Diagnosis Serum procalcitonin in cerebral ventriculitis
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Summary
Posted By:	Celia Bradford
E-Mail:	celiabradford@telstra.com
Posted Date:	2/7/04
Title:	Serum procalcitonin in cerebral ventriculitis
Authors:	Berger, Christian MD; Schwarz, Stefan MD; Schaebitz, Wolf R. MD; Aschoff, Alfred MD; Schwab, Stefan MD
Reference:	Critical Care Medicine. 30(8):1778-81, 2002 Aug.
Link:	Click here for a direct link to the paper. A password may be required for access to fulltext.
Abstract:	Objectives: The objective of this study was to test the hypothesis that serum procalcitonin is increased in patients with bacterial cerebral ventricular infections after the insertion of temporary external ventricular drains. Patients and Methods: This open, prospective study included patients requiring temporary external ventricular drains for various neurologic conditions such as intracerebral hemorrhage with ventricular hemorrhage or space-occupying lesions in the posterior fossa (cerebellar infarctions or hemorrhages). Patients experiencing primary central nervous system infection or sepsis were excluded. Procalcitonin, C-reactive protein, and white blood cell count were measured daily. Cerebrospinal fluid was investigated every other day, including cerebrospinal fluid cell count, lactate, glucose, and cerebrospinal fluid culture. Results were categorized according to presence of bacterial cerebrospinal fluid infection as determined by positive cerebrospinal fluid cultures. Results: A total of 34 consecutive patients were included. Procalcitonin was significantly higher (4.7 vs. 0.2 ng/mL) in patients with proven bacterial ventriculitis. Cerebrospinal fluid cell count (456 vs. 478 cells/µL) could not distinguish bacterial infection from abacterial reactions, mainly because of blood contamination of the cerebrospinal fluid. Conclusion: Cerebrospinal fluid of patients treated with temporary external ventricular drains is frequently characterized by blood contamination because of the insertion procedure, the underlying neurologic disorder such as ventricular hemorrhage, or the presence of an abacterial chemical ventriculitis. Thus, diagnosis of a bacterial ventricular infection requiring immediate antibiotic therapy is less certain. Serum procalcitonin adds to the diagnostic precision in bacterial ventriculitis.
Are the Results Valid?
1. Was there an independent, blind comparison with a reference standard?
	Yes.The diagnosis of a bacterial ventricular CSF infection was based on one of the following: 1) a positive CSF culture or 2) a negative CSF culture with either a positive CSF antigen test or identification of bacteria on Gram staining of the CSF. There is no gold standard to diagnose sepsis. This is a pretty good effort.All PCT measurements were performed routinely by the department of laboratory medicine, which was blinded to the CSF culture results.
2. Did the patient sample include an appropriate spectrum of patients to whom the diagnostic test will be applied in clinical practice?
	Yes. Patients who required the neurosurgical insertion of a temporary external ventricular CSF drainage device because of any neurologic disease
3. Did the results of the test being evaluated influence the decision to perform the reference standard?
	No. All patients had the reference standard checked.
4. Were the methods for performing the test described in sufficient detail to permit replication?
	Yes. PCT serum levels were measured with a specific immunoluminometric assay. Further details are given.
What are the Results?
1. Are likelihood ratios for the test results presented or data necessary for their calculation provided?
	Patients with and without positive CSF culture had a PCT level of 4.7+/-1 vs 0.2 +/-0.01 ng/mL respectively.Five out of Five Patients with a high PCT had positive cultures. Zero of twenty-nine with a low PCT had a positive culture.
Will the Results Help Me In Caring For My Patients?
1. Will the reproducibility of the test result and its interpretation be satisfactory in my setting?
	This is a small study, but this shows promise for reducing the use of antibiotics in patients with EVDs. In our institution we have had a spate of resistant organisms develop in patients who have been treated with cephalosporins for unproven encephalitis. Using a PCT level ma add to our diagnostic armamentarium.
2. Are the results applicable to my patient?
	Yes. The patients included in the study had similar conditions to those in my institution who have EVDs. In this study patients were not given prophylactic antibiotics, whereas in our institution all patients with EVDs are given prophylactic first generation cephalosporins which may impact on using PCT as a diagnostic test.
3. Will the results change my management?
	Maybe. In this situation it may be the neurosurgeons who are difficult to convince that a larger trial is warranted.
4. Will patients be better off as a result of the test?
	Further larger studies are needed. This shows promise and may decrease the chance of unnecessary exposure to antibiotics, eg if a patient has a high WCC or high CRP
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