CALIBRATING THE SYSTEMIC EFFECTS OF INFECTION WITH LABORATORY INVESTIGATIONS

1. CALIBRATING THE SYSTEMIC EFFECTS OF INFECTION WITHLABORATORY INVESTIGATIONS Pakistan November 2015

2. OBJECTIVES • Greater accuracy in establishment of: • Diagnosis of infection • Duration of therapy • Safety for implantation of prostheses • Assessment and classification for clinical trials • Establish prognosis in • Medico-legal disputes

3. ANAEMIA OF CHRONIC INFECTIONPathogenesis • éRBC turnover • Iron retention in RES • êIron, é ferritin • Hypochromia, microcytosis • Anisocytosis, anisochromia, • basophilia

4. ANAEMIA OF CHRONIC INFECTIONPathogenisis • Malabsorbtion of dietary iron • êProtein (transferrin-carrier) • êRenal haemopoietin • êMarrow activity • Result – fewer smaller, paler, red blood cells

5. WHITE CELLS IN CHRONICBONE INFECTION • Most often no change • Neutrophil leucocytosis • Lymphocytosis • Thrombocytosis • Toxic granulation • Shift to left

6. PROTEIN DISTURBANCE INCHRONIC INFECTION é C-reactive protein é Sedimentation rate é Plasma viscosity é Mucoproteins Rouleaux formation ê Transferrin (iron carrier)

7. INTERPRETATION OF PROCALCITONIN (PCT) • TEST RESULTS • S-PCT (ng/ml) INTERPRETATION • < 0.5Systemic bacterial infection unlikely • 0.5 – 2 Local infection possible. Severe sepsis • or septic shock unlikely. • 2 – 10 Systemic (bacterial or fungal) infection • likely. • 10 Severe bacterial infection with systemic inflammation probable (sepsis with organ failure and possible shock). NOTE: PCT HAS A HALF-LIFE OF 24 HOURS PCT DETECTABLE WITHIN 6 HOURS OF ONSET.

8. 1191 Patients studied and followed as severity of infection eventually subsided or continued to fluctuate

9. GRADES OF INFECTION • ACUTE • Grade - • 1 Fulminating • 2 Subacute • 3 Insidious onset • 6/3 Acute on chronic • 7/3 exacerbation

10. GRADES OF INFECTION • CHRONIC • Grade - • 4 Overwhelming • 5 Inflammation • 6 Diffuse • 7 Localised • 8 Not Infected

11. GRADE 4 – OVERWHELMING Large necrotic lesions Copious pus (> 10 ml/day) Systemic toxaemia Impaired immunity Cahexia protein deficit Poor containment (scarring) Procalcitonin elevated X-Ray Bone destruction > sclerosis and callus formation

12. GRADE 5 – EXTENSIVE + INFLAMMATION Extensive lesion with oedema Cellulitis and adenopathy Possible low-grade pyrexia Lesion moderately contained Moderate purulence (> 5 ml/day) X-Ray Florid periosteal reaction

13. GRADE 6 – EXTENSIVE NOT INFLAMED Extensive lesion (whole bone) No pyrexia Area warm and indurated maybe sinus mild purulence (>2 ml/day) Lesion well contained by scar tissue X-RayMembranous periosteal reaction

14. GRADE 7 – LOCALISED LESION Local Warmth No induration Pinhole sinus at times Spot of discharge Lesion very well contained X-Ray Sclerotic border - normal bone beyond No clear periosteal reaction: fuzzy surface

15. GRADE 8 - NOT INFECTED Non infective inflammatory disease Haematoma, Aseptic loosening Tumours, Reflex Sympathetic Dystrophy

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23. SERUM FERRITIN : IRON RATIO Grade 4 53.1 5 23.8 6 14.5 7 7.1 8 5.6 27% Variation

24. RED BLOOD CORPUSCLES Grade 1 2 3 4 5 6 7 RBC ± - - ± - - HB - - ± - PCV - - ± - MCV ± - - ± - MCH ± - - ± - MCHC - - - ± - -

25. LEUCOCYTES Grade 1 2 3 4 5 6 7 WBC ± ± - - NEUT ± ± - - LYMPH - - ± - - - TOX GRAN - - ± - - L SHIFT - - ± - - PLATELETS - - ± - -

26. ABNORMALITIESOFRED CORPUSCLES Grade 1 2 3 4 5 6 7 ABNORMAL ± - - ± - - ROULEAUX ± - - - SED. RATE± ± -

27. IRON STUDIES Grade 1 2 3 4 5 6 7 IRON ± - ± TRANSFERRIN - - - - - SATURATION - - - ± TRANSFERRIN - - - - - FERRITIN ± -

28. Haemoglobin Sedimentation Serum Iron Iron Saturation Ferritin Clinical History Signs & Symptoms X-RAY

29. SLIDING SCALE OF SYSTEMIC RESPONSES TO INCREASING INTENSITY OF SEPSIS No Infection Gr. 8Grade 7Grade 6Grade 5Grade 4 é Ferritin:Iron ratio -------------------------------------------------------------------- é Ferritin ------------------------------------------------------------------ ê Serum Iron --------------------------------------------------- ê Saturation --------------------------------------------------- é CRP ----------------------------------------------------- é ESR ------------------------------------------------- ê Mean Cell Volume ----------------------------- ` ê Mean Cell Haemoglobin ------------------------- ê Hematocrit ------------------------------------- ê Haemoglobin -------------------------------------- PCT 0.5 to 2 ------ PCT above 2 --- é Leucocytes ----------------------- é Platelets --------------------------- ê Red Cell Count -------------- ê Left Shift --------------------- Toxic Granulation ----------- Abnormal Red Cells -------- ê Transferrin --- ê MCHC --------

30. LABORATORY CRITERIA Activity tests Sedimentation Rate Plasma viscosity C-Reactive protein (ESR) Neutrophil leucocytosis Red cell morphology Anaemia Iron deficiency Blood ferritin increased

31. CLINICAL CRITERIA Pyrexia Exudate Inflammation Induration Oedema Lymphadenopathy Local warmth

32. RADIOLOGICAL CRITERIA Further bone destruction Sequestrum formation Periosteal reaction Fuzzy or layered – (onion) Increasing sclerosis Reconstitution of medulla Re-trabeculation Persistent sclerosis

33. EVALUATION OF DEGREE OF INFECTION

34. POINTS AWARDED