The Prognostic Role of Serum Procalcitonin for Adult Patients with Acute Diarrhea in the Emergency Department
by
, , ,
Antonella Gallo
1
,
Marcello Covino
2,3,*
,
Eleonora Ianua’
4,
Andrea Piccioni
2
,
Davide Della Polla
2,
Benedetta Simeoni
2,
Francesco Franceschi
2,3,
Francesco Landi
1,5 and
Massimo Montalto
1,5 1
Department of Geriatrics, Orthopedics and Rheumatology, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, 00168 Rome, Italy
2
Department of Emergency Medicine, Fondazione Policlinico Universitario “A. Gemelli”, IRCCS, 00168 Rome, Italy
3
Department of Emergency Medicine, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
4
Department of Internal Medicine, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
5
Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
*
Author to whom correspondence should be addressed.
Diagnostics 2025, 15(6), 734; https://doi.org/10.3390/diagnostics15060734
Submission received: 29 December 2024
/
Revised: 19 February 2025
/
Accepted: 8 March 2025
/
Published: 15 March 2025
(This article belongs to the Special Issue Diagnostics in the Emergency and Critical Care Medicine)
Abstract
:Background. Acute diarrhea is one of the leading causes of Emergency Department (ED) access. The search for the causative pathogen cannot be routinely performed since conventional methods, like stool cultures, are time-consuming, requiring days for growth and delaying diagnosis and the start of therapy. In this large sample retrospective study, we evaluated the prognostic role of serum procalcitonin (PCT) for adult patients with acute diarrhea in the ED. Methods. In a retrospective, mono-centric study, we enrolled all patients visiting our ED complaining of acute diarrhea and then hospitalized over five years. Final diagnosis of an infective (including bacterial) diarrhea, any other infection, and a bloodstream infection (BSI) was collected by clinical records, according to the International Disease Classification 10th edition. Procalcitonin determination was obtained upon request of the ED physician at the admission visit based on patient evaluation and clinical judgment. Results. Of a total of 1910 patients, early PCT values (cut-off of 0.5 ng/mL) did not show a significant predictive value for infective diarrhea (OR 0.554 [0.395–0.778]), nor for bacterial diarrhea (OR 0.596 [0.405–0.875]). Conversely, PCT levels at ED admission showed a significant predictive value for a final diagnosis of any infection (OR 1.793 [1.362–2.362]) and, above all, of bloodstream infection (BSI) (OR 6.694 [4.869–9.202]). Conclusions. Our data suggest that in ED, where the complexity and heterogeneity of patients are very high, indiscriminate PCT-guided management of patients with diarrhea is not indicated. Conversely, in patients with diarrhea but also clinical suspicion of BSI, PCT determination remains a useful instrument, possibly improving clinical management.
1. Introduction
Acute diarrhea represents a leading cause of mortality and morbidity worldwide [1] and is one of the most common symptoms reported by patients referred to the Emergency Department (ED) [1,2]. Even in the most developed countries, it is often of infectious origin, mainly viral [3]; however, looking for diarrhea etiology usually represents a challenge for the ED physician, as it may be present in various clinical conditions [4].
Since now, only a few studies focused on acute diarrhea etiology among adults visiting the ED [3,4,5,6]. Viruses, mainly Norovirus, resulted as the most frequently involved agents, above all during the winter months [3,4]. Bacterial infections, mainly by Salmonella and Vibrio parahaemolyticus agents, were responsible for about a quarter of cases. However, in more than one-third of cases, the etiological agent was not detected [3,4].
As a result, providing an accurate diagnosis based solely on the clinical presentation in the ED could be difficult, and when infectious diarrhea is suspected, the early diagnosis of acute bacterial gastroenteritis remains challenging. Laboratory investigation in healthy and immunocompetent subjects is usually not indicated considering that the majority of acute diarrheal illnesses are often of short duration, self-limited, or characterized by mild symptoms [6,7,8]. However, selected patients, above all frailer and immunosuppressed patients, may deserve a more accurate diagnostic work-up since the higher risk of complications and severe disease is usually associated with specific pathogens [6,7,9].
An early and accurate diagnosis can significantly contribute to identifying the correct strategy, guiding physicians in the decision-making process, supporting in the discrimination of those patients that can be safely discharged to home or need hospitalization, and, in particular, aiding in the decision whether to prescribe an empiric antibiotic therapy. Nevertheless, the search for the causative pathogen cannot be routinely performed in the ED since conventional methods, like stool culture, are time-consuming, requiring days for growth and delaying diagnosis and consequent therapeutic approach [10,11].
Non-invasive techniques, including stool or blood biomarkers, may represent feasible and reliable tools able to improve clinical management. To date, however, only a few studies have been focused on this topic [12,13,14,15]. In the last decade, interest has grown in real-time PCR-based multiplex stool testing, able to provide a result within one hour, and, consequently, early identification of the main viral, bacterial, and parasitic pathogens responsible for acute diarrhea [16,17]. However, its availability is still limited and is not routinely performed in an ED setting.
Serum procalcitonin (PCT) is a precursor protein of calcitonin expressed by human cells [18]. Its production is upregulated by pro-inflammatory cytokines, like interleukin (IL)-1, IL-2, IL-6, tumor necrosis factor-alpha, and by bacterial endotoxins and lipopolysaccharide. Additionally, it is downregulated during viral infections [18,19]. Procalcitonin determination has been recently approved in acute respiratory infections, providing good predictive values for the diagnosis and exclusion of pneumonia, and, above all, for a diagnosis of sepsis [20]. Different works show that it can perform better than C-reactive protein (CRP) for bacterial infection among inpatients [14,20] and can also improve clinical outcomes [21,22]. In particular, PCT-guided management, mainly regarding antibiotic therapy, leads to a significant benefit in patient management, showing the best advantage in high-risk patient populations [23]. Conversely, in a heterogeneous population, such as non-septic ED patients with fever [24] or those affected by lower respiratory tract [25] or urinary tract infections [26], current evidence is not conclusive.
2. Materials and Methods
This is a retrospective mono-centric study conducted in a tertiary urban University Hospital with annual attendance at the ED of about 75,000 patients (more than 87% adults). We evaluated the clinical records of consecutive patients admitted to our ED in five years from 1 January 2018 to 31 December 2023. We included all patients accessing the ED for acute diarrhea in the 24 h before the admission who had a PCT determination in the ED and were subsequently hospitalized. We excluded from the study cohort patients < 18 years old and all patients discharged home or transferred to other hospitals from the ED.
2.1. Patient Characteristics and Clinical History
All clinical and demographic data were extracted anonymously from the hospital’s computerized clinical records. Patient data were reviewed to assess demographic data, major comorbidities, and clinical symptoms at admission.
All patients included in the study cohort were evaluated for the following:
- Demographic data (age, sex).
- Vital signs at the ED admission (arterial pressure, heart rate, body temperature).
- Clinical symptoms (including cough, chest pain, abdominal pain, vomiting, gastrointestinal bleeding, neurological impairment, renal failure, asthenia).
- Comorbidities: We recorded the comorbidities included in the Charlson’s comorbidity score which was calculated for all the patients [27]. In particular, history of cancer, solid and hematological transplantation, inflammatory bowel disease (IBD), ischemic cardiac disease, heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, chronic renal failure, liver disease, and dementia were collected from clinical records.
- Laboratory findings included hemoglobin, white cell count, fibrinogen glucose, platelet count, procalcitonin, C-reactive protein, and serum creatinine. The procalcitonin determination was obtained upon request of the emergency physician based on patient evaluation and clinical judgment. Procalcitonin determinations were available 24 h a day in our ED, with a lab time response of about 1 h.
- Clinical outcomes were evaluated at hospital discharge or death and included all-cause in-hospital death, length of hospital stay (LOS), need for abdominal surgery, diagnosis of infective gastroenteritis (either bacterial or viral), diagnosis of bloodstream infection, diagnosis of any infective disease.
2.2. Outcome Measures
The definition of infective diarrhea included “any or specified bacterial diarrhea, including Clostridioides difficile infection”, and “probable infective diarrhea”. The other infective diagnosis included “any other infection (respiratory infection, urinary tract infection, abdominal infection, and other types of infection if not included in the previous ones)” and bloodstream infection (BSI). The diagnoses were based on the clinical records according to the International Disease Classification 10th edition (ICD-10) [28].
The in-hospital length of stay (LOS) was calculated from the time of ED admission to the hospital discharge.
2.3. Study Endpoints
As the primary endpoint, we evaluated the role of serum PCT in the diagnosis of acute gastrointestinal infection.
As secondary endpoints, we evaluated the relationship between serum PCT and diagnosis of bloodstream infection, the diagnosis of any infective disease, and in-hospital death.
2.4. Statistical Analysis and Sample Size
Categorical variables are presented as absolute numbers and percentages; continuous variables are presented as median (interquartile range). Categorical variables were statistically compared using Chi-square test or Fisher exact test, as appropriate. Continuous variables were compared with the Mann–Whitney U test or, in the case of three or more groups, with the Wilcoxon ANOVA median test.
Significant factors at univariate analysis were entered into a multivariate logistic regression model to identify independent risk predictors for the defined outcomes. The significant variables at univariate analysis were included in a logistic model to find the independent predictors for the defined outcomes. In the case of combined variables, such as single comorbidities and the Charlson Index, the composing factors were excluded from the analysis to avoid parameter overestimation and instability. The finding of an abnormal PCT value (>0.5 ng/mL) was forced in all the logistic models. Similarly, to include in the analysis the overall burden of comorbidities for each patient, the Charlson Index was forced in all the analyses. Logistic regression analysis results were reported as Odds Ratio (OR) [95% confidence interval].
The discrimination ability of serum Procalcitonin for the defined outcomes was evaluated with the Receiver Operating Characteristics (ROC) curve analysis. Survival curves were calculated using the Kaplan–Meier method. All p values were 2-sided, with a significance threshold set at 0.05, and corrected in case of multiple group comparison.
No a priori sample size calculation was performed because all eligible records were used in this retrospective study
The study analysis was conducted with SPSS version 25 (IBM, Armonk, NY, USA).
2.5. Statement of Ethics
The study was conducted according to the principles expressed in the Declaration of Helsinki and its later amendments and approved by the Institutional Review Board (#0025817/22 on 03/08/2022).
The authors declare no conflict of interest.
3. Results
During the study period, 2125 patients evaluated in the ED for acute diarrhea were admitted to our hospital wards. Among these, 215 did not meet inclusion criteria or had incomplete or inconsistent clinical records and were excluded. Thus, the study cohort consisted of 1910 patients with a median age of 70 [55–80] years. There were 893 (46.8%) males. Early PCT determination at ED admission resulted below the normal range (<0.5 ng/mL) in 1528 (65.9%) patients and above the normal range in 649 (34.1%) patients. Other clinical and demographic data of enrolled patients are shown in Table 1.
Figure 1 shows the distribution of infective diagnosis at hospital discharge, with a particular focus on those patients receiving a definitive infective bacterial diagnosis, as confirmed by stool cultural testing.
In-hospital death occurred in 207 cases (10.8%), and the median LOS was 9.0 [5.7–15.3] days. ICU admission occurred in 89 (4.7%) patients. As expected, the LOS, the in-hospital death, and the percentage of ICU admission were higher in those subjects showing increased values of PCT at ED admission (Table 1). Abdominal surgery was performed in 101 (5.5%) patients; in this case, no significant differences were reported according to PCT values at ED admission.
3.1. Early PCT Determination in Infective Intestinal Diagnosis
At discharge, infective diarrhea was reported in 285 (14.9%) patients in the study cohort. Table 2 shows differences among these subjects and those not receiving this final diagnosis. At univariate analysis, PCT values at ED admission did not correlate with a final infective diagnosis (p = 0.813).
At multivariate analysis, early PCT values (with a cut-off of 0.5 ng/mL) did not discriminate between the two groups (OR 0.554 [0.395–0.778]), conversely to white blood cell (WBC) count (OR 1.015 [1.002–1.028]), serum creatinine levels (OR 1.020 [0.919–1.097]), and C-reactive protein (CRP) levels (OR 1.001 [1.000–1.003]). Moreover, older (OR 1.025 [1.014–1.037]) and more comorbid patients (OR 1.004 [0.949–1.076]) more likely received a final intestinal infective diagnosis.
These results were confirmed when analyzing the subgroups of patients receiving a final diagnosis of bacterial diarrhea (Table 3).
Also, in these patients, univariate analysis showed that PCT values at ED admission did not correlate with a final diagnosis of bacteria diarrhea (p = 0.430). As the same, at multivariate analysis, early PCT values did not discriminate between the two groups (OR 0.596 [0.405–0.875]), conversely to white blood cell (WBC) count (OR 1.026 [1.010–1.043]), serum creatinine levels (OR 1.004 [0.917–1.098]), and C-reactive protein (CRP) levels (OR 1.002 [1.000–1.004]). Also, in this case, older (OR 1.042 [1.024–1.057]) and more comorbid patients (OR 1.005 [0.926–1.076]), in addition to febrile patients (OR 1.043 [0.736–1.477]), more likely received a final diagnosis of bacteria diarrhea.
3.2. Early PCT Determination in Non-Intestinal Infection Diagnosis
Table 4 and Table 5 report the association of the same parameters with a final diagnosis of any infection (not including intestinal infection) and BSI.
Conversely to intestinal infective diagnosis and bacteria diarrhea, PCT levels at ED admission showed the strongest predictive value for a final diagnosis of any infection (OR 1.793 [1.362–2.362]), performing better than WBC count (OR 1.009 [0.999–1.020]) and CRP levels (OR 1.003 [1.001–1.004]). These data resulted as more significant for a final diagnosis of BSI, as shown in Table 5.
In this case, PCT levels at ED admission showed the strongest predictive value (OR 6.694 [4.869–9.202]), performing much better than WBC count (OR 1.002 [0.989–1.015]) and CRP levels (OR 1.002 [1.000–1.003]).
In each of the two subgroups, older patients were more likely to receive an infective diagnosis or a diagnosis of BSI.
4. Discussion
This represents the first retrospective study on a large sample aimed at evaluating the usefulness of early PCT determination in a heterogeneous real-world ED adult population hospitalized for diarrhea.
Our main finding is that PCT determination at ED admission does not represent a significant predictive biomarker for a final infective intestinal diagnosis, even of bacterial etiology.
Management of patients with acute diarrhea arriving at the ED often represents a challenge for physicians. An early discrimination between infectious or non-infectious etiology, and between bacterial and viral origin, could ideally guide different therapeutic approaches.
Current guidelines, provided by the American College of Gastroenterology (ACG) [7] and the Infectious Diseases Society of America (IDSA) Society [8] represent the most recent recommendations on the management of adults with acute diarrhea, although there are no specific paragraphs dedicated to the ED setting.
While, regardless of the etiology, there is a consensus about common measures such as fluid repletion and nutrition maintenance that should be promptly warranted to all subjects, the major concerns regard antibiotic prescription. Emergency physicians notoriously have to deal both with limited information to achieve a definitive diagnosis and with patients’ expectations and satisfaction, already known to possibly influence the therapeutical approach [29]. Karras et al. showed that, in a cohort of American adults and children admitted to the ED with diarrhea, physicians more likely prescribed antibiotics not only for suspicion of bacterial enteritis but also when they simply believed that patients expected to be given them [29]. Moreover, whereas 100% of patients treated with antibiotics were satisfied with their treatment, only 90% of patients who were not prescribed antibiotics showed the same level of satisfaction [29].
Since etiologic diagnosis by stool culture or polymerase chain reaction requires time and costs, often incompatible with the ED setting, the search for accurate, rapid, and non-invasive diagnostic tools can, therefore, represent one of the most interesting focuses of research in the management of diarrheal diseases. However, only a few small sample studies are available on this topic, mainly conducted in the children population [12,13,14,15,30,31].
Among different available inflammatory biomarkers, interest in the role of PCT determination in a particular clinical setting such as the ED has been rapidly growing. Levels of PCT increase significantly and early when an inflammatory bacterial process occurs, due to inflammatory cytokines and bacterial endotoxins being released [18,19,20]. A PCT-guided approach has been largely reported to significantly and positively impact overall patient management in different infectious conditions, most of all in BSI [21,22,23,24,25,26].
Nevertheless, conclusive evidence on the utility of PCT in patients complaining of acute diarrhea is still lacking [12,13,14,15]. Thia et al. [13] performed a prospective study on 81 patients with acute gastroenteritis (as confirmed by stool cultures for standard pathogens), 18.5% of whom were of bacterial etiology, showing that levels of PCT and C-reactive protein helped in the discrimination of bacterial and undifferentiated gastroenteritis. However, the sample of this study was very small since only fifteen patients received a diagnosis of bacterial gastroenteritis [13].
Also, in a pediatric setting [30], Ismaili-Jaha et al. found that PCT represented an important but not conclusive marker of bacterial etiology in children younger than 5 years since its levels resulted in a significant difference between bacterial and viral gastroenteritis, but they were not able to discriminate between bacterial and extra-intestinal diarrhea [30].
More recently, Shin et al. [14] reported in a cohort of 514 patients with diarrhea that the determination of serum PCT may have a significant predictive value (OR 1.321, AUC 0.797) for the detection of inflammatory diarrhea, showing a better predictive value compared with CRP (OR 1.145, AUC 0.697). Discrimination between inflammatory and non-inflammatory group diarrhea was based on endoscopic and/or radiological parameters, such as abnormal bowel wall thickening and fluid collection at abdominal CT or typical mucosal alterations on colonoscopy [14].
In this retrospective study, all patients were supposed to be affected by “acute infectious diarrhea”; although no stool cultural examinations or discharge diagnosis were provided, general inclusion criteria consisted of fever (>37.8 °C), abdominal pain, and diarrhea. Similarly, no information about the clinical history and comorbidities were reported. It is plausible that higher levels of PCT may be related to the intensity of the inflammatory response, maybe identifying more severe clinical pictures and potentially helping the clinician’s decision-making in starting or not starting an empiric antibiotic treatment. However, as the same authors concluded, a global patient evaluation should be encouraged always when approaching patients with acute diarrhea and PCT levels alone is not a gold standard for the inflammatory subgroup [14].
As average age increases, concepts such as frailty, comorbidity, and functional status have been receiving growing attention to improve health care in a population notably experiencing higher rates of adverse outcomes compared to other people of the same age [32,33,34]. Therefore, a global assessment of frailty and functional status should be encouraged and incorporated into the standard evaluation, regardless of age, including in people visiting the ED for acute diarrhea [6,34]. An early and careful identification of the most vulnerable patients, in fact, may significantly support physicians in targeting the approach and balancing the beneficial and harmful potential of each intervention [32,33,34].
Our results showed that an indiscriminate PCT sampling in all ED populations complaining of acute diarrhea should not be recommended; rather it should be reserved for those subjects with clinical features suggestive for sepsis associated with diarrhea. This result confirmed both our previous findings showing that a PCT-guided management in ED results in benefits only in severely ill patients [24]. Conversely, in more heterogeneous populations, even if admitted to ICU wards, the PCT-guided management did not show the same significant advantages compared to standard management [26,35].
In particular, we found that early PCT determination at ED admission cannot predict a bacterial infectious diarrhea diagnosis, even a Clostridioides difficile infection. This result is in line with a previous but smaller study by Casella de Abreu et al. [15]. They included 80 patients admitted to the ED with acute infectious diarrhea, 21 with acute colitis and 24 with another illness causing diarrhea. They found that PCT levels remained low in the case of bacterial enteritis, concluding that this biomarker cannot represent a guide to antibiotic therapy in these patients [15].
It is known that CRP is the most frequent biomarker used in the ED in patients admitted for acute diarrhea [36]. In our study, as for de Abreu et al. [15], CRP levels showed a better predictive value than PCT, although the lack of widely recognized cut-offs limits its utility in discriminating between bacterial and viral infections, thus not helping physicians in deciding whether or not to start an antibiotic therapy [14]. Molecular testing, like PCR GI panel, may be very useful in the ED setting, due to the quickness of results (about 1 h) and the high diagnostic accuracy in pathogen detection [16,17]. However, the accessibility to these diagnostic tools is still limited, and further studies are needed to confirm their usefulness in clinical practice.
4.1. Study Limitations
Although conducted on a very large cohort of patients, our study had some limitations: first, its retrospective nature. For this reason, we were not able to retrieve the information about the use of antibiotic therapy in the month before the ED access. Moreover, the final discharge diagnosis was collected by reviewing clinical records, and a comparison with a gold standard such as stool or blood culture examinations was not available for most of the patients. Moreover, we only measured PCT levels on ED admission and did not collect the following levels during admission. However, our main purpose was to evaluate the usefulness of the early measurement on ED admission and not during hospitalization, when, usually, physicians have more time and more accurate diagnostic tests available to guide them in identifying the correct approach.
4.2. Conclusions
Our data suggest that in ED, where the complexity and heterogeneity of patients are very high, indiscriminate PCT-guided management of patients with diarrhea is not indicated. Conversely, in patients with diarrhea and a clinical suspicion of BSI, PCT determination remains a useful instrument, possibly improving clinical management.
Author Contributions
Conceptualization, M.C. and A.G.; methodology M.C., B.S., M.M. and F.F.; formal analysis, M.C. and E.I.; data curation D.D.P., A.P. and B.S.; writing—original draft preparation A.G., E.I., D.D.P. and A.P.; writing—review and editing, M.C., A.G., F.F., F.L. and M.M.; supervision, F.F., F.L. and M.M. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (#0025817/22 on 03/08/2022).
Informed Consent Statement
All patients provided consent to participate in the study.
Data Availability Statement
All data are included within the main test.
Conflicts of Interest
The authors declare no conflicts of interest.
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Figure 1.
Infective diagnosis at discharge in the total population.
Table 1.
Demographic and clinical characteristics of the 1910 patients included in the study.
| Variable | PCT Values | Univ. | ||
|---|---|---|---|---|
| <0.5 (n. 1258) | >0.5 (n. 649) | p Values | ||
| Males | 893 (46.8%) | 583 (46.3%) | 310 (47.5%) | 0.617 |
| Median age (years) | 70 [55–80] | 69 [53–80] | 71 [59–80] | 0.008 |
| ED Presentation | ||||
| Triage Code | <0.001 | |||
| 97 (5.1%) | 42 (3.3) | 55 (8.4) | |
| 528 (27.6%) | 308 (24.5) | 220 (33.7) | |
| 1285 (67.3%) | 908 (72.2) | 377 (57.8) | |
| Associated symptoms | ||||
| Cough | 193 (10.1) | 148 (11.8) | 45 (6.9) | 0.001 |
| Vomiting | 636 (33.3) | 429 (34.1) | 207 (31.7) | 0.301 |
| Abdominal pain | 716 (37.5) | 485 (38.6) | 231 (35.4) | 0.181 |
| Chest pain | 49 (2.6) | 35 (2.8) | 14 (2.1) | 0.405 |
| Syncope | 188 (9.8) | 117 (9.3) | 71 (10.9) | 0.269 |
| Gastrointestinal bleeding | 101 (5.3) | 76 (6.0) | 25 (3.8) | 0.041 |
| Asthenia | 386 (20.2) | 244 (19.4) | 142 (21.8) | 0.219 |
| Confusion | 112 (5.9) | 66 (5.2) | 46 (7.1) | 0.111 |
| Anuresis | 35 (1.8) | 15 (1.2) | 20 (3.1) | 0.004 |
| Laboratory parameters | ||||
| Hb (g/dL) | 12.2 [10.4–13.7] | 12.5 [10.7–13.9] | 11.7 [10.0–13.3] | <0.001 |
| WBC (cell/mm3) | 9.9 [6.5–14.7] | 9.1 [6.4–12.8] | 12.4 [7.2–17.8] | <0.001 |
| Creatinine (mg/dL) | 1.0 [0.8–1.6] | 0.9 [0.7–1.3] | 1.4 [0.9–2.4] | <0.001 |
| Blood glucose (mg/dL) | 111.0 [96.0–140.0] | 109.0 [96.0–133.0] | 118.0 [99.0–150.5] | <0.001 |
| Procalcitonin (ng/dL) | 0.19 [0.06–1.01] | 0.09 [0.05–0.18] | 2.60 [0.97–13.9] | <0.001 |
| CRP (mg/L) | 81.5 [25.7–156.0] | 47.1 [15.7–115.6] | 156 [88.1–230.2] | <0.001 |
| Clinical history | ||||
| Charlson comorbidity score | 4 [2–6] | 4 [2–6] | 5 [3–6] | <0.001 |
| Cancer | 378 (19.8) | 220 (17.5) | 158 (24.2) | <0.001 |
| Immunosuppressive therapy | 54 (2.8) | 37 (2.9) | 17 (2.6) | 0.676 |
| IBD | 136 (7.1) | 117 (9.3) | 19 (2.9) | <0.001 |
| Ischemic cardiac disease | 174 (9.1) | 108 (8.6) | 66 (10.1) | 0.268 |
| Heart failure | 123 (6.4) | 86 (6.8) | 37 (5.7) | 0.327 |
| COPD | 150 (7.9) | 99 (7.9) | 51 (7.8) | 0.971 |
| Diabetes | 237 (12.4) | 139 (11.0) | 98 (15.0) | 0.012 |
| Chronic renal failure | 330 (17.3) | 161 (12.8) | 169 (25.9) | <0.001 |
| Liver disease | 145 (7.6) | 92 (7.3) | 53 (8.1) | 0.523 |
| Dementia | 147 (7.7) | 101 (8.0) | 46 (7.1) | 0.449 |
| Main Infective discharge diagnosis | ||||
| Bacterial diarrhea | 207 (10.8) | 142 (11.3) | 65 (10.0) | 0.379 |
| Infective diarrhea (any) | 285 (14.9) | 202 (16.1) | 83 (12.7) | 0.053 |
| Infection (any) | 1248 (65.3) | 753 (59.9) | 495 (75.9) | <0.001 |
| BSI | 337 (17.8) | 92 (7.3) | 245 (37.6) | <0.001 |
| COVID-19 infection | 179 (9.4) | 150 (11.9) | 29 (4.4) | <0.001 |
| Clinical outcomes | ||||
| Lenght of hospitalization | 9.0 [5.7–15.3] | 8.4 [5.5–14.4] | 10.0 [6.0–17.2] | 0.002 |
| Death | 207 (10.8) | 100 (7.9) | 107 (16.4) | <0.001 |
| ICU admission | 89 (4.7) | 35 (2.8) | 54 (8.3) | <0.001 |
| Abdominal surgery | 101 (5.3) | 67 (5.3) | 34 (5.2) | 0.918 |
Table 2.
Demographic and clinical features of patients with a final diagnosis of infective diarrhea.
Table 2.
Demographic and clinical features of patients with a final diagnosis of infective diarrhea.
| Variable | Infecrive Diarrhea | Univ. p Value | Odds Ratio [95% CI] | Multiv. p Value | |
|---|---|---|---|---|---|
| NO (N 1625) | YES (N 285) | ||||
| Sex (Male) | 778 (47.9%) | 115 (40.4%) | 0.019 | 0.800 [0.613–1.045] | 0.101 |
| Median age (years) | 69 [54–79] | 78 [66–83] | <0.001 | 1.023 [1.013–1.034] | <0.001 |
| ED Presentation | |||||
| Triage Code | 0.425 | ||||
| 85 (5.2) | 12 (4.2) | |||
| 456 (28.1) | 72 (25.3) | |||
| 1084 (66.7) | 201 (70.5) | |||
| Associated symptoms | |||||
| Cough | 184 (11.3) | 9 (3.2) | 0.001 | 0.265 [0.133–0.529] | <0.001 |
| Vomiting | 542 (33.4) | 94 (33.0) | 0.902 | ||
| Abdominal pain | 626 (38.5) | 90 (31.6) | 0.026 | ||
| Chest pain | 44 (2.7) | 5 (1.8) | 0.348 | ||
| Syncope | 162 (10.0) | 26 (9.1) | 0.658 | ||
| Gastrointestinal bleeding | 86 (5.3) | 15 (5.3) | 0.964 | ||
| Asthenia | 340 (20.9) | 46 (16.1) | 0.064 | ||
| Confusion | 96 (5.9) | 16 (5.6) | 0.846 | ||
| Anuresis | 32 (2.0) | 3 (1.1) | 0.287 | ||
| Laboratory parameters | |||||
| Hb (g/dL) | 12.2 [10.4–13.8] | 12.1 [10.4–13.5] | 0.566 | ||
| WBC (cell/mm3) | 9.6 [6.3–14.3] | 11.0 [7.6–16.4] | <0.001 | 1.015 [1.002–1.028] | 0.027 |
| Creatinine (mg/dL) | 0.9 [0.7–1.3] | 1.4 [0.9–2.4] | 0.018 | 1.040 [0.974–1.111] | 0.244 |
| Blood glucose (mg/dL) | 112.0 [97.0–140.7] | 109.0 [94.5–135.5] | 0.151 | ||
| PCT (ng/dL) | 0.18 [0.06–1.09] | 0.21 [0.07–13.9] | 0.813 | ||
| PCT > 0.5 ng/dL (%) | 569 (35.0) | 83 (29.1) | 0.053 | 0.629 [0.470–0.843] | 0.002 |
| CRP (mg/L) | 77.8 [24.6–156.2] | 101.4 [38.3–153.9] | 0.054 | ||
| Clinical history | |||||
| Charlson comorbidity score | 4 [2–6] | 5 [3–6] | <0.001 | 0.966 [0.906–1.029] | 0.278 |
| Immunosuppressive therapy | 48 (3.0) | 8 (2.1) | 0.425 | ||
| IBD | 129 (7.9) | 7 (2.5) | 0.001 | 0.336 [0.152–0.740] | 0.007 |
| Ischemic cardiac disease | 149 (9.2) | 25 (8.8) | 0.830 | ||
| Heart failure | 93 (5.7) | 30 (10.5) | 0.002 | ||
| COPD | 123 (7.6) | 27 (9.5) | 0.270 | ||
| Diabetes | 196 (12.1) | 41 (14.4) | 0.272 | ||
| Chronic renal failure | 265 (16.3) | 65 (22.8) | 0.007 | ||
| Liver disease | 130 (8.0) | 15 (5.3) | 0.108 | ||
| Dementia | 116 (7.1) | 31 (10.9) | 0.0.29 | ||
| Cancer | 349 (21.5) | 29 (10.2) | <0.001 | ||
| Clinical outcomes | |||||
| Abdominal surgery | 95 (5.8) | 8 (2.1) | 0.009 | ||
| Lenght of hospitalization | 8.9 [5.5–15.0] | 9.4 [6.0–15.4] | 0.279 | ||
Table 3.
Demographic and clinical features of patients with a final diagnosis of bacterial diarrhea.
Table 3.
Demographic and clinical features of patients with a final diagnosis of bacterial diarrhea.
| Variable | Bacterial Diarrhea | Univ. p Value | Odds Ratio [95% CI] | Multiv. p Value | |
|---|---|---|---|---|---|
| NO (N 1703) | YES (N 207) | ||||
| Sex (Male) | 815 (47.9%) | 78 (37.7%) | 0.006 | 0.728 [0.527–1.005] | 0.054 |
| Median age (years) | 69 [54–79] | 79 [71–84] | <0.001 | 1.045 [1.031–1.059] | <0.001 |
| ED Presentation | |||||
| Triage Code | 0.562 | ||||
| 87 (5.1) | 10 (4.8) | |||
| 477 (28.0) | 51 (24.6) | |||
| 1139 (66.9) | 146 (70.5) | |||
| Associated symptoms | |||||
| Cough | 187 (11.0) | 6 (2.9) | <0.001 | 0.274 [0.118–0.638] | 0.003 |
| Vomiting | 574 (33.7) | 62 (30.0) | 0.279 | ||
| Abdominal pain | 653 (38.3) | 63 (30.4) | 0.026 | 0.796 [0.569–1.114] | 0.183 |
| Chest pain | 46 (2.7) | 3 (1.4) | 0.282 | ||
| Syncope | 170 (10.0) | 18 (8.7) | 0.557 | ||
| Gastrointestinal bleeding | 94 (5.5) | 7 (3.4) | 0.194 | ||
| Asthenia | 354 (20.8) | 32 (15.5) | 0.071 | ||
| Confusion | 100 (5.9) | 12 (5.8) | 0.965 | ||
| Anuresis | 33 (1.9) | 2 (1.0) | 0.325 | ||
| Laboratory parameters | |||||
| Hb (g/dL) | 12.3 [10.5–13.8] | 11.7 [10.3–13.2] | 0.022 | 0.988 [0.921–1.060] | 0.739 |
| WBC (cell/mm3) | 9.6 [6.3–14.2] | 12.3 [8.3–18.1] | <0.001 | 1.023 [1.008–1.038] | 0.003 |
| Creatinine (mg/dL) | 1.0 [0.8–1.6] | 1.1 [0.7–2.0] | 0.103 | ||
| Blood glucose (mg/dL) | 111.0 [97.0–140.0] | 113.0 [94.0–137.0] | 0.434 | ||
| PCT (ng/dL) | 0.18 [0.06–1.06] | 0.21 [0.08–0.78] | 0.430 | ||
| PCT > 0.5 ng/dL (%) | 587 (34.5) | 65 (31.4) | 0.379 | 0.617 [0.420–0.906] | 0.014 |
| CRP (mg/L) | 75.7 [24.8–154.1] | 116.7 [45.1–160.8] | 0.002 | 1.002 [1.000–1.004] | 0.024 |
| Clinical history | |||||
| Charlson comorbidity score | 4 [2–6] | 5 [4–6] | <0.001 | 0.960 [0.889–1.037] | 0.303 |
| Immunosuppressive therapy | 51 (3.0) | 3 (1.4) | 0.205 | ||
| IBD | 130 (7.6) | 6 (2.9) | 0.012 | 0.483 [0.189–1.231] | 0.127 |
| Ischemic cardiac disease | 157 (9.2) | 17 (8.2) | 0.635 | ||
| Heart failure | 102 (6.0) | 21 (10.1) | 0.021 | ||
| COPD | 127 (7.5) | 23 (11.1) | 0.065 | ||
| Diabetes | 208 (12.2) | 29 (14.0) | 0.459 | ||
| Chronic renal failure | 280 (16.4) | 50 (24.2) | 0.006 | ||
| Liver disease | 133 (7.8) | 12 (5.8) | 0.302 | ||
| Dementia | 120 (7.0) | 27 (13.0) | 0.002 | ||
| Cancer | 359 (21.1) | 19 (9.2) | <0.001 | ||
| Clinical outcomes | |||||
| Need for abdominal surgery | 95 (5.6) | 6 (2.9) | 0.104 | ||
| Lenght of hospitalization | 8.5 [5.5–15.0] | 11–0 [7.2–19.0] | <0.001 | ||
Table 4.
Demographic and clinical features of patients with a final diagnosis of any infection.
| Variable | Infection (Any) | Univ. p Value | Odds Ratio [95% CI] | Multiv. p Value | |
|---|---|---|---|---|---|
| NO (N 662) | YES (N 1248) | ||||
| Males | 309 (46.7%) | 584 (46.8%) | 0.961 | ||
| Median age (years) | 66 [52–78] | 72 [58–82] | <0.001 | 1.030 [1.022–1.038] | <0.001 |
| Ed Presentation | |||||
| Triage Code | 0.372 | ||||
| 32 (4.8) | 65 (5.2) | |||
| 196 (29.6) | 332 (26.6) | |||
| 434 (65.6) | 851 (68.2) | |||
| Vital signs | |||||
| Heart rate | 90 [78–105] | 90 [79–104] | 0.967 | ||
| Maximum Blood pressure (mmHg) | 120 [103–139] | 120 [103–139] | 0.837 | ||
| Fever (>37.5 °C) | 421 (63.6) | 984 (78.8) | <0.001 | ||
| Associated symptoms | |||||
| Cough | 42 (6.3) | 151 (12.1) | <0.001 | 1.888 [1.280–2.784] | 0.001 |
| Vomiting | 221 (33.4) | 415 (33.3) | 0.954 | ||
| Abdominal pain | 293 (44.3) | 423 (33.9) | <0.001 | 0.775 [0.624–0.962] | 0.021 |
| Chest pain | 22 (3.3) | 27 (2.2) | 0.127 | ||
| Syncope | 65 (9.8) | 123 (9.9) | 0.979 | ||
| Gastrointestinal bleeding | 56 (8.5) | 46 (3.6) | <0.001 | 0.539 [0.344–0.844] | 0.007 |
| Asthenia | 151 (22.8) | 235 (18.8) | 0.039 | ||
| Confusion | 36 (5.4) | 76 (6.1) | 0.563 | ||
| Anuresis | 15 (2.3) | 20 (1.6) | 0.304 | ||
| Laboratory parameters | |||||
| Hb (g/dL) | 12.2 [10.3–13.8] | 12.2 [10.5–13.7] | 0.392 | ||
| WBC (cell/mm3) | 9.5 [6.5–13.5] | 10.1 [6.6–13.5] | 0.005 | 1.006 [0.994–1.017] | 0.352 |
| Creatinine (mg/dL) | 1.0 [0.7–1.7] | 1.0 [0.8–1.6] | 0.087 | ||
| Blood glucose (mg/dL) | 111.0 [96.0–138] | 111.0 [97.0–141.0] | 0.495 | ||
| PCT (ng/dL) | 0.14 [0.05–0.47] | 0.25 [0.07–1.68] | <0.001 | ||
| PCT > 0.5 ng/dL (%) | 157 (23.7) | 495 (39.7) | <0.001 | 1.634 [1.258–2.121] | <0.001 |
| CRP (mg/L) | 50.8 [12.5–129.5] | 95.9 [38.3–171.4] | <0.001 | 1.003 [1.002–1.004] | <0.001 |
| Clinical history | |||||
| Charlson comorbidity score | 4 [2–6] | 5 [3–6] | 0.125 | 0.859 [0.819–0.902] | <0.001 |
| Immunosuppressive therapy | 18 (2.7) | 36 (2.9) | 0.835 | ||
| IBD | 99 (15.0) | 37 (3.0) | <0.001 | 0.234 [0.153–0.360] | <0.001 |
| Ischemic cardiac disease | 53 (8.0) | 121 (9.7) | 0.222 | ||
| Heart failure | 39 (5.9) | 84 (6.7) | 0.477 | ||
| COPD | 24 (3.6) | 126 (10.1) | <0.001 | ||
| Diabetes | 83 (12.5) | 154 (12.3) | 0.272 | ||
| Chronic renal failure | 107 (16.2) | 223 (17.9) | 0.348 | ||
| Liver disease | 60 (9.1) | 85 (6.8) | 0.077 | ||
| Dementia | 32 (4.8) | 115 (9.2) | 0.001 | ||
| Cancer | 192 (29.0) | 186 (14.9) | <0.001 | ||
| Clinical outcomes | |||||
| Abdominal surgery | 25 (3.8) | 76 (6.1) | 0.032 | ||
| Lenght of hospitalization | 7.5 [5.1–12.4] | 10.0 [6.0–17.0] | <0.001 | ||
Table 5.
Demographic and clinical features of patients with a final diagnosis of sepsis.
| Variable | Sepsis | Univ. p Value | Odds Ratio [95% CI] | Multiv. p Value | |
|---|---|---|---|---|---|
| NO (N 1573) | YES (N 337) | ||||
| Males | 734 (46.7%) | 159 (47.2%) | 0.863 | 1.011 [0.768–1.329] | 0.940 |
| Median age (years) | 69 [54–80] | 73 [62–81.5] | <0.001 | 1.008 [0.997–1.019] | 0.152 |
| ED presentation | |||||
| Triage Code | <0.001 | ||||
| 57 (3.6) | 40 (11.9) | |||
| 401 (25.5) | 127 (37.7) | |||
| 1115 (70.9) | 170 (50.4) | |||
| Vital signs | |||||
| Heart rate | 89 [78–104] | 94 [82.3–94] | 0.001 | ||
| Maximum Blood pressure (mmHg) | 121 [106–139] | 113 [95–136] | <0.001 | ||
| Fever (>37.5 °C) | 1152 (73.2) | 253 (75.1) | 0.487 | 0.960 [0.697–1.323] | 0.804 |
| Associated symptoms | |||||
| Cough | 178 (11.3) | 15 (4.5) | 0.001 | ||
| Vomiting | 526 (33.4) | 110 (32.6) | 0.778 | ||
| Abdominal pain | 613 (39.0) | 103 (30.6) | 0.004 | ||
| Chest pain | 42 (2.7) | 7 (2.1) | 0.532 | ||
| Syncope | 140 (8.9) | 48 (14.2) | 0.003 | ||
| Gastrointestinal bleeding | 89 (5.7) | 12 (3.6) | 0.116 | ||
| Asthenia | 314 (20.0) | 72 (21.4) | 0.560 | ||
| Confusion | 77 (4.9) | 35 (10.4) | <0.001 | ||
| Anuresis | 28 (1.8) | 7 (2.1) | 0.712 | ||
| Laboratory parameters | |||||
| Hb (g/dL) | 12.4 [10.6–13.9] | 11.2 [9.9–12.8] | <0.001 | ||
| WBC (cell/mm3) | 9.7 [6.6–14.1] | 11.1 [5.8–16.9] | <0.001 | 1.002 [0.989–1.015] | 0.759 |
| Creatinine (mg/dL) | 0.9 [0.7–1.3] | 1.4 [0.9–2.4] | 0.360 | 0.943 [0.865–1.027] | 0.179 |
| Blood glucose (mg/dL) | 111.0 [96.0–138.0] | 116.5 [96.2–148.0] | 0.090 | ||
| PCT (ng/dL) | 0.14 [0.05–0.52] | 2.6 [0.36–20.78] | <0.001 | ||
| PCT > 0.5 ng/dL (%) | 407 (25.9) | 245 (72.7) | <0.001 | 6.694 [4.869–9.202] | <0.001 |
| CRP (mg/L) | 68.4 [22.0–143.7] | 148.7 [69.2–217.4] | <0.001 | 1.002 [1.000–1.003] | 0.025 |
| Clinical history | |||||
| Charlson comorbidity score | 4 [2–6] | 5 [3–7] | <0.001 | 1.060 [0.992–1.132] | 0.087 |
| Immunosuppressive therapy | 41 (2.6) | 13 (3.9) | 0.209 | 2.069 [0.990–4.370] | 0.067 |
| IBD | 128 (8.1) | 6 (2.4) | <0.001 | 0.481 [0.212–1.090] | 0.003 |
| Ischemic cardiac disease | 136 (8.6) | 38 (11.3) | 0.128 | ||
| Heart failure | 101 (6.4) | 22 (6.5) | 0.942 | ||
| COPD | 122 (7.8) | 28 (8.3) | 0.732 | ||
| Diabetes | 190 (12.1) | 47 (13.9) | 0.345 | ||
| Chronic renal failure | 234 (14.9) | 96 (28.5) | <0.001 | ||
| Liver disease | 123 (7.8) | 22 (6.5) | 0.417 | ||
| Dementia | 122 (7.8) | 25 (7.4) | 0.833 | ||
| Cancer | 1290 (18.4) | 88 (26.) | 0.001 | ||
| Clinical outcomes | |||||
| Abdominal surgery | 384 (5.3) | 17 (5.0) | 0.826 | ||
| Lenght of hospitalization | 8.4 [5.4–14.0] | 13.5 [7.8–25.1] | <0.001 | ||
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Gallo, A.; Covino, M.; Ianua’, E.; Piccioni, A.; Della Polla, D.; Simeoni, B.; Franceschi, F.; Landi, F.; Montalto, M. The Prognostic Role of Serum Procalcitonin for Adult Patients with Acute Diarrhea in the Emergency Department. Diagnostics 2025, 15, 734. https://doi.org/10.3390/diagnostics15060734
AMA Style
Gallo A, Covino M, Ianua’ E, Piccioni A, Della Polla D, Simeoni B, Franceschi F, Landi F, Montalto M. The Prognostic Role of Serum Procalcitonin for Adult Patients with Acute Diarrhea in the Emergency Department. Diagnostics. 2025; 15(6):734. https://doi.org/10.3390/diagnostics15060734
Chicago/Turabian StyleGallo, Antonella, Marcello Covino, Eleonora Ianua’, Andrea Piccioni, Davide Della Polla, Benedetta Simeoni, Francesco Franceschi, Francesco Landi, and Massimo Montalto. 2025. "The Prognostic Role of Serum Procalcitonin for Adult Patients with Acute Diarrhea in the Emergency Department" Diagnostics 15, no. 6: 734. https://doi.org/10.3390/diagnostics15060734
APA StyleGallo, A., Covino, M., Ianua’, E., Piccioni, A., Della Polla, D., Simeoni, B., Franceschi, F., Landi, F., & Montalto, M. (2025). The Prognostic Role of Serum Procalcitonin for Adult Patients with Acute Diarrhea in the Emergency Department. Diagnostics, 15(6), 734. https://doi.org/10.3390/diagnostics15060734
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