Procalcitonin for Discerning the Etiology of Fever in Children Receiving Allogeneic Hematopoietic Stem Cell Transplantation

Background:

Fever is common in children receiving allogeneic hematopoietic stem cell transplantation (allo-HSCT). Discriminating infection (IF) from non infection-related fever (NIF) is critical for the judicious use of antibiotics in these patients. Our aim was to determine whether procalcitonin (PCT) helps in discriminating IF (overall and gram negative) vs. NIF in children receiving allo-HSCT.

Methods:

We performed a retrospective chart review of all children and adolescents (0-18 years) receiving an allo-HSCT between January 1^st, 2012 and May 1^st, 2016 at Centro Medico Imbanaco, in Cali, Colombia.

Patients who developed fever between day -5 and engraftment were included. Procalcitonin (PCT) levels were documented for the first febrile episode. Each episode was classified as IF (gram –, gram +, viral or fungal) or NIF (alloreactivity, drug fever or fever without source). A ROC curve was constructed to evaluate test performance.

Results:

Eighty-two patients received an allo-HSCT during the study period. 72 of them developed fever, at a median of 0 days post transplant. Their mean age was 9.6 years (standard deviation: 5.0) and 54% were male. 54 patients with fever had at least 1 PCT measured during their febrile episode. (table)

For gram – vs. NIF, the 1^st PCT value had an AUC of 0.7 in its ROC curve (figure 1). At a cutoff of 0.99, the PCT had a sensitivity of 88%, specificity of 56%, + likelihood ratio (LR) of 1.97 and – LR of 0.23.

Conclusion:

 

PCT may help discriminating IF from NIF, especially in gram – infections.  As patients are usually neutropenic during this period, discriminating gram – infections from NIF is of particular relevance. This biomarker may be useful in developing strategies to offer a more judicious use of antibiotics to this fragile population.

Table 1. PCT values in NIF, IF and gram – infections

Variables Median (IQR)	Non-infection related fever (N=27)	Infection related fever (N=27)	P value
PCT* value 1	0.67 (0.09;3.06)	1.22 (0.13;4.46)	0.44
PCT value 2	0.52 (0.14;1.11)	1.85  (0.16;7.51)	0.34
	Non-infection related fever (N=27)	Gram – infections (N=13)
PCT value 1	0.67 (0.09; 3.06)	2.24(1.15; 10.47)	0.09
PCT value 2	0.52 (0.14; 1.11)	8.78 (4.66; 71.12)**	N/A

^* In ng/mL units

^** Samples obtained in 3 patients (23%)