Introduction
Materials and methods
Statistical analysis
Results
Patient characteristics
Low EAA (<0.40) | Intermediate EAA (0.4-0.59) | High EAA (≥0.6) | P value | |
---|---|---|---|---|
Number | 104 | 79 | 27 | |
Age (range), years | 67.5 (19-96) | 71 (23-97) | 76 (25-92) | 0.59 |
Percentage of males | 69.8 | 60 | 74 | 0.25 |
Body temperature (range), °C | 37.0 (36.4-37.6) | 37.2 (34-39.2) | 37.3 (36-39.2) | 0.51 |
White blood cells (IQR),/mm3 | 12,030 (8,720-18,150) | 12,030 (7,080-17,053) | 11,550 (2,522-15,888) | 0.22 |
Stab neutrophils (IQR), percentage | 9.0 (2.4-21.4) | 7.5 (2.0-23.0) | 10.0 (2.8-37.8) | 0.45 |
Segmented neutrophils (IQR), percentage | 78.5 (66.0-84.6) | 78.0 (59.8-85.5) | 71.0 (36.1- 84.8) | 0.19 |
Left shift of neutrophils, percentage | 37.7 | 36.3 | 44.4 | 0.77 |
C-reactive protein (IQR), mg/dL | 11.6 (7.0-19.6) | 12.2 (6.9-19.9) | 13.2 (6.4-21.2) | 0.06 |
Procalcitonin (IQR), ng/mL | 1.0 (0.2-5.2) | 1.7 (0.3-7.7) | 4.7 (1.6-24.8) | 0.003 |
Gram-negative organism, percentage | 27.4 | 51.3 | 70.4 | <0.0001 |
Gram-negative bacteremia, percentage | 3.8 | 10 | 25.9 | <0.0001 |
ICU mortality, percentage | 17.3 | 22.5 | 37 | 0.13 |
EAA levels and Gram-negative infection
Organisms and intermediate EAA
Culture sample | Organism | Low EAA (<0.4) | Intermediate EAA (0.4-0.59) | High EAA (≥0.6) | |
---|---|---|---|---|---|
Blood | Gram-negative |
Escherichia coli
| 3 | 4 | |
Klebsiella pneumoniae
| 4 | 4 | |||
Klebsiella oxytoca
| 1 | ||||
Bacteroides fragilis
| 1 | 1 | 1 | ||
Pseudomonas aeruginosa
| 1 | ||||
Serratia marcescens
| 1 | ||||
Gram-positive |
Streptococcus pyogenes
| 2 | 1 | 1 | |
Staphylococcus epidermidis
| 1 | 1 | 1 | ||
MSSA
| 4 | 6 | 1 | ||
MRSA
| 5 | 1 | |||
Enterococcus faecalis
| 1 | ||||
Suptum | Gram-negative |
Escherichia coli
| 2 | 2 | 1 |
Pseudomonas aeruginosa
| 3 | 4 | 4 | ||
Enterobacter aergenes
| 2 | ||||
Enterobacter cloacae
| 1 | 2 | |||
Klebsiella pneumoniae
| 1 | 9 | 4 | ||
Klebsiella oxytoca
| 1 | ||||
Acinetobacter
| 2 | 2 | 1 | ||
Serratia marcescens
| 4 | 3 | 2 | ||
Stenotrophomonas maltophilia
| 4 | 8 | 2 | ||
Proteus mirabilis
| 2 | ||||
Haemophilus influenzae
| 1 | ||||
Gram-positive |
Streptococcus pneuminiae
| 6 | 2 | ||
Staphylococcus aureus
| 2 | 2 | |||
Corynebacterium sp. | 2 | 2 | |||
MSSA
| 13 | 3 | |||
MRSA
| 9 | 7 | 4 | ||
Enterococcus faecalis
| 3 | 1 | 2 | ||
Fungus |
Candida albicans
| 18 | 5 | ||
Urine | Gram-negative |
Escherichia coli
| 3 | 7 | 2 |
Pseudomonas aeruginosa
| 1 | 5 | 2 | ||
Klebsiella pneumoniae
| 4 | 3 | 3 | ||
Klebsiella oxytoca
| 1 | 2 | |||
Citrobacter freundii
| 2 | ||||
Gram-positive |
Streptococcus
| 1 | |||
Enterococcus
| 3 | ||||
MSSA
| 2 | ||||
MRSA
| 1 | ||||
Fungus |
Candida albicans
| 3 | 3 | ||
Ascites | Gram-negative |
Escherichia coli
| 1 | 2 | |
Bacteroides fragilis
| 1 | ||||
Pleural effusion | Gram-negative |
Pseudomonas aeruginosa
| 1 | ||
Klebsiella pneumoniae
| 2 | ||||
Gram-positive |
MRSA
| 3 | 2 | ||
Abscess, wound | Gram-negative |
Pseudomonas aeruginosa
| 1 | 1 | |
Bacteroides fragilis
| 2 | 3 | |||
Klebsiella pneumoniae
| 1 | 3 | |||
Escherichia coli
| 2 | 2 | 1 | ||
Gram-positive |
MSSA
| 2 | 1 | 1 | |
MRSA
| 3 | ||||
Streptococcus
| 5 | 1 | |||
Enterococcus faecalis
| 2 | 2 |
Patient characteristics in the intermediate EAA levels (0.4 to 0.59)
Gram-negative organism in cultures (n = 42) | No Gram-negative organism in any cultures (n = 37) | P value | |
---|---|---|---|
Age (range), years | 76 (23-97) | 71.0 (32-92) | 0.10 |
Percentage of males | 69 | 51 | 0.11 |
Body temperature (range), °C | 37.4 (34.6-39.2) | 37.4 (34.0-39.0) | 0.98 |
White blood cells (IQR),/mm3 | 11,070 (6,130-17,480) | 12,410 (6,740-16,290) | 0.95 |
Stab neutrophils (IQR), percentage | 18 (3.5-32.0) | 3.5 (1.4-7.8) | 0.0006 |
Segmented neutrophils (IQR), percentage | 65.0 (48.5-78.5) | 83.0 (70.5-86.5) | 0.0004 |
Left shift of neutrophils, percentage | 57.9 | 18.9 | 0.0004 |
C-reactive protein (IQR), mg/dL | 13.1 (6.0-21.4) | 13.7 (6.6-19.4) | 0.91 |
Procalcitonin (IQR), ng/mL | 4.9 (0.4-13.8) | 1.7 (0.2-3.0) | 0.05 |
EAA value (IQR) | 0.5 (0.45-0.53) | 0.49 (0.45-0.52) | 0.88 |
Combining PCT levels, left shift of neutrophils, and Gram-negative organisms in patients with intermediate EAA levels (0.4 to 0.59)
Gram-negative organism in cultures (n = 42) | No Gram-negative organism in any cultures (n = 37) | |
---|---|---|
Left shift (+) or PCT (≥ 5.0 ng/mL) or both | 25 | 11 |
Left shift (−) or PCT (<5.0 ng/mL) or both | 17 | 26 |
Discussion
Conclusions
Key messages
-
High Endotoxin Activity Assay (EAA) levels (≥0.6) can be used to help diagnose sepsis due to Gram-negative infections.
-
Low EAA levels (<0.4) can be used to rule out Gram-negative infections.
-
Procalcitonin levels and presence of shift to the left of white blood cells (WBCs) show differences between Gram-negative infection and no Gram-negative infection in intermediate EAA levels.
-
Combining procalcitonin and differential of WBCs can help to diagnosis sepsis in intermediate EAA levels.