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Langenbeck's Archives of Surgery

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01-06-2006 | Original Article

Pre-emptive antibiotic treatment vs ‘standard’ treatment in patients with elevated serum procalcitonin levels after elective colorectal surgery: a prospective randomised pilot study

Authors: Ansgar Michael Chromik, Frank Endter, Waldemar Uhl, Arnulf Thiede, Hans Bernd Reith, Ulrich Mittelkötter

Published in: Langenbeck's Archives of Surgery | Issue 3/2006

Abstract

Background

Procalcitonin (PCT) is regarded as a specific indicator of bacterial infection. Infectious complications in patients after colorectal surgery are a common cause of morbidity and mortality. The aim of this study was to investigate (a) whether PCT could serve as a negative predictive marker for postoperative complications and (b) whether, in patients with elevated PCT levels, a pre-emptive treatment with the third-generation cephalosporin ceftriaxone is superior to an antibiotic treatment starting later on the appearance of clinical signs and symptoms of infection.

Patients and methods

By screening 250 patients with colorectal surgery, we identified 20 patients with PCT serum levels more than 1.5 ng/ml on at least 2 of the first 3 postoperative days. The remaining 230 patients were followed-up for the occurrence of infectious complications. The 20 patients with elevated PCT were included in a prospective randomised pilot study comparing pre-emptive antibiotic treatment with ceftriaxone vs standard treatment.

Results

The negative predictive value of PCT for systemic infectious complications was 98.3%. In patients receiving pre-emptive antibiotic treatment (ceftriaxone), both the incidence and the severity of postoperative systemic infections were significantly lower compared to those in a control group (Pearson’s χ ² test; p=0.001 and p=0.007, respectively). Major differences were also observed with respect to duration of antibiotic treatment and length of hospital stay.

Conclusions

PCT is an early marker for systemic infectious complications after colorectal surgery with a high negative predictive value. A significant reduction in the rate of postoperative infections in patients with elevated PCT serum concentrations was achieved by means of pre-emptive antibiotic treatment.

Fowler CL, Pattisapu R, Johnson LM, Assimacopoulos C, Halverson K (1988) Complications of colorectal surgery. A review of factors affecting surgical complication in 411 colorectal procedures. S D J Med 41:19–23PubMed

Kingston RD, Jeacock J, Walsh S, Keeling F (1995) The outcome of surgery for colorectal cancer in the elderly: a 12-year review from the Trafford Database. Eur J Surg Oncol 21:514–516CrossRefPubMed

Urbach DR, Kennedy ED, Cohen MM (1999) Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis. Ann Surg 229:174–180CrossRefPubMed

Daly JM, DeCosse JJ (1983) Complications in surgery of the colon and rectum. Surg Clin North Am 63:1215–1231PubMed

Song F, Glenny AM (1998) Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials. Br J Surg 85:1232–1241CrossRefPubMed

Zanella E, Rulli F (2000) A multicenter randomized trial of prophylaxis with intravenous cefepime + metronidazole or ceftriaxone + metronidazole in colorectal surgery. The 230 Study Group. J Chemother 12:63–71PubMed

Woodfield JC, Van Rij AM, Pettigrew RA, van der Linden AJ, Solomon C, Bolt D (2003) A comparison of the prophylactic efficacy of ceftriaxone and cefotaxime in abdominal surgery. Am J Surg 185:45–49CrossRefPubMed

Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR, Reid CR (1993) Nosocomial infections in surgical patients in the United States, January 1986–June 1992. National Nosocomial Infections Surveillance (NNIS) System. Infect Control Hosp Epidemiol 14:73–80PubMedCrossRef

Arozullah AM, Khuri SF, Henderson WG, Daley J (2001) Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med 135:847–857PubMed

10.

Johnson CC, Baldessarre J, Levison ME (1997) Peritonitis: update on pathophysiology, clinical manifestations, and management. Clin Infect Dis 24:1035–1045; quiz 1046–1037PubMedCrossRef

11.

Grant SW, Hopkins J, Wilson SE (1995) Operative site bacteriology as an indicator of postoperative infectious complications in elective colorectal surgery. Am Surg 61:856–861PubMed

12.

The Norwegian Study Group for Colorectal Surgery (1985) Should antimicrobial prophylaxis in colorectal surgery include agents effective against both anaerobic and aerobic microorganisms? A double-blind, multicenter study. Surgery 97:402–408

13.

Mittelkotter U (2001) Antimicrobial prophylaxis for abdominal surgery: is there a need for metronidazole? J Chemother 13(Spec No 1):27–34PubMed

14.

Rau HG, Mittelkotter U, Zimmermann A, Lachmann A, Kohler L, Kullmann KH (2000) Perioperative infection prophylaxis and risk factor impact in colon surgery. Chemotherapy 46:353–363CrossRefPubMed

15.

Bone RC (1996) Immunologic dissonance: a continuing evolution in our understanding of the Systemic Inflammatory Response Syndrome (SIRS) and the Multiple Organ Dysfunction Syndrome (MODS). Ann Intern Med 125:680–687PubMed

16.

Al-Nawas B, Krammer I, Shah PM (1996) Procalcitonin in diagnosis of severe infections. Eur J Med Res 1:331–333PubMed

17.

Al-Nawas B, Shah P (1997) Procalcitonin in acute malaria. Eur J Med Res 2:206–208PubMed

18.

Snider RH Jr, Nylen ES, Becker KL (1997) Procalcitonin and its component peptides in systemic inflammation: immunochemical characterization. J Investig Med 45:552–560PubMed

19.

Gendrel D, Raymond J, Assicot M, Moulin F, Iniguez JL, Lebon P, Bohuon C (1997) Measurement of procalcitonin levels in children with bacterial or viral meningitis. Clin Infect Dis 24:1240–1242PubMedCrossRef

20.

Viallon A, Zeni F, Lambert C, Pozzetto B, Tardy B, Venet C, Bertrand JC (1999) High sensitivity and specificity of serum procalcitonin levels in adults with bacterial meningitis. Clin Infect Dis 28:1313–1316PubMedCrossRef

21.

Zeni F, Viallon A, Assicot M (1994) Procalcitonin serum concentration and severity of sepsis. Clin Intensive Care 5:89–98

22.

Assicot M, Gendrel D, Carsin H, Raymond J, Guilbaud J, Bohuon C (1993) High serum procalcitonin concentrations in patients with sepsis and infection. Lancet 341:515–518CrossRefPubMed

23.

Muller B, Becker KL, Schachinger H, Rickenbacher PR, Huber PR, Zimmerli W, Ritz R (2000) Calcitonin precursors are reliable markers of sepsis in a medical intensive care unit. Crit Care Med 28:977–983CrossRefPubMed

24.

Wanner GA, Keel M, Steckholzer U, Beier W, Stocker R, Ertel W (2000) Relationship between procalcitonin plasma levels and severity of injury, sepsis, organ failure, and mortality in injured patients. Crit Care Med 28:950–957CrossRefPubMed

25.

Moulin F, Raymond J, Lorrot M, Marc E, Coste J, Iniguez JL, Kalifa G, Bohuon C, Gendrel D (2001) Procalcitonin in children admitted to hospital with community acquired pneumonia. Arch Dis Child 84:332–336CrossRefPubMed

26.

Nylen ES, Snider RH Jr, Thompson KA, Rohatgi P, Becker KL (1996) Pneumonitis-associated hyperprocalcitoninemia. Am J Med Sci 312:12–18CrossRefPubMed

27.

Bernard L, Ferriere F, Casassus P, Malas F, Leveque S, Guillevin L, Lortholary O (1998) Procalcitonin as an early marker of bacterial infection in severely neutropenic febrile adults. Clin Infect Dis 27:914–915PubMedCrossRef

28.

Rau B, Kruger CM, Schilling MK (2004) Procalcitonin: improved biochemical severity stratification and postoperative monitoring in severe abdominal inflammation and sepsis. Langenbecks Arch Surg 389:134–144CrossRefPubMed

29.

Reith HB, Mittelkotter U, Wagner R, Thiede A (2000) Procalcitonin (PCT) in patients with abdominal sepsis. Intensive Care Med 26:165–169CrossRef

30.

Reith HB, Mittelkotter U, Debus ES, Kussner C, Thiede A (1998) Procalcitonin in early detection of postoperative complications. Dig Surg 15:260–265CrossRefPubMed

31.

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference (1992) definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874CrossRef

32.

Carrol ED, Thomson AP, Hart CA (2002) Procalcitonin as a marker of sepsis. Int J Antimicrob Agents 20:1–9CrossRefPubMed

33.

Al-Nawas B, Shah PM (1996) Procalcitonin in patients with and without immunosuppression and sepsis. Infection 24:434–436CrossRefPubMed

34.

Engel A, Steinbach G, Kern P, Kern WV (1999) Diagnostic value of procalcitonin serum levels in neutropenic patients with fever: comparison with interleukin-8. Scand J Infect Dis 31:185–189CrossRefPubMed

35.

Meisner M, Tschaikowsky K, Hutzler A, Schick C, Schuttler J (1998) Postoperative plasma concentrations of procalcitonin after different types of surgery. Intensive Care Med 24:680–684CrossRefPubMed

36.

Molter GP, Soltesz S, Kottke R, Wilhelm W, Biedler A, Silomon M (2003) Procalcitonin plasma concentrations and systemic inflammatory response following different types of surgery. Anaesthesist 52:210–217CrossRefPubMed

37.

Di Filippo A, Lombardi A, Ognibene A, Messeri G, Tonelli F (2002) Procalcitonin as an early marker of postoperative infectious complications. Minerva Chir 57:59–62PubMed

38.

Schwenk W, Haase O, Raue W, Neudecker J, Muller JM (2004) Establishing “fast-track”-colonic surgery in the clinical routine. Zentralbl Chir 129:502–509CrossRefPubMed

39.

Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH (2001) ‘Fast track’ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 88:1533–1538CrossRefPubMed

Title: Pre-emptive antibiotic treatment vs ‘standard’ treatment in patients with elevated serum procalcitonin levels after elective colorectal surgery: a prospective randomised pilot study
Authors: Ansgar Michael Chromik
Frank Endter
Waldemar Uhl
Arnulf Thiede
Hans Bernd Reith
Ulrich Mittelkötter
Publication date: 01-06-2006
Publisher: Springer-Verlag
Published in: Langenbeck's Archives of Surgery / Issue 3/2006
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-005-0009-1

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Pre-emptive antibiotic treatment vs ‘standard’ treatment in patients with elevated serum procalcitonin levels after elective colorectal surgery: a prospective randomised pilot study

Abstract

Background

Patients and methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Patients and methods

Results

Conclusions

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