also use for monitoring in pediatric and post-operative

patients

N Eng J Med 1999;340:448–54.

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Procalcitonin (PCT)

• A peptide precursor of the hormone calcitonin

• Composed of 116 amino acids with a half-life of 25 to 30 hours

• Produced by parafollicular cells (C cells) of the thyroid and the

neuroendocrine cells of the lung and the intestine

• Level in healthy individuals is below the limit of detection (10 pg/mL)

• Rises in a response to a pro-inflammatory stimulus, especially of

bacterial origin (not in viral infection or non-infectious inflammations)

• Produced mainly by the cells of the lung and the intestine

• High procalcitonin levels produced during infections are not followed

by a parallel increase in calcitonin or a decrease in serum calcium

levels.

Lancet Infect Dis 2013;13: 426–35

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Procalcitonin-guided interventions against

infections in ICU: an RCT

Procalcitonin-guided interventions against

infections in ICU: an RCT

Crit Care Med 2011; 39:2048 –2058

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Conclusion from the study

• A strategy with escalation of broad spectrum

antimicrobials in the intensive care unit guided by daily

procalcitonin measurements as used in this trial did NOT

improve survival and did lead to an increased use of

broad-spectrum antimicrobials, which is concerning in

regard to toxicity, resistance, and economics.

• We observed deleterious effects on organ function and

length of stay in the intensive care unit and the strategy

cannot be recommended.

Crit Care Med 2011; 39:2048 –2058

Biomarkers of activated neutrophils and

monocytes in sepsis

Neutrophil Macrophage

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Four Promising Biomarkers for Acute

Infection

•sTREM-1

•suPAR

•ProADM

•sCD14 (Presepsin)

LBP and sCD14 (Presepsin)

• Elevated levels of LBP can identify patients with infection, but this protein effectively neutralizes LPS, and may even be anti-inflammatory

• Therefore, LBP may be less discriminating than other biomarkers with regard

to risk of developing severe sepsis

• Recently, there has been interest in measuring a soluble form of CD14

(Presepsin) as a biomarker of sepsis.

• Soluble CD14 levels were shown to be comparable to PCT for diagnosis of bacterial infection and correlated with the degree of severity in septic patients

J Infect Chemother 2012;18:891–7., J Infect Chemother 2011;17:764–9.

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Soluble CD14-subtype (sCD14-ST)

• CD14 is a 13 kDa protein that is present in macrophage,

monocyte, and granulocyte cells and their cell

membranes

• Responsible for intracellular transduction of endotoxin

signals

• Its soluble fraction is present in blood and is thought to be

produced in association with infections

J Infect Chemother 2011;17:764–9.

sCD14 in Clinical Use

Annals of Intensive Care 2013, 3:22.

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sCD14 Value in Different Conditions

J Infect Chemother 2011;17:764–9.

sCD14 and Other Biomarkers in Sepsis

Infection vs. non-infection SIRS: infection vs. sepsis

J Infect Chemother 2011;17:764–9.

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sCD14 and APACHE II Score

J Infect Chemother 2011;17:764–9.

sCD14 in Emergency Department

Critical Care 2013, 17: R244

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sCD14 in Emergency Department

Critical Care 2013, 17: R244

Diagnosis of sepsis Predicting severe sepsis

Multicenter, Randomized ALBIOS Trial - sCD14 and Organ Failure

Intensive Care Med. 2014 Oct 16

Total 997 patients 1 = <597 ng/L 2 = 597-1397 ng/L

3 = >1397 ng/L

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ALBIOS Trial: Appropriateness of ATB Therapy and sCD14

Intensive Care Med. 2014 Oct 16

ALBIO Trial: Day 1 sCD14 Concentration and Mortality

Intensive Care Med. 2014 Oct 16

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ALBIOS Trial: Changes in sCD14 and Mortality

Intensive Care Med. 2014 Oct 16

D1-2 1st : < -14.9

2nd : -14.9-13.7

3rd : > 13.7

D1-7 1st : < -38.4

2nd : -38.4- 15.8

3rd : > 15.8

Burn Sepsis

Burns. 2014;40:664-9

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Burns. 2014;40:664-9

Burn Sepsis

Abdominal Sepsis Intra-abdominal infections Sample size: Healthy 70, SIRS 30, Sepsis 20, Severe sepsis 10

Clin Chem Lab Med 2013;51:2053-62

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sCD14 in Sepsis vs SIRS (non-infection)

Area under ROC sCD14: 0.996

PCT: 0.912 CRP: 0.857

WBC: 0.777

Clin Chem Lab Med 2013;51:2053-62

Biomarkers in Febrile Neutropenia in

Pediatric Oncology Patients

Cytokine 2013:62:34-37

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sCD14-ST in Adult Febrile Neutropenia

• Preliminary data from Siriraj Hospital

• Total = 25

• Male 12 (48%), female 13 (52%)

• Mean age 43 ± 11 years

• Underlying diseases

• AML 14 (56%)

• ALL 4 (16%)

• CML 1 (4%)

• NHL 5 (20%)

• Other 1 (4%)

Bacteremia and Biomarkers

sCD14-ST Procalcitonin

*

*

*

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Summary

• Biomarkers are promising for use for diagnosis and

prognosis in sepsis as well as initiation and determination

of antimicrobial therapy

• Biomarkers available for clinical use include PCT, CRP,

IL6 and sCD14

• Increasing data of sCD14-ST for clinical use in intensive

care and emergency department

THANK YOU FOR YOUR

ATTENTION