CSF Procalcitonin may be a valuable marker for diagnosing intracranial infection in patients after neurosurgery; in particular, the specificity of CSF PCT is higher if the CSF PCT level is higher than the serum PCT level ¹⁾.

Routine use of PCT as a predictor of postoperative infection is not supported ²⁾.

For ventriculostomy related infection diagnosis procalcitonin alone was found not to be helpful ³⁾.

Procalcitonin (PCT) is a biomarker of bacterial infections with more sensitivity and specificity than commonly used inflammatory markers. PCT can be particularly helpful in the postsurgical population where the surgery itself often leads to noninfectious inflammation. We aimed to examine the utility of perioperative profiles of PCT in predicting infection in two pediatric surgical populations.

Methods: We conducted a prospective observational study of perioperative PCT in children undergoing cardiac or neurosurgery. Consenting patients with no preoperative infection or immune deficiency were enrolled. We measured plasma PCT levels within 24 h preprocedure and 24-48 h postprocedure. Demographic, clinical, and laboratory data were collected from the medical records including clinical suspicion and confirmed infections. Perioperative PCT changes and their associations with these data are reported.

Results: We enrolled 26 neuro and 15 cardiac surgery patients. There was postoperative clinical suspicion of infection in 3 neuro and 5 cardiac patients, and 1 neuro and 2 cardiac patients had subsequently confirmed infections. Cardiac patients had higher overall perioperative PCT increase than neuro cohort (P = 0.006). Neuro patient with infection had higher perioperative change in PCT (0.5 to 1.4 ng/mL) than noninfected neurosurgery patients. Cardiac patients with confirmed infections had higher postoperative levels which exceeded the previously described infection threshold of 2 ng/mL.

PCT is a useful early biomarker of postoperative infection in pediatric patients undergoing cardiac and neurosurgery. Patients who underwent cardiac surgery have significantly higher perioperative PCT rise than patients who underwent neurosurgery, and all patients with subsequently confirmed infections had at least 2-fold perioperative PCT increase ⁴⁾.

Last revision of February 2020

5: Lee Y, Lim J, Choi SW, Han S, Park B, Youm JY. Changes of Biomarkers before and after Antibiotic Treatment in Spinal Infection. Korean J Neurotrauma. 2019 Aug 28;15(2):143-149. doi: 10.13004/kjnt.2019.15.e19. eCollection 2019 Oct. PubMed PMID: 31720268; PubMed Central PMCID: PMC6826089.

6: Carabias CS, Gomez PA, Panero I, Eiriz C, Castaño-León AM, Egea J, Lagares A; i+12 Neurotraumatology Group Collaborators. Chitinase-3-Like Protein 1, Serum Amyloid A1, C-Reactive Protein, and Procalcitonin Are Promising Biomarkers for Intracranial Severity Assessment of Traumatic Brain Injury: Relationship with Glasgow Coma Scale and Computed Tomography Volumetry. World Neurosurg. 2019 Oct 10. pii: S1878-8750(19)32587-2. doi: 10.1016/j.wneu.2019.09.143. [Epub ahead of print] PubMed PMID: 31606503.

7: Zervos T, Walters BC. Diagnosis of Ventricular Shunt Infection in Children: A Systematic Review. World Neurosurg. 2019 Sep;129:34-44. doi: 10.1016/j.wneu.2019.05.057. Epub 2019 May 14. PubMed PMID: 31100520.

8: Shin H, Kim JG, Kim W, Lim TH, Jang BH, Cho Y, Choi KS, Ahn C, Lee J, Na MK. Procalcitonin as a prognostic marker for outcomes in post-cardiac arrest patients: A systematic review and meta-analysis. Resuscitation. 2019 May;138:160-167. doi: 10.1016/j.resuscitation.2019.02.041. Epub 2019 Mar 11. Review. PubMed PMID: 30872069.

9: Zhu L, Dong L, Li Y, Lu G, Zhang H, Wang X, Liu X, Teng Z, Xia B, Zhang P. The Diagnostic and Antibiotic Reference Values of Procalcitonin for Intracranial Infection After Craniotomy. World Neurosurg. 2019 Jun;126:e1-e7. doi: 10.1016/j.wneu.2018.10.241. Epub 2018 Dec 11. PubMed PMID: 30550873.

10: Liu GB, Cui XQ, Wang ZB, Wen L, Duan HL. Detection of serum procalcitonin and hypersensitive C-reactive protein in patients with pneumonia and sepsis. J Biol Regul Homeost Agents. 2018 Sep-Oct;32(5):1165-1169. PubMed PMID: 30334408.

11: Zhang G, Yang C, Kang X, Gao Z, Wan H, Liu Y. The combination of cerebrospinal fluid procalcitonin, lactate, interleukin-8 and interleukin-10 concentrations for the diagnosis of postneurosurgical bacterial meningitis: A prospective study. Ann Clin Biochem. 2019 Jan;56(1):133-140. doi: 10.1177/0004563218794729. Epub 2018 Aug 27. PubMed PMID: 30056757.

12: Liu DB, Zhang HP, Yu K, Lu QB, Zhu ZF. A study on correlations of procalcitonin and interleukin-6 with viral meningitis. Eur Rev Med Pharmacol Sci. 2018 Jun;22(11):3474-3478. doi: 10.26355/eurrev_201806_15173. PubMed PMID: 29917201.

13: Wang XY, Zhang J, Liu L, Ji Z, Chen C, Yang JY, Li MY. [The significance of clinical indicators of different Gram-stained bacteria resulted in secondary intracranial infection after craniocerebral operation]. Zhonghua Yi Xue Za Zhi. 2018 May 29;98(20):1588-1592. doi: 10.3760/cma.j.issn.0376-2491.2018.20.012. Chinese. PubMed PMID: 29886650.

14: Gautam-Goyal P, Malhotra P, Epstein M, Luka A, Schwartz RM, Burshtein A, Burshtein J, Bensam B, Sy H, Ledoux D. Can Procalcitonin Be Used as a Reliable Marker for Infectious Fever in Patients with Intracranial Hemorrhage? World Neurosurg. 2018 Aug;116:e968-e974. doi: 10.1016/j.wneu.2018.05.142. Epub 2018 May 29. PubMed PMID: 29857212.

15: Zhao B, Ye MS, Zheng R. Enterococcus gallinarum meningitis: a case report and literature review. BMC Infect Dis. 2018 May 21;18(1):231. doi: 10.1186/s12879-018-3151-4. Review. PubMed PMID: 29783937; PubMed Central PMCID: PMC5963013.

16: Fu J, Lan Q, Wang D, Wang Y, Liu Y. [Predictive value of red cell distribution width on the prognosis of patients with abdominal sepsis]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2018 Mar;30(3):230-233. doi: 10.3760/cma.j.issn.2095-4352.2018.03.008. Chinese. PubMed PMID: 29519281.

17: Lenski M, Huge V, Schmutzer M, Ueberschaer M, Briegel J, Tonn JC, Schichor C, Thon N. Inflammatory Markers in Serum and Cerebrospinal Fluid for Early Detection of External Ventricular Drain-associated Ventriculitis in Patients With Subarachnoid Hemorrhage. J Neurosurg Anesthesiol. 2019 Apr;31(2):227-233. doi: 10.1097/ANA.0000000000000496. PubMed PMID: 29494414.

18: Rotman LE, Agee BS, Chagoya G, Davis MC, Markert JM. Clinical Utility of Serum Procalcitonin Level and Infection in the Neurosurgical Intensive Care Unit. World Neurosurg. 2018 Apr;112:e368-e374. doi: 10.1016/j.wneu.2018.01.050. Epub 2018 Jan 31. PubMed PMID: 29355796.

19: Hostettler IC, Muroi C, Richter JK, Schmid J, Neidert MC, Seule M, Boss O, Pangalu A, Germans MR, Keller E. Decision tree analysis in subarachnoid hemorrhage: prediction of outcome parameters during the course of aneurysmal subarachnoid hemorrhage using decision tree analysis. J Neurosurg. 2018 Dec 1;129(6):1499-1510. doi: 10.3171/2017.7.JNS17677. PubMed PMID: 29350603.

20: Yu Y, Li HJ. Diagnostic and prognostic value of procalcitonin for early intracranial infection after craniotomy. Braz J Med Biol Res. 2017 Apr 20;50(5):e6021. doi: 10.1590/1414-431×20176021. PubMed PMID: 28443989; PubMed Central PMCID: PMC5441286.

21: Halvorson K, Shah S, Fehnel C, Thompson B, Stevenson Potter N, Levy M, Wendell L. Procalcitonin is a Poor Predictor of Non-Infectious Fever in the Neurocritical Care Unit. Neurocrit Care. 2017 Oct;27(2):237-241. doi: 10.1007/s12028-016-0337-8. PubMed PMID: 28054289.

22: Alons IM, Verheul RJ, Kuipers I, Jellema K, Wermer MJ, Algra A, Ponjee G. Procalcitonin in cerebrospinal fluid in meningitis: a prospective diagnostic study. Brain Behav. 2016 Aug 16;6(11):e00545. eCollection 2016 Nov. PubMed PMID: 27843698; PubMed Central PMCID: PMC5102643.

23: Ma L, Zhang H, Yin YL, Guo WZ, Ma YQ, Wang YB, Shu C, Dong LQ. Role of interleukin-6 to differentiate sepsis from non-infectious systemic inflammatory response syndrome. Cytokine. 2016 Dec;88:126-135. doi: 10.1016/j.cyto.2016.08.033. Epub 2016 Sep 4. Review. PubMed PMID: 27599258.

24: Jeong DK, Lee HW, Kwon YM. Clinical Value of Procalcitonin in Patients with Spinal Infection. J Korean Neurosurg Soc. 2015 Sep;58(3):271-5. doi: 10.3340/jkns.2015.58.3.271. Epub 2015 Sep 30. PubMed PMID: 26539272; PubMed Central PMCID: PMC4630360.

25: Lim JX, King N, Low S, Ng WH. Serum procalcitonin is a marker for prediction of readmission from an intermediate care to an acute care hospital in neurosurgical patients. Surg Neurol Int. 2015 Aug 28;6:144. doi: 10.4103/2152-7806.163819. eCollection 2015. PubMed PMID: 26430533; PubMed Central PMCID: PMC4561388.

26: Liu ZH, Tu PH, Chen NY, Yip PK, Bowes AL, Lee CC, Chan SH, Kung CC, Wang AY, Wu CT, Lee ST. Raised Proinflammatory Cytokine Production Within Cerebrospinal Fluid Precedes Fever Onset in Patients With Neurosurgery-Associated Bacterial Meningitis. Crit Care Med. 2015 Nov;43(11):2416-28. doi: 10.1097/CCM.0000000000001188. PubMed PMID: 26196350.

27: Bhardwaj N, Mathur P, Kumar S, Gupta A, Gupta D, John NV, Varghese P, Misra MC. Depressed Monocytic Activity may be a Predictor for Sepsis. J Lab Physicians. 2015 Jan-Jun;7(1):26-31. doi: 10.4103/0974-2727.154785. PubMed PMID: 25949056; PubMed Central PMCID: PMC4411806.

28: Wang C, Gao L, Zhang ZG, Li YQ, Yang YL, Chang T, Zheng LL, Zhang XY, Man MH, Li LH. Procalcitonin Is a Stronger Predictor of Long-Term Functional Outcome and Mortality than High-Sensitivity C-Reactive Protein in Patients with Ischemic Stroke. Mol Neurobiol. 2016 Apr;53(3):1509-1517. doi: 10.1007/s12035-015-9112-7. Epub 2015 Feb 4. PubMed PMID: 25650122.

29: Omar AS, ElShawarby A, Singh R. Early monitoring of ventriculostomy-related infections with procalcitonin in patients with ventricular drains. J Clin Monit Comput. 2015 Dec;29(6):759-65. doi: 10.1007/s10877-015-9663-1. Epub 2015 Feb 1. PubMed PMID: 25638513.

30: Li Y, Zhang G, Ma R, Du Y, Zhang L, Li F, Fang F, Lv H, Wang Q, Zhang Y, Kang X. The diagnostic value of cerebrospinal fluids procalcitonin and lactate for the differential diagnosis of post-neurosurgical bacterial meningitis and aseptic meningitis. Clin Biochem. 2015 Jan;48(1-2):50-4. doi: 10.1016/j.clinbiochem.2014.10.007. Epub 2014 Oct 30. PubMed PMID: 25445228.

31: Tian G, Pan SY, Ma G, Liao W, Su QG, Gu BC, Qin K. Serum levels of procalcitonin as a biomarker for differentiating between sepsis and systemic inflammatory response syndrome in the neurological intensive care unit. J Clin Neurosci. 2014 Jul;21(7):1153-8. doi: 10.1016/j.jocn.2013.09.021. Epub 2013 Dec 2. PubMed PMID: 24508074.

32: Choi SH, Choi SH. Predictive performance of serum procalcitonin for the diagnosis of bacterial meningitis after neurosurgery. Infect Chemother. 2013 Sep;45(3):308-14. doi: 10.3947/ic.2013.45.3.308. Epub 2013 Sep 27. PubMed PMID: 24396632; PubMed Central PMCID: PMC3848519.

33: Tomio R, Akiyama T, Shibao S, Yoshida K. Procalcitonin as an early diagnostic marker for ventriculoperitoneal shunt infections. Surg Infect (Larchmt). 2013 Oct;14(5):433-6. doi: 10.1089/sur.2012.087. Epub 2013 Jul 17. Review. PubMed PMID: 23862561.

34: Muroi C, Lemb JB, Hugelshofer M, Seule M, Bellut D, Keller E. Early systemic procalcitonin levels in patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2014 Aug;21(1):73-7. doi: 10.1007/s12028-013-9844-z. PubMed PMID: 23839707.

35: Muroi C, Hugelshofer M, Seule M, Tastan I, Fujioka M, Mishima K, Keller E. Correlation among systemic inflammatory parameter, occurrence of delayed neurological deficits, and outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2013 Mar;72(3):367-75; discussion 375. doi: 10.1227/NEU.0b013e31828048ce. Erratum in: Neurosurgery. 2013 Oct;73(4):E753. PubMed PMID: 23208059.

36: Tu Y, Diao YF, Yang XP, Sun HT, Zhang S. [Effect of ulinastatin in traumatic brain injury with multiple injuries]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. 2012 Nov;24(11):677-9. Chinese. PubMed PMID: 23131288.

37: Zhao ML, Sun SZ, Yang XP, Tu Y, Li JJ, Ma TZ, Zhang S. [Clinical analysis of linezolid in treatment of infection with methicillin–resistant Staphylococcus in 14 neurosurgical patients]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. 2012 Mar;24(3):175-8. Chinese. PubMed PMID: 22401163.

38: Chung YG, Won YS, Kwon YJ, Shin HC, Choi CS, Yeom JS. Comparison of Serum CRP and Procalcitonin in Patients after Spine Surgery. J Korean Neurosurg Soc. 2011 Jan;49(1):43-8. doi: 10.3340/jkns.2011.49.1.43. Epub 2011 Jan 31. PubMed PMID: 21494362; PubMed Central PMCID: PMC3070894.

39: Nie H, Jiang D, Ou Y, Quan Z, Hao J, Bai C, Huang X, An H. Procalcitonin as an early predictor of postoperative infectious complications in patients with acute traumatic spinal cord injury. Spinal Cord. 2011 Jun;49(6):715-20. doi: 10.1038/sc.2010.190. Epub 2011 Jan 18. PubMed PMID: 21243003.

40: Pavcnik-Arnol M, Bonac B, Groselj-Grenc M, Derganc M. Changes in serum procalcitonin, interleukin 6, interleukin 8 and C-reactive protein in neonates after surgery. Eur J Pediatr Surg. 2010 Jul;20(4):262-6. doi: 10.1055/s-0030-1253358. Epub 2010 May 3. PubMed PMID: 20440673.

41: Krämer S, Maarouf M, Müller-Lung U. [Prolonged fever and monocytosis after hemorrhoidectomy and treatment with methotrexate–listeriosis with cerebral abscess]. Dtsch Med Wochenschr. 2009 Jun;134(23):1218-21. doi: 10.1055/s-0029-1222597. Epub 2009 May 26. German. PubMed PMID: 19472093.

42: Laifer G, Wasner M, Sendi P, Graber P, Gratzl O, Huber P, Fluckiger U, Zimmerli W. Dynamics of serum procalcitonin in patients after major neurosurgery. Clin Microbiol Infect. 2005 Aug;11(8):679-81. PubMed PMID: 16008624.

43: Berger C, Schwarz S, Schaebitz WR, Aschoff A, Schwab S. Serum procalcitonin in cerebral ventriculitis. Crit Care Med. 2002 Aug;30(8):1778-81. PubMed PMID: 12163792.

45: Hoffmann O, Reuter U, Masuhr F, Holtkamp M, Kassim N, Weber JR. Low sensitivity of serum procalcitonin in bacterial meningitis in adults. Scand J Infect Dis. 2001;33(3):215-8. PubMed PMID: 11303813.