Diagnostic accuracy of procalcitonin, neutrophil-lymphocyte count ratio, C-reactive protein, and lactate in patients with suspected bacterial sepsis
Open accessAbstract
BACKGROUND: Early recognition is a key factor to achieve improved outcomes for septic patients. Combinations of biomarkers, as opposed to single ones, may improve timely diagnosis and survival. We investigated the performance characteristics of sepsis biomarkers, alone and in combination, for diagnosis of verified bacterial sepsis using Sepsis-2 and Sepsis-3 criteria, respectively. METHODS: Procalcitonin (PCT), neutrophil-lymphocyte count ratio (NLCR), C-reactive protein (CRP), and lactate were determined in a total of 1,572 episodes of adult patients admitted to the emergency department on suspicion of sepsis. All sampling were performed prior to antibiotic administration. Discriminant analysis was used to construct two composite biomarkers consisting of linear combinations of the investigated biomarkers, one including three selected biomarkers (i.e., NLCR, CRP, and lactate), and another including all four (i.e., PCT, NLCR, CRP, and lactate). The diagnostic performances of the composite biomarkers as well as the individual biomarkers were compared using the area under the receiver operating characteristic curve (AUC). RESULTS: For diagnosis of bacterial sepsis based on Sepsis-3 criteria, the AUC for PCT (0.68; 95% CI 0.65-0.71) was comparable to the AUCs for the both composite biomarkers. Using the Sepsis-2 criteria for bacterial sepsis diagnosis, the AUC for the NLCR (0.68; 95% CI 0.65-0.71) but not for the other single biomarkers, was equal to the AUCs for the both composite biomarkers. For diagnosis of severe bacterial sepsis or septic shock based on the Sepsis-2 criteria, the AUCs for both composite biomarkers were significantly greater than those of the single biomarkers (0.85; 95% CI 0.82-0.88 for the composite three-biomarker, and 0.86; 95% CI 0.83-0.89 for the composite four-biomarker). CONCLUSIONS: Combinations of biomarkers can improve the diagnosis of verified bacterial sepsis in the most critically ill patients, but in less severe septic conditions either the NLCR or PCT alone exhibit equivalent performance.
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For lactate as a sepsis screen, sensitivities range from 66 to 83% and specificities from 80 to 85%.
“Sensitivities range from 66 to 83%, with specificities ranging from 80 to 85%.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [52]
An elevated lactate level increases and a normal lactate level decreases the likelihood of a final diagnosis of sepsis in patients with suspected sepsis.
“In summary, the presence of an elevated or normal lactate level significantly increases or decreases, respectively, the likelihood of a final diagnosis of sepsis in patients with suspected sepsis.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [52]
Lactate cutoffs for an elevated level ranged from 1.6 to 2.5 mmol/L, with similar diagnostic characteristics regardless of cutoff.
“The lactate cutoffs determining an elevated level ranged from 1.6 to 2.5 mmol/L, although diagnostic characteristics were similar regardless of the cutoff.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [52]
Lactate alone is neither sensitive nor specific enough to rule in or rule out sepsis.
“However, lactate alone is neither sensitive nor specific enough to rule-in or rule-out the diagnosis on its own.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [52]
Pooled positive and negative likelihood ratios from three studies for lactate in suspected sepsis are 4.75 and 0.29, respectively.
“Pooled positive and negative likelihood ratios from the three studies are 4.75 and 0.29, respectively.”
From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [52]
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- Authors
- Ljungström, L., Pernestig, A.-K., Jacobsson, G., Andersson, R., Usener, B., & Tilevik, D.
- Affiliations
- Skaraborg Hospital (SE)
- University of Skövde (SE)
- Sahlgrenska University Hospital (SE)
- Corresponding author
- Tilevik, Diana
- Venue
- PLOS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2017-07-20
- Volume
- 12
- Issue
- 7
- Pages
- e0181704
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC5519182
- OpenAlex
- W2737554657
- Cited by
- 219
- References
- 86
- Citations by year
- 2026: 19 · 2025: 23 · 2024: 20 · 2023: 28 · 2022: 27 · 2021: 35 · 2020: 25 · 2019: 22 · 2018: 10 · 2017: 10
- FWCI
- 14.35
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Diva portal (Dalarna University Library) (submittedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Life Sciences › Immunology and Microbiology › Immunology › Inflammation biomarkers and pathways
- Health Sciences › Medicine › Nephrology › Acute Kidney Injury Research
- Keywords
- bacterial sepsis, sepsis diagnosis, procalcitonin, C-reactive protein, lactate, composite biomarker, Sepsis-3 criteria, septic shock, emergency department, diagnostic accuracy, combined biomarker detection, early sepsis detection
- MeSH terms
- Aged, Aged, 80 and over, C-Reactive Protein, Calcitonin, Female, Humans, Leukocyte Count, Male, Middle Aged, Neutrophils, Prospective Studies, ROC Curve, Severity of Illness Index, Biomarkers, Discriminant Analysis, Linear Models, Bacteremia, Lymphocyte Count, Lactic Acid, Area Under Curve, Early Diagnosis
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