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The Value of Serum Procalcitonin Level for Differentiation of Infectious from Noninfectious Causes of Fever After Orthopaedic Surgery
Sabina Hunziker, MD1; Thomas Hügle, MD1; Katrin Schuchardt, MD1; Isabelle Groeschl, MD1; Philipp Schuetz, MD1; Beat Mueller, MD1; Walter Dick, MD2; Urs Eriksson, MD1; Andrej Trampuz, MD3
1 Department of Internal Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
2 Department of Orthopaedic Surgery, University Hospital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland
3 Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland. E-mail address: andrej.trampuz@chuv.ch
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Swiss National Science Foundation (3200B0-112547/1), Stanley Thomas Johnson Foundation, and Gebert Rüf Stiftung. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Departments of Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jan 01;92(1):138-148. doi: 10.2106/JBJS.H.01600
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Abstract

Background: 

Early diagnosis of postoperative orthopaedic infections is important in order to rapidly initiate adequate antimicrobial therapy. There are currently no reliable diagnostic markers to differentiate infectious from noninfectious causes of postoperative fever. We investigated the value of the serum procalcitonin level in febrile patients after orthopaedic surgery.

Methods: 

We prospectively evaluated 103 consecutive patients with new onset of fever within ten days after orthopaedic surgery. Fever episodes were classified by two independent investigators who were blinded to procalcitonin results as infectious or noninfectious origin. White blood-cell count, C-reactive protein level, and procalcitonin level were assessed on days 0, 1, and 3 of the postoperative fever.

Results: 

Infection was diagnosed in forty-five (44%) of 103 patients and involved the respiratory tract (eighteen patients), urinary tract (eighteen), joints (four), surgical site (two), bloodstream (two), and soft tissues (one). Unlike C-reactive protein levels and white blood-cell counts, procalcitonin values were significantly higher in patients with infection compared with patients without infection on the day of fever onset (p = 0.04), day 1 (p = 0.07), and day 3 (p = 0.003). Receiver-operating characteristics demonstrated that procalcitonin had the highest diagnostic accuracy, with a value of 0.62, 0.62, and 0.71 on days 0, 1, and 3, respectively. In a multivariate logistic regression analysis, procalcitonin was a significant predictor for postoperative infection on days 0, 1, and 3 of fever with an odds ratio of 2.3 (95% confidence interval, 1.1 to 4.4), 2.3 (95% confidence interval, 1.1 to 5.2), and 3.3 (95% confidence interval, 1.2 to 9.0), respectively.

Conclusions: 

Serum procalcitonin is a helpful diagnostic marker supporting clinical and microbiological findings for more reliable differentiation of infectious from noninfectious causes of fever after orthopaedic surgery.

Level of Evidence: 

Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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