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Limited diagnostic value of serum inflammatory biomarkers in the diagnosis of fracture-related infections.
Bone Joint J. 2020 Jul; 102-B(7):904-911.BJ

Abstract

AIMS

The aim of this study was to evaluate the diagnostic value of preoperative serum CRP, white blood cell count (WBC), percentage of neutrophils (%N), and neutrophil to lymphocyte ratio (NLR) when using the fracture-related infection (FRI) consensus definition.

METHODS

A cohort of 106 patients having surgery for suspected septic nonunion after failed fracture fixation were studied. Blood samples were collected preoperatively, and the concentration of serum CRP, WBC, and differential cell count were analyzed. The areas under the curve (AUCs) of diagnostic tests were compared using the z-test. Regression trees were constructed and internally cross-validated to derive a simple diagnostic decision tree.

RESULTS

Using the FRI consensus definition, 46 patients (43%) were identified as infected. Sensitivity, specificity, and AUC of CRP were 67% (95% confidence interval (CI) 52% to 80%), 61% (95% CI 47% to 74%), and 0.64 (95% CI 0.54 to 0.74); of WBC count were 17% (95% CI 9% to 31%), 95% (95% CI 86% to 99%), and 0.57 (95% CI 0.50 to 0.62); of %N 13% (95% CI 6% to 26%), 87% (95% CI 76% to 93%), and 0.50 (95% CI 0.43 to 0.56); and of NLR 28% (95% CI 17% to 43%), 80% (95% CI 68% to 88%), and 0.54 (95% CI 0.46 to 0.63), respectively. A better performance of serum CRP was shown in comparison to the leucocyte count (p = 0.006), %N (p < 0.001), and NLR (p = 0.001). A statistically lower serum CRP level was shown in patients with an infection caused by a low virulence microorganism in comparison to high virulence bacteria (p = 0.008). We found that a simple decision tree approach using only low serum neutrophils (< 3.615 × 109/l) and low CRP (< 2.45 mg/l) may allow better identification of aseptic cases.

CONCLUSION

The evaluated serum inflammatory markers showed limited diagnostic value in the preoperative diagnosis of FRI when using the uniform FRI Consensus Definition. Therefore, they should remain as suggestive criteria in diagnosing FRI. Although CRP showed a higher performance in comparison to the other serum markers, it is insufficiently accurate to diagnose a septic nonunion, especially when caused by low virulence microorganisms. Cite this article: Bone Joint J 2020;102-B(7):904-911.

Authors+Show Affiliations

The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK. Medical University of Vienna, Department of Orthopaedics and Trauma Surgery, Vienna, Austria.The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK.The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK.Department of Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland.The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK.The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, UK.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

32600147

Citation

Sigmund, Irene K., et al. "Limited Diagnostic Value of Serum Inflammatory Biomarkers in the Diagnosis of Fracture-related Infections." The Bone & Joint Journal, vol. 102-B, no. 7, 2020, pp. 904-911.
Sigmund IK, Dudareva M, Watts D, et al. Limited diagnostic value of serum inflammatory biomarkers in the diagnosis of fracture-related infections. Bone Joint J. 2020;102-B(7):904-911.
Sigmund, I. K., Dudareva, M., Watts, D., Morgenstern, M., Athanasou, N. A., & McNally, M. A. (2020). Limited diagnostic value of serum inflammatory biomarkers in the diagnosis of fracture-related infections. The Bone & Joint Journal, 102-B(7), 904-911. https://doi.org/10.1302/0301-620X.102B7.BJJ-2019-1739.R1
Sigmund IK, et al. Limited Diagnostic Value of Serum Inflammatory Biomarkers in the Diagnosis of Fracture-related Infections. Bone Joint J. 2020;102-B(7):904-911. PubMed PMID: 32600147.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Limited diagnostic value of serum inflammatory biomarkers in the diagnosis of fracture-related infections. AU - Sigmund,Irene K, AU - Dudareva,Maria, AU - Watts,Daniel, AU - Morgenstern,Mario, AU - Athanasou,Nicholas A, AU - McNally,Martin A, PY - 2020/7/1/entrez PY - 2020/7/1/pubmed PY - 2020/7/14/medline KW - CRP KW - Diagnosis KW - Fracture-related infection KW - Leukocyte count KW - Septic nonunion KW - Serum inflammatory markers KW - White blood cell count SP - 904 EP - 911 JF - The bone & joint journal JO - Bone Joint J VL - 102-B IS - 7 N2 - AIMS: The aim of this study was to evaluate the diagnostic value of preoperative serum CRP, white blood cell count (WBC), percentage of neutrophils (%N), and neutrophil to lymphocyte ratio (NLR) when using the fracture-related infection (FRI) consensus definition. METHODS: A cohort of 106 patients having surgery for suspected septic nonunion after failed fracture fixation were studied. Blood samples were collected preoperatively, and the concentration of serum CRP, WBC, and differential cell count were analyzed. The areas under the curve (AUCs) of diagnostic tests were compared using the z-test. Regression trees were constructed and internally cross-validated to derive a simple diagnostic decision tree. RESULTS: Using the FRI consensus definition, 46 patients (43%) were identified as infected. Sensitivity, specificity, and AUC of CRP were 67% (95% confidence interval (CI) 52% to 80%), 61% (95% CI 47% to 74%), and 0.64 (95% CI 0.54 to 0.74); of WBC count were 17% (95% CI 9% to 31%), 95% (95% CI 86% to 99%), and 0.57 (95% CI 0.50 to 0.62); of %N 13% (95% CI 6% to 26%), 87% (95% CI 76% to 93%), and 0.50 (95% CI 0.43 to 0.56); and of NLR 28% (95% CI 17% to 43%), 80% (95% CI 68% to 88%), and 0.54 (95% CI 0.46 to 0.63), respectively. A better performance of serum CRP was shown in comparison to the leucocyte count (p = 0.006), %N (p < 0.001), and NLR (p = 0.001). A statistically lower serum CRP level was shown in patients with an infection caused by a low virulence microorganism in comparison to high virulence bacteria (p = 0.008). We found that a simple decision tree approach using only low serum neutrophils (< 3.615 × 109/l) and low CRP (< 2.45 mg/l) may allow better identification of aseptic cases. CONCLUSION: The evaluated serum inflammatory markers showed limited diagnostic value in the preoperative diagnosis of FRI when using the uniform FRI Consensus Definition. Therefore, they should remain as suggestive criteria in diagnosing FRI. Although CRP showed a higher performance in comparison to the other serum markers, it is insufficiently accurate to diagnose a septic nonunion, especially when caused by low virulence microorganisms. Cite this article: Bone Joint J 2020;102-B(7):904-911. SN - 2049-4408 UR - https://www.unboundmedicine.com/medline/citation/32600147/Limited_diagnostic_value_of_serum_inflammatory_biomarkers_in_the_diagnosis_of_fracture_related_infections_ L2 - https://online.boneandjoint.org.uk/doi/10.1302/0301-620X.102B7.BJJ-2019-1739.R1?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -