Procalcitonin as a diagnostic aid in diabetic foot infections.

NewsBot · Dec 14, 2007

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Procalcitonin as a diagnostic aid in diabetic foot infections.Uzun G, Solmazgul E, Curuksulu H, Turhan V, Ardic N, Top C, Yildiz S, Cimsit M.
Tohoku J Exp Med. 2007 Dec;213(4):305-12.

The diagnosis of diabetic foot infection (DFI) is usually a challenge to the clinician. Procalcitonin (PCT), a 116-amino acid propeptide of calcitonin, is a new marker of bacterial infections and sepsis. We evaluated the serum value of PCT as a marker of bacterial infection in diabetic patients with foot ulcers. Forty-nine diabetic patients with foot ulcers were consecutively enrolled into the study. DFI was diagnosed clinically by the presence of purulent secretions or at least two of the symptoms of inflammation including redness, warmth, swelling, and pain. According to these criteria, DFI was determined in 27 patients (DFI group) and not detected in 22 patients (NDFI group). The blood samples were taken for biochemical analysis on admission. PCT, white blood cell count (WBC) and erythrocyte sedimentation rate (ESR), but not C-reactive protein (CRP), was found significantly higher in DFI group compared with NDFI group. The best cut-off value, sensitivity and specificity were 0.08 ng/ml, 77% and 100% for PCT, 32.1 mg/dl, 29% and 100% for CRP, 8.6 10(9)/L, 70% and 72% for WBC and 40.5 mm/h, 77% and 77% for ESR, respectively. The area under the receiver operating characteristic curve for infection identification was greatest for PCT (0.859; p < 0.001), followed by WBC (0.785; p = 0.001), ESR (0.752; p = 0.003), and finally CRP (0.625; p = 0.137). These results suggest that PCT may be a useful diagnostic marker for DFI. Additional research is needed to better define the role of PCT in DFI.
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NewsBot · Jun 11, 2011

Can procalcitonin predict bone infection in diabetic persons with infected foot ulcers? A pilot study.
Mutluoğlu M, Uzun G, Ipcioğlu OM, Sildiroglu O, Ozcan O, Turhan V, Mutlu H, Yildiz S.
Diabetes Res Clin Pract. 2011 Jun 7. [Epub ahead of print]

AIMS:
The diagnosis of osteomyelitis is a key step of diabetic foot management. Previous studies showed that procalcitonin (PCT), a novel infection marker, is superior to conventional infection markers in the diagnosis of diabetic foot infection. This study aimed to investigate the serum levels of PCT and other conventional infection markers in diabetic persons with and without osteomyelitis.

METHODS:
Twenty-four patients (18 male, mean age: 61.9±10.8 years) with infected foot ulcers were prospectively enrolled. Clinical characteristics of the wounds were noted. Blood samples were obtained for biochemical analysis. Magnetic resonance imaging of the foot was performed in all patients to diagnose osteomyelitis.

RESULTS:
Osteomyelitis was found in 13 of 24 (54%) patients. PCT levels were 66.7±43.5pg/ml in patients with osteomyelitis and 58.6±35.5pg/ml in patients without osteomyelitis. The difference did not reach statistical significance (p=0.627). Erythrocyte sedimentation rate, but not C-reactive protein and white blood cell count, was found significantly higher in patients with osteomyelitis.

CONCLUSION:
In this group of patients, PCT failed to discriminate patients with bone infection. Erythrocyte sedimentation rate can be used as a marker of osteomyelitis in diabetic persons.
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NewsBot · Apr 24, 2012

Does treatment affect the levels of serum Interleukin-6, Interleukin-8 and procalcitonin in diabetic foot infection? A pilot study.
Altay FA, Sencan I, Sentürk GC, Altay M, Güvenman S, Unverdi S, Açıkgöz ZC.
J Diabetes Complications. 2012 Apr 19.

AIMS:
To investigate about serum PCT, IL-6 and IL-8 levels and how they are affected by the treatment in diabetic foot patients.

METHODS:
Fifty patients' blood samples were taken to study ESR and CRP, IL-6, IL-8 and PCT before and at the 14th day of the treatment.

RESULTS:
The pretreatment results of the 50 patients showed positive correlations between PCT and either ESH (r=0.49, p<0.001), or CRP (r=0.56, p<0.001). Similarly, there was a positive correlation between IL-6 and ESH (r=0.46, p=0.001), just like as it was between IL-6 and CRP (r=0.54, p<0.001). At the 14th day, the levels of ESR (70±30.2 and 58.4±26.2, p=0.02), CRP (63.8±73.1 and 18.1±19.7, p<0.001) and PCT (0.6±2.1 and 0.05±0.02, p=0.007) were significantly decreased while IL-6 was decreased at a close range to statistical significancy at healing patients (97.5±147.2 and 47.1±77.6; p=0.05), but they did not at nonhealing patients. IL-8 levels were not changed anyhow.

CONCLUSIONS:
PCT was significantly decreased such as ESR and CRP were in the early phase of healing; IL-6 and IL-8 levels were also decreased by the treatment, but not statistically significantly. IL-6 and PCT were affected in correlation with the other inflammatory parameters in the beginning, but IL-8 was not. PCT and IL-6 may be useful like CRP and ESR in the diagnosis and follow up of diabetic foot infection, but IL-8 is not. Further investigation is needed.
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NewsBot · Dec 7, 2013

The value of procalcitonin measurement in localized skin and skin structure infection, diabetic foot infections, septic arthritis and osteomyelitis
Kordo Saeed, Nusreen Ahmad and Matthew Dryden
Expert Review of Molecular Diagnostics

Serum procalcitonin (PCT) is an established diagnostic marker for severe or systemic bacterial infections such as pneumonia, sepsis and septic shock. Data regarding the role of PCT in localized infections without systemic inflammatory response syndrome are scarce. The aim of this review is to assess the value of PCT measurements in localized infections such as skin and skin structure infections, diabetic foot infections, septic arthritis (SA) and osteomyelitis. It appears that serum PCT is unlikely to change the clinical practice in skin and skin structure infection. However, serum PCT could have a role in diagnosis and monitoring of diabetic foot infections in hospitalized settings. There are conflicting reports regarding the ability of serum PCT to distinguish SA from non-SA; synovial PCT may be more appropriate in these settings, including in implant-related infections. Better designed studies are needed to evaluate the usefulness of PCT with or without other biomarkers in localized infections.
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NewsBot · Apr 4, 2014

Can procalcitonin be an accurate diagnostic marker for the classification of diabetic foot ulcers?
Jonaidi Jafari N, Safaee Firouzabadi M, Izadi M, Safaee Firouzabadi MS, Saburi A.
Int J Endocrinol Metab. 2014 Jan 5;12(1):e13376. doi: 10.5812/ijem.13376. eCollection 2014.

BACKGROUND:
The differentiation of infected diabetic foot ulcers (IDFU) from non infected diabetic foot ulcers (NIDFU) is a challenging issue for clinicians.
OBJECTIVES:
Recently, procalcitonin (PCT) was introduced as a remarkable inflammatory marker. We aimed to evaluate the accuracy of PCT in comparison to other inflammatory markers for distinguishing IDFU from NIDFU.
MATERIALS AND METHODS:
We evaluated PCT serum level as a marker of bacterial infection in patients with diabetic foot ulcers. Sixty patients with diabetic foot ulcers were consecutively enrolled in the study. A total of 30 patients were clinically identified as IDFU by an expert clinician, taking as criteria for purulent discharges or at least two of manifestations of inflammation including warmth, redness, swelling and pain.
RESULTS:
Procalcitonin, white blood cells (WBCs), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), were found significantly higher in the IDFU group compared to the NIDFU group. The best cut-off value, sensitivity and specificity were 40.5 mm/h, 90% and 94% for ESR, 7.1 mg/dL, 80% and 74% for CRP, 0.21, 70% and 74% for PCT, and 7.7×10(9)/L, 66% and 67% for WBCs, respectively. The area under the receiver operating characteristic curve for ESR was the greatest (0.967; P < 0.001), followed by CRP (0.871; P < 0.001), PCT (0.729; P < 0.001), and finally WBCs (0.721; P = 0.001).
CONCLUSIONS:
These results suggest that PCT can be a diagnostic marker in combination with other markers like ESR and CRP to distinguish infected from non-infected foot ulcers, when clinical manifestations are un specific. Additional research is needed before the routine usage of PCT to better define the role of PCT in IDFU.
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NewsBot · Jun 21, 2014

Predictive Value of Soluble CD14, Interleukin-6 and Procalcitonin For Lower Extremity Amputation in People with Diabetes with Foot Ulcers: A Pilot Study.
Karakas A, Arslan E, Cakmak T, Aydin I, Akgul EO, Demirbas S.
Pak J Med Sci. 2014 May;30(3):578-82. doi: 10.12669/pjms.303.4575.

Objective: The aim of this pilot study was to determine clinical and laboratory factors that predict amputation surgery and to evaluate the predictive value of soluble CD14 (sCD14), interleukin-6 (IL-6), and procalcitonin (PCT) in patients with diabetic foot ulcers (DFUs).

Methods: Twenty-seven (20 males, 7 females) Diabetic Foot Ulcers (DFU) patients admitted to our department were consecutively enrolled. The patients' demographics and wound characteristics were noted. IL-6, PCT, and sCD14 were measured at admission.

Results: Six of the 27 patients (22%) eventually underwent lower extremity amputation. Compared to the non-amputation group, a previous history of amputation (p=0.017), the presence of gangrene (p=0.044), the Wagner grade (p=0.011), the IL-6 concentration (p=0.018), the white blood cell count (WBC) (p=0.036), and the erythrocyte sedimentation rate (ESR) (p=0.042) were significantly high in the amputation group. However, the sCD14 and PCT concentration were not significantly different.

Conclusion: We have shown for the first time that IL-6 may have predictive value for lower extremity amputation in patients with DFU. Further studies are needed to confirm its predictive value in this patient group.
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NewsBot · Oct 30, 2015

The role of procalcitonin as a marker of diabetic foot ulcer infection.
Massara M et al
Int Wound J. 2015 Oct 28. doi: 10.1111/iwj.12536.

Foot ulcers are frequent in diabetic patients and are responsible for 85% of amputations, especially in the presence of infection. The diagnosis of diabetic foot ulcer infection is essentially based on clinical evaluation, but laboratory parameters such as erythrocyte sedimentation rate (ESR), white blood count (WBC), C-reactive protein (CRP) and, more recently, procalcitonin (PCT) could aid the diagnosis, especially when clinical signs are misleading. Fifteen diabetic patients with infected foot ulcers were admitted to our department and were compared with an additional group of patients with non-infected diabetic foot ulcers (NIDFUs). Blood samples were collected from all patients in order to evaluate laboratory markers. In the current study, the diagnostic accuracy of PCT serum levels was evaluated in comparison with other inflammatory markers such as CRP, ESR and WBC as an indicator to make the distinction between infected diabetic foot ulcers (IDFUs) and NIDFUs. CRP, WBC, ESR and especially PCT measurements represent effective biomarkers in the diagnosis of foot infections in diabetic patients particularly when clinical signs are misleading.
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NewsBot · Dec 16, 2015

Is Procalcitonin An Effective Marker For Osteomyelitis?

NewsBot · Mar 22, 2017

Procalcitonin as a Biomarker for Predicting Amputation Level in Lower Extremity Infections
Matthew M. Reiner et al
JFAS; Articles in Press

Inflammatory markers are essential tools in the decision-making process for lower extremity infections. When coupled with objective findings, clinicians can more accurately diagnose and treat these entities. Typically, markers such as the white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are used to initially assess these patients or monitor the progression of medical or surgical therapy. Procalcitonin is a newer inflammatory marker that is specific for an infectious process. Originally, procalcitonin was used to monitor antibiotic therapy and sepsis for patients in the intensive care setting, but it has now been expanded to other facets of medicine. The utility of procalcitonin has been described for diagnosing infection or osteomyelitis in diabetic foot ulcers. However, limited research has compared inflammatory marker levels and the level of amputation. A retrospective inpatient medical record review was performed of 156 consecutive patient occurrences during 25 months in which surgical intervention was required for a lower extremity infection and an initial procalcitonin level had been obtained. This initial procalcitonin value was then compared with the level of amputation at the final surgical intervention. A highly statistically significant difference was found when comparing those who underwent a below-the-knee or above-the-knee amputation (median procalcitonin 1.72 ng/mL) and those who did not (median procalcitonin 0.105 ng/mL; p < .001). Therefore, patients with higher initial procalcitonin values were more likely to undergo below-the-knee or above-the-knee amputation or require aggressive surgical intervention. Thus, the procalcitonin level can provide valuable initial information to the clinician.
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NewsBot · Apr 28, 2017

Role of procalcitonin in infected diabetic foot ulcer.
Park JH et al
Diabetes Res Clin Pract. 2017 Apr 13;128:51-57.

AIMS:
Procalcitonin (PCT) has been recently accepted as a marker for diagnosing infection. The aim of the present study was to determine whether PCT levels are associated with infection severity of diabetic foot ulcers and whether PCT levels would be helpful to differentiate infected diabetic foot ulcer (IDFU) from IDFU associated with other infectious diseases (IDFU+O).
METHODS:
We prospectively included 123 diabetic patients hospitalized for IDFU. Infection severity of diabetic foot ulcers was graded according to the Infectious Diseases Society of America-International Working Group on the Diabetic Foot clinical classification of diabetic foot infection. Chest radiograph, urinalysis, urine microscopy, urine culture, and blood cultures (if fever was present) were performed for all patients to diagnose other infectious diseases. Laboratory parameters were measured from blood venous samples.
RESULTS:
PCT (Spearman's ρ=0.338, P<0.001) and C-reactive protein (Spearman's ρ=0.477, P<0.001) levels were significantly associated with infection severity of diabetic foot ulcers. However, only PCT levels could differentiate patients with associated infectious diseases from patients with no concomitant infection (area under the receiver-operator characteristic curve 0.869, P<0.0001; cut-off value 0.59; sensitivity 94.7; specificity 88.5).
CONCLUSION:
PCT and CRP levels positively correlated with infection severity of diabetic foot ulcers and PCT levels>0.59ng/mL in patients with IDFU may be associated with other systemic bacterial infection.
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NewsBot · Jul 24, 2017

Levels of wound calprotectin and other inflammatory biomarkers aid in deciding which patients with a diabetic foot ulcer need antibiotic therapy (INDUCE study).
Ingram JR et al
Diabet Med. 2017 Jul 22. doi: 10.1111/dme.13431.

AIMS:
Deciding if a diabetic foot ulcer is infected in a community setting is challenging without validated point-of-care tests. Four inflammatory biomarkers were investigated to develop a composite algorithm for mildly infected diabetic foot ulcers: venous white cell count, C-reactive protein (CRP) and procalcitonin, and a novel wound exudate calprotectin assay. Calprotectin is a marker of neutrophilic inflammation.
METHODS:
In a prospective study, people with uninfected or mildly infected diabetic foot ulcers who had not received oral antibiotics in the preceding 2 weeks were recruited from community podiatry clinics for measurement of inflammatory biomarkers. Antibiotic prescribing decisions were based on clinicians' baseline assessments and participants were reviewed 1 week later; ulcer infection was defined by clinicians' overall impression from their two assessments.
RESULTS:
Some 363 potential participants were screened, of whom 67 were recruited, 29 with mildly infected diabetic foot ulcers and 38 with no infection. One participant withdrew early in each group. Ulcer area was 1.32 cm2 [interquartile range (IQR) 0.32-3.61 cm2 ] in infected ulcers and 0.22 cm2 (IQR 0.09-1.46 cm2 ) in uninfected ulcers. Baseline CRP for mild infection was 9.00 mg/ml and 6.00 mg/ml for uninfected ulcers; most procalcitonin levels were undetectable. Median calprotectin level in infected diabetic foot ulcers was 1437 ng/ml and 879 ng/ml in uninfected diabetic foot ulcers. Area under the receiver operating characteristic curve for a composite algorithm incorporating calprotectin, CRP, white cell count and ulcer area was 0.68 (95% confidence intervals 0.52-0.82), sensitivity 0.64, specificity 0.81.
CONCLUSIONS:
A composite algorithm including CRP, calprotectin, white cell count and ulcer area may help to distinguish uninfected from mildly infected diabetic foot ulcers. Venous procalcitonin is unhelpful for mild diabetic foot ulcer infection.
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NewsBot · Aug 22, 2017

Levels of wound calprotectin and other inflammatory
biomarkers aid in deciding which patients with a diabetic
foot ulcer need antibiotic therapy (INDUCE study)
J. R. Ingram et al
Diabet. Med. 00, 000–000 (2017)

Aims Deciding if a diabetic foot ulcer is infected in a community setting is challenging without validated point-of-care
tests. Four inflammatory biomarkers were investigated to develop a composite algorithm for mildly infected diabetic foot
ulcers: venous white cell count, C-reactive protein (CRP) and procalcitonin, and a novel wound exudate calprotectin
assay. Calprotectin is a marker of neutrophilic inflammation.
Methods In a prospective study, people with uninfected or mildly infected diabetic foot ulcers who had not received oral
antibiotics in the preceding 2 weeks were recruited from community podiatry clinics for measurement of inflammatory
biomarkers. Antibiotic prescribing decisions were based on clinicians’ baseline assessments and participants were
reviewed 1 week later; ulcer infection was defined by clinicians’ overall impression from their two assessments.
Results Some 363 potential participants were screened, of whom 67 were recruited, 29 with mildly infected diabetic foot
ulcers and 38 with no infection. One participant withdrew early in each group. Ulcer area was 1.32 cm2 [interquartile range
(IQR) 0.32–3.61 cm2
] in infected ulcers and 0.22 cm2 (IQR 0.09–1.46 cm2
) in uninfected ulcers. Baseline CRP for mild
infection was 9.00 mg/ml and 6.00 mg/ml for uninfected ulcers; most procalcitonin levels were undetectable. Median
calprotectin level in infected diabetic foot ulcers was 1437 ng/ml and 879 ng/ml in uninfected diabetic foot ulcers. Area
under the receiver operating characteristic curve for a composite algorithm incorporating calprotectin, CRP, white cell
count and ulcer area was 0.68 (95% confidence intervals 0.52–0.82), sensitivity 0.64, specificity 0.81.
Conclusions A composite algorithm including CRP, calprotectin, white cell count and ulcer area may help to
distinguish uninfected from mildly infected diabetic foot ulcers. Venous procalcitonin is unhelpful for mild diabetic foot
ulcer infection.
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NewsBot · Sep 15, 2017

Procalcitonin levels and other biochemical parameters in patients with or without diabetic foot complications.
Al-Shammaree SAW, Abu-ALkaseem BA, Salman IN.
J Res Med Sci. 2017 Aug 16;22:95. doi: 10.4103/jrms.JRMS_906_16. eCollection 2017.

BACKGROUND:
Diagnosis of infection in diabetic foot ulcer (DFU) is not always simple. The analytic precision of procalcitonin (PCT) was evaluated to clarify the use of PCT for distinguish the presence of infection in DFU in comparison to other inflammatory markers.
MATERIALS AND METHODS:
This study comprised 88 subjects distributed into four groups: 16 nondiabetic healthy subjects (group control), 17 patients with type 2 diabetes mellitus without foot Complication (group DM), 25 patients with noninfected diabetic foot (group NIDF), and 30 patients with infected diabetic foot (group IDF). Fasting blood samples were taken for measurement of glucose, hemoglobin A1C, lipid profile, renal function, erythrocyte sedimentation rate (ESR), and white blood cell (WBC) and its derivatives. Plasma PCT was determined using an enzyme-linked immunosorbent assay.
RESULTS:
PCT, WBC, ESR, and neutrophils (NEU) were found significantly higher in IDF group than other groups. The receiver operating characteristic analysis showed that sensitivity, specificity, the best cutoff value, and the area under the curve were for ESR (100%, 93%, 31.5 mm/h, 1; P < 0.001), for PCT (87.5%, 86.7%, 66.55 pg/dl, 0.977; P < 0.001), for NEU (93.8%, 93.3%, 5.35, 0.957; P < 0.001) and for WBC (93.8%, 90%, 9.29 × 109/L, 0.942; P < 0.001), respectively.
CONCLUSION:
The outcomes of this study recommend that PCT can be an asymptomatic marker in the diagnosis of infection in DFU with higher Wagner grades in combination with different inflammatory markers.
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NewsBot · Oct 15, 2017

Procalcitonin as a diagnostic and prognostic marker in diabetic foot infection. A current literature review.
Velissaris D et al
Rom J Intern Med. 2017 Oct 11

Diabetic foot ulcers (DFUs) are a very common cause of mortality and morbidity. The distinction between infected and non-infected DFU remains a very challenging task for clinicians in everyday practice. Even when infection is documented, the spectrum of diabetic foot infection is wide, ranging from cellulitis and soft tissue infection to osteomyelitis. Procalcitonin (PCT), a well-established sepsis biomarker, has been used in the diagnosis of several infections including osteomyelitis in patients with diabetes mellitus. This review gathers and presents all the relevant data, up until now, regarding the use of PCT as an assessment tool in diabetic patients with foot infection. Current evidence suggests that PCT levels could aid clinicians in distinguishing infected from non-infected DFUs as well as in the distinction between soft tissue infection and bone involvement, but further and larger studies are warranted to confirm these findings.
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NewsBot · Apr 9, 2018

Diagnostic Value of Serum Procalcitonin Level for
Detecting Infected Diabetic Foot Ulcers
Kahe Efat et al
Ann Med Health Sci Res. 2018;8:79-81

Introduction: Differentiating infectious and non-infectious diabetic foot ulcers and
determining its severity based on clinical finding is chall
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enging for most physicians. In this
study we tried to investigate diagnostic value of procalcitonin level for diabetic foot ulcers
and compare it with other customary inflammatory biomarkers. Material and methods: fiftyseven
diabetic patients with foot ulcers, who were intended in endocrinology clinic of Imam
Khomeini hospital were selected and classified based on infectious foot ulcer (N=37) versus
non-infectious ulcer (N=20). Serum levels of procalcitonin and White blood cell (WBC) count
were measured concomitant with recording demographic data. The results were analyzed.
Results: the mean age of the patients was 68.5 ± 4.9 years; the diabetes disease duration was
11.6 ± 0.46 years. The serum procalcitonin level and WBC count in diabetics with infectious
ulcer were higher (p<0.05). The sensitivity and specificity of procalcitonin in diagnosis of
infectious diabetic foot ulcer were measured 23.3% and 100% respectively. There was no
statistically meaningful intergroup difference according to CRP level. Conclusions: This
study showed procalcitonin has high specificity for diagnosis of infectious diabetic foot
ulcers, so it could be used in the setting of suspicious infected diabetic foot ulcer but due to
its low sensitivity, it is not useful screening test.
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NewsBot · Apr 21, 2018

The Role of Serum Procalcitonin, Interleukin-6, and Fibrinogen Levels in Differential Diagnosis of Diabetic Foot Ulcer Infection.
Korkmaz P et al
J Diabetes Res. 2018 Feb 21;2018:7104352.

AIMS:
We aimed to evaluate the roles of interleukin-6 (IL-6), PCT, and fibrinogen levels in the differential diagnosis of the patients with infected diabetic foot ulcer (IDFU) and noninfected diabetic foot ulcer (NIDFU) and to compare those with C-reactive protein (CRP), white blood cell (WBC), and erythrocyte sedimentation rate (ESR).

METHODS:
Patients over 18 years with a diagnosis of type 2 diabetes mellitus and DFU who were followed up in our hospital between 1 January 2016 and 1 January 2017 were included in the study. In addition to this patient group, patients with diabetes but without DFU were determined as the control group.

RESULTS:
Thirty-eight patients with IDFU, 38 patients with NIDFU, and 43 patients as the control group were included in the study. Fifty-six point three percent of the patients who participated in the study were males, and the mean age was 61.07 ± 11.04 years. WBC, ESR, CRP, IL-6, and fibrinogen levels of the cases with IDFU were determined to be significantly higher compared to the cases in NIDFU (p < 0.01). The area under the ROC curve (AUROC) value was highest for CRP (0.998; p < 0.001), and the best cut-off value for CRP was 28 m/L. The best cut-off values for fibrinogen, IL-6, ESR, and WBC were 480 mg/dL, 105.8 pg/mL, 31 mm/h, and 11.6 (103 μ/L), respectively.

CONCLUSION:
Serum PCT levels were not found to be effective in the discrimination of IDFU and NIDFU. Serum IL-6 and fibrinogen levels seem to be two promising inflammatory markers in the discrimination of IDFU.
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NewsBot · Apr 27, 2019

Role of Procalcitonin as a Predictor of Clinical Outcome in Acute Diabetic Foot Infections: A Prospective Study.
Asirvatham AR et al
Indian J Endocrinol Metab. 2019 Jan-Feb;23(1):122-127. doi: 10.4103/ijem.IJEM_525_18.

BACKGROUND:
Prediction of outcome in diabetic foot infection (DFI) remains difficult due to lack of active signs of infection, and apparently normal white blood cell (WBC) count. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have been studied previously in this regard and were not useful. Hence, we evaluated procalcitonin (PCT) as a prognostic marker in this study.

OBJECTIVES:
We aimed to study the role of PCT, CRP, and ESR levels in predicting clinical outcome of acute DFI.

MATERIALS AND METHODS:
A total of 250 subjects (197 men, 53 women) with acute DFI were enrolled. WBC count, ESR, CRP, and PCT were done for all subjects at admission after obtaining informed consent. Subjects were managed according to hospital protocol and followed up for 1 month. Clinical outcome was assessed based on mobility and morbidity status of the subject.

RESULTS:
Old age, anemia, hyponatremia, hypoalbuminemia, and elevated serum creatinine were risk factors for poor outcome. Presence of cardiac failure, diabetic retinopathy, peripheral vascular disease, previous amputations, and positive bone culture had negative influence on clinical outcome. Elevated WBC count, ESR, CRP, and serum PCT were significantly associated with bad outcome. Elevated PCT (>2 ng/ml) [odds ratio (OR) (95% confidence interval (CI)), 2.03 (1.13-5.19), P < 0.001], gangrene [OR (95% CI), 2.2 (1.02-4.73), P = 0.04], and sepsis [OR (95% CI), 10.101 (4.34-23.25), P < 0.001] were good predictors of clinical outcome in acute DFI.

CONCLUSION:
PCT proved to be a reliable marker of acute DFI and good predictor of clinical outcome than existing markers WBC count, ESR, and CRP. Hence it should be useful for clinicians while managing acute DFI.
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NewsBot · Aug 18, 2019

Procalcitonin Is a Prognostic Marker of Hospital Outcomes in
Patients with Critical Limb Ischemia and Diabetic Foot Infection
Marco Meloni et al
Journal of Diabetes Research Volume 2019, 14 August 2019

Aim. To evaluate the prognostic role of procalcitonin (PCT) in patients with diabetic foot infection (DFI) and critical limb
ischemia (CLI). Materials and Methods. The study group was composed of diabetic patients with DFI and CLI. All patients
were treated according to a preset limb salvage protocol which includes revascularization, wound debridement, antibiotic
therapy, and offloading. Inflammatory markers, including PCT, were evaluated at admission. Only positive values of PCT,
greater than 0.5 ng/ml, were considered. Hospital outcomes were categorized as limb salvage (discharge with preserved limb),
major amputation (amputation above the ankle), and mortality. Results. Eighty-six patients were included. The mean age was
67 3 ± 11 4 years, 80.7% were male, 95.1% had type 2 diabetes, and the mean diabetes duration was 20 5 ± 11 1 with a mean
HbA1c of 67 ± 16 mmol/mol. 66/86 (76.8%) of patients had limb salvage, 7/86 (8.1%) had major amputation, and 13/86
(15.1%) died. Patients with positive PCT baseline values in comparison to those with normal values showed a lower rate of
limb salvage (30.4 versus 93.6%, p = 0 0001), a higher rate of major amputation (13 versus 6.3%, p = 0 3), and a higher rate of
hospital mortality (56.5 versus 0%, p < 0 0001). At the multivariate analysis of independent predictors found at univariate
analysis, positive PCT was an independent predictor of major amputation [OR 3.3 (CI 95% 2.0-5.3), p = 0 0001] and mortality
[OR 4.1 (CI 95% 2.2-8.3), p < 0 0001]. Discussion. Positive PCT at admission increased the risk of major amputation and
mortality in hospital patients with DFI and CLI.
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NewsBot · Sep 28, 2019

Pro-Calcitonin, Erythrocyte Sedimentation Rate and C - reactive Protein in Predicting Diabetic Foot Ulcer Characteristics; a Cross Sectional Study.
Hadavand F et al
Arch Acad Emerg Med. 2019 Jul

INTRODUCTION:
Considering the importance of early diagnosis of diabetic foot ulcers and its complications, this study aimed to evaluate the accuracy of erythrocyte sedimentation rate (ESR), C - reactive protein (CRP), and pro-calcitonin (PCT) in predicting the ulcer class, osteomyelitis, and peripheral arterial disease (PAD).

METHODS:
This cross-sectional study was performed on 200 consecutive patients suffering from diabetic foot ulcer who were referred to Infectious Disease Ward. The levels of PCT, ESR, and CRP were measured for all patients and the screening performance characteristics of each marker in predicting the ulcer class, osteomyelitis, and PAD was calculated.

RESULTS:
The levels of PCT, ESR and CRP were significantly higher in patients with class IV foot ulcer compared to those with class III ulcers (p<0.001). Patients with evidence of osteomyelitis had significantly higher level of PCT, ESR and CRP. The best cutoff points of PCT, ESR and CRP in predicting osteomyelitis were 0.35 ng/ml (86.1% sensitivity, 45.3% specificity), 56.5 mm/hours (95.8% sensitivity, and 50.0% specificity) and 44 mg/ml (90.3% sensitivity, 57.0% specificity), respectively. The presence of PAD was significantly associated with increased levels of the three biomarkers. The best cutoff values for PCT, ESR and CRP in predicting PAD were 0.45 (70.8% sensitivity, 71.7% specificity), 61.5 (83.3% sensitivity, 52.0% specificity) and 49 (83.3% sensitivity, 63.8% specificity), respectively.

CONCLUSION:
Based on the findings of the present study, although the accuracy of PCT, ESR, and CRP in predicting the severity of diabetic foot ulcers was fair, increase in the three parameters can predict the occurrence of osteomyelitis and PAD following diabetic food development with good accuracy and acceptable sensitivity.
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NewsBot · May 1, 2020

Is Procalcitonin more superior to hs-CRP in the diagnosis of infection in diabetic foot ulcer?
Zakariah NA et al
Malays J Pathol. 2020 Apr;42(1):77-84.

INTRODUCTION:
Procalcitonin (PCT) has recently emerged as a marker for diagnosing infection. This study aimed to compare the performance of PCT and other infection markers in diagnosing infected diabetic foot ulcer (IDFU).

MATERIALS AND METHODS:
A total of 128 diabetic patients with foot ulcers were recruited and divided into two groups, consisting of 73 patients in the IDFU group and 55 in the non-infected diabetic foot ulcer (NIDFU). The severity of infection in IDFU patients was graded based on the Infectious Disease Society of America-International Working Group on the Diabetic Foot classification. Blood samples from all the patients were collected for measurement of PCT, high sensitivity C-reactive protein (hs-CRP) and white cell count (WBC). The area under the receiver operating curves (AUC) were then constructed and analysed.

RESULTS:
PCT, hs-CRP and WBC levels were significantly higher in the IDFU group compared to NIDFU with hs-CRP demonstrated the highest AUC (0.91; p <0.001) followed by PCT (0.814; p < 0.001) and lastly WBC (0.775; p < 0.001). The best cut off value, sensitivity and specificity for the presence of infection in diabetic foot, were 3.47 mg/dL, 80% and 89% for hs-CRP, 0.11 ng/ml, 70% and 87% for PCT and 11.8x109/L, 60% and 90% for WBC. All the infection markers showed significant positive correlations with infection severity of DFU.

CONCLUSION:
This study showed that hs-CRP is a more sensitive marker for diagnosing IDFU. Although PCT is useful in differentiating IDFU from NIDFU, the use of PCT is not necessary as it adds little value to the current practice.
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NewsBot · Jul 18, 2021

Usefulness of Procalcitonin in Diagnosing Diabetic Foot Osteomyelitis: A Pilot Study
Venkat N Vangaveti et al
Wounds. 2021 Jul;33(7):192-196

Introduction: Infected diabetic foot is the leading cause of hospital admissions for people with diabetes mellitus. Diabetic foot osteomyelitis (DFO) causes high morbidity and significant mortality. Current diagnostic tests for DFO are either expensive, invasive, or of low diagnostic yield.

Objective: The objective of the study was to determine whether serum levels of procalcitonin (PCT), an inflammatory marker, differ between DFO and diabetic foot ulcers without osteomyelitis (ie, cellulitis) as controls. The authors also aimed to assess the usefulness of PCT in diagnosing DFO.

Methods: A case-control study was designed comparing DFO with diabetic foot cellulitis as the control. Patients were classified as having osteomyelitis and cellulitis based on the International Working Group on the Diabetic Foot diagnostic criteria. Serum inflammatory markers PCT, adiponectin, C-reactive protein-1, osteoprotegerin (OPG), osteopontin (OPN), and interleukin 6 (IL-6) were analyzed in patients with DFO and controls.

Results: The median serum procalcitonin was significantly higher in the DFO group 108.5 pg/mL (range, 65.0-124.0 pg/mL) compared with 57.0 pg/mL (range, 37.2-77.0 pg/mL) controls (P = .02). Procalcitonin had a sensitivity of 79% compared with 50%, 63%, 66%, and 75% for adiponectin, OPG, OPN, and IL-6, respectively. Procalcitonin had a specificity of 70% compared with 50%, 71%, 70%, and 64%. Receiver operator characteristic curves showed a value of area under the curve of 0.73 and 0.77 for PCT and IL-6 compared with 0.4, 0.6, and 0.6 for adiponectin, OPG, and OPN, respectively.

Conclusions: In this study, procalcitonin was a useful diagnostic test for DFOs and provided distinct diagnostic discrimination between DFO from cellulitis. It may serve as a useful marker for diagnosing DFO. Further studies in a larger population are needed to verify the findings.
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NewsBot · Jul 14, 2022

Diagnostic value of procalcitonin, erythrocyte sedimentation rate (ESR), quantitative C-reactive protein (CRP) and clinical findings associated with osteomyelitis in patients with diabetic foot
Zahra Soleimani et al
Hum Antibodies. 2021;29(2):115-121. doi: 10.3233/HAB-210439.

Background: The diagnosis of osteomyelitis is a key step of diabetic foot management. Procalcitonin (PCT) is a novel infection marker. This study aimed to investigate the diagnostic value of procalcitonin and other conventional infection markers and clinical findings in diagnosis of osteomyelitis in diabetic foot patients.

Methods and materials: This diagnostic value study was carried out on ninety patients with diabetic infected foot ulcers admitted in Kashan Beheshti Hospital, 2016. After obtaining consent, 10 cc blood sample was taken for measuring serum PCT, CBC, ESR, CRP and FBS. Clinical characteristics of the wounds were noted. Magnetic resonance imaging of the foot was performed in all patients to diagnose osteomyelitis. All statistical analyses were done with the use of SPSS-16.

Results: PCT levels were 0.13 ± 0.02 ng/mili patients with osteomyelitis (n= 45) and 0.04 ± 0.02 ng/ml in patients without osteomyelitis (n= 45). PCT, Erythrocyte sedimentation rate and C-reactive protein was found significantly higher in patients with osteomyelitis (p< 0.001). The ROC curve was calculated for PCT. The area under the ROC curve for infection identification was 1 (p< 0.001). The best cut-off value for PCT was 0.085 ng/ml. Sensitivity, specificity, and positive and negative predictive values were 100%, 97.8%,97.8% and 100%, respectively.

Conclusion: In this group of patients, PCT was useful to discriminate patients with bone infection. Also, Erythrocyte sedimentation rate and C-reactive protein can be used as a marker of osteomyelitis in diabetic patients
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NewsBot · Aug 7, 2023

Serum Procalcitonin (PCT) - Is there a Role as an Early
Biomarker in Infected Diabetic Foot Ulcer (IDFU) Patients?
Omar J et al
Malaysian Orthopaedic Journal 2023 Vol 17 No 2

Introduction: Infected diabetic foot ulcers may lead to
serious complications if not recognised in the early stage.
Diagnosis of infection is particularly challenging at that
stage; thus, a sensitive inflammatory biomarker may be
helpful. We aimed to evaluate the role of procalcitonin (PCT)
as an early biomarker for infected diabetic foot ulcers
(IDFU).
Materials and method: This cross-sectional study was
conducted at Klinik Rawatan Keluarga (KRK), Orthopedic
clinic and wards in Hospital Universiti Sains Malaysia
(USM) from May 2020 to December 2020. A total of 264
participants were recruited and divided into three groups: 50
diabetic patients with no ulcers (control), 107 patients with
non-infected diabetic foot ulcers (NIDFU), and 107 patients
with infected diabetic foot ulcers (IDFU). The level of PCT
was taken for all patients. Total white count (TWC) and Creactive protein (CRP) were taken only for IDFU patients.
Diagnosis of infection was based on the Infectious Disease
Society of America-International Working Group of Diabetic
Foot (IDSA-IMWGDF), and the severity of infection was
graded according to the Wagner Classification.
Results: The level of PCT was higher in IDFU than in
NIDFU and diabetic patient, with a median (IQR) of 0.355
(0.63) ng/mL, 0.077 (0.15) ng/mL and 0.028 (0.02) ng/mL,
respectively. PCT and CRP showed moderate positive
correlations in IDFU patients (p<0.001). The sensitivity and
specificity were 63.6% and 83.2%, respectively, at the best
cut-off at 0.25 ng/mL.
Conclusion: PCT is a valuable biomarker for the diagnosis
of infection; however, it adds little value in the early
diagnosis of IDFU in view of its low sensitivity.
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