European Journal of Trauma
Quantitative versus Semiquantitative
Procalcitonin Measurement
Experience in a Trauma Intensive Care Unit
Linda E. Pelinka1, Katharina Sendova2, Walter Mauritz2, Heinz Redl1
Abstract
Background: Procalcitonin, an excellent marker of sep-
sis, is measured in trauma intensive care units by a
standard quantitative test. Recently, a quicker semi-
quantitative test has become available. The aim of this
study was to compare both tests to determine whether
the quicker new test is as reliable as the standard test
for trauma patients.
Patients and Methods: This prospective 4-month study
included all severely traumatized patients admitted to
our intensive care unit. Parallel procalcitonin measure-
ments were performed daily, comparing the standard
LUMItestPCT® to the categorization (normal < 0.5
ng/ml, moderately increased 0.5–2 ng/ml, or highly
increased > 2 ng/ml) by the quicker PCT-Q® test (both
B.R.A.H.M.S.-Diagnostica GmbH, Henningsdorf, Ger-
many).
Results: Procalcitonin was measured in 167 samples
from 15 patients (Injury Severity Score 29 ± 13). Among
the increased procalcitonin levels (increased LUMItest-
PCT®), the PCT-Q® test picked up only 14 of 38 samples
(36.8%). Among the normal procalcitonin levels (nor-
mal LUMItestPCT®) the PCT-Q® test classified 127 of 129
samples (98.4%) the same, i.e. correctly, and two sam-
ples (1.6%) moderately increased, i.e. too high. Com-
pared to the LUMItestPCT®, the PCT-Q® test has a low
sensitivity of 44% and a high specificity of 97%.
Conclusions: The semiquantitative PCT-Q® test is high-
ly specific but far less sensitive than the LUMItestPCT®.
Normal procalcitonin readings by the PCT-Q® test are
often incorrectly low, while moderately (0.5–2 ng/ml)
1
Ludwig Boltzmann Institute for Experimental and Clinical Trauma-
tology, Vienna, Austria,
2
Department of Anesthesiology and Intensive Care Medicine, Lorenz
Boehler Trauma Center, Vienna, Austria.
Received: July 4, 2002; revision accepted: February 20, 2003
European Journal of Trauma 2003 · No. 2 © Urban & Vogel
Original Article
and highly increased (> 2 ng/ml) readings are usually
correct. Because of the rate of incorrectly low readings,
the PCT-Q® test is unreliable for trauma patients.
Key Words
Trauma intensive care · Sepsis marker · Sensitivity ·
Specificity
Eur J Trauma 2003;29:81–4
DOI 10.1007/s00068-003-1233-4
Introduction
Procalcitonin is an excellent marker of sepsis of various
origins [1–3], ranging from neonatal sepsis [4] to trans-
plant rejection [5, 6] and acute pancreatitis [7, 8] with a
high positive as well as negative predictive value in non-
leukopenic patients [9]. In the trauma intensive care set-
ting, early identification of patients who are developing
sepsis and might benefit from early intensive manage-
ment and/or surgical revision is of utmost importance.
To help accomplish this, procalcitonin has been meas-
ured routinely in our trauma intensive care unit for sev-
eral years by means of a quantitative test. Recently, a
semiquantitative test which is twice as quick as the stan-
dard quantative test has become available. The aim of
this study was to compare the quicker semiquantitative
test to the standard quantitative test in order to deter-
mine whether the quicker test is equally reliable and
thus suitable for the trauma intensive care setting.
81
Pelinka LE, et al. Quantitative vs Semiquantitative Procalcitonin Measurement
Patients and Methods
This prospective study was conducted for 4 months and
included all severely traumatized patients admitted to
the intensive care unit of our trauma center.
Prior to inclusion into the study, informed written
consent was obtained from the next of kin. The trial pro-
tocol was approved by an ethics committee in accor-
dance with the Declaration of Helsinki. Procalcitonin
was measured daily, both by the quantitative immunolu-
minometric LUMItestPCT® and by the semiquantita-
tive immunochromatographic PCT-Q® test (both
B.R.A.H.M.S.-Diagnostica GmbH, Henningsdorf, Ger-
many). According to the manufacturer, both the PCT-
Q® test and the LUMItestPCT® can measure procalci-
tonin in serum and in plasma. We performed all
procalcitonin measurements in serum according to the
instructions provided by the manufacturer. According-
ly, we used a luminometer (Lumat LB 9507, Bethold
GmbH, Bad Wildbad, Germany) for the procalcitonin
readings with the LUMItestPCT®. Procalcitonin levels
were measured by the LUMItestPCT® and compared to
the corresponding categorization (< 0.5 ng/ml, 0.5–2
ng/ml, and > 2 ng/ml) by the PCT-Q® test.
Statistics
For sensitivity (increased LUMItestPCT® and PCT-Q®
test/LumitestPCT®) and specificity (normal LUMItest-
PCT® and PCT-Q® test/LumitestPCT®), raw and simul-
taneous 95% confidence intervals were calculated from
the percentiles of 10,000 bootstrap resamples [10]. To
adjust for the different numbers of samples per patient,
the values were weighted by the reciprocal individual
sample size. The bootstrap resamples were taken by a
nested design. The values between separate patients
and in individual patients were resampled. The statisti-
cal calculations were performed with R 1.6.2.
Results
Procalcitonin was measured daily in 167 samples from 15
severely traumatized patients (Injury Severity Score 29 ±
13) for an average of 11.6 days (range 3–25 days). Among
the increased procalcitonin levels (as measured by the
LUMItestPCT®), the PCT-Q® test classified three of six
highly increased procalcitonin levels (50%) and eleven of
32 moderately increased procalcitonin levels (34.4%) the
same (> 2 ng/ml and 0.5–2 ng/ml, respectively), i.e. cor-
rectly (Figure 1). The PCT-Q® test classified all remain-
ing samples with increased procalcitonin levels (as meas-
ured by the LUMItestPCT®) too low, i.e. incorrectly.
82
100 98.4
PCT-Q ® higher than LUMItestPCT ®
PCT-Q ® same as LUMItestPCT ®
PCT-Q ® lower than LUMItestPCT ®
80
% of readings per category
65.6
60
50.0 50.0
40
34.4
20
1.6
0
Normal Moderately Highly increased
(< 0.5 ng/ml) increased (> 2 ng/ml)
(< 0.5–2 ng/ml)
Procalcitonin readings
Figure 1. Comparison of procalcitonin readings by semiquantitative
PCT-Q® test (three categories: normal < 0.5 ng/ml, moderately
increased 0.5–2 ng/ml, and highly increased > 2 ng/ml) versus quanti-
tative LUMItestPCT®. Among the samples with normal procalcitonin
readings (by LUMItestPCT®), the PCT-Q® test classified 98.4% the
same, i.e., correctly, and the remaining 1.6% too high. Among the sam-
ples with moderately increased procalcitonin readings (by LUMItest-
PCT®), the PCT-Q® test classified 34.4% the same, i.e., correctly, the
remaining 65.6% too low, and none too high. Among the samples
with highly increased procalcitonin readings (by LUMItestPCT®), the
PCT-Q® test classified 50% the same, i.e., correctly, and the remaining
50% too low.
Thus, the PCT-Q® test only picked up 14 of all 38
increased procalcitonin levels (36.8%). Among the nor-
mal procalcitonin levels (as measured by the LUMItest-
PCT®), however, the PCT-Q® test classified 127 of 129
samples (98.4%) the same (< 0.5 ng/ml), i.e., correctly,
and only two of 129 samples (1.6%) as moderately
increased (0.5–2 ng/ml), i.e. incorrectly (Figure 1). We
found that normal procalcitonin readings (< 0.5 ng/ml) by
the PCT-Q® test were often incorrectly low (falsely nor-
mal), while moderately (0.5–2 ng/ml) and highly
increased (> 2 ng/ml) readings were usually correct.
The sensitivity was low (44%), whereas the speci-
ficity was high (97%) for the PCT-Q® test compared to
the LUMItestPCT®. The PCT-Q® test only picked up
increased procalcitonin levels in 14 (increased PCT-Q®
test and increased LUMItestPCT®) of 38 samples
(Table 1a). The sensitivity of the PCT-Q® test was 44%.
The true value can be expected in the range from 6% to
72% with a probability of 95% (Table 2). The PCT-Q®
European Journal of Trauma 2003 · No. 2 © Urban & Vogel
Pelinka LE, et al. Quantitative vs Semiquantitative Procalcitonin Measurement

Tables 1a and 1b. Results by the LUMItestPCT® versus the PCT-Q® test. patients and the highly increased procalcitonin levels (>
The results counting each sample separately (a) were similar to the
2 ng/ml) found in systemic inflammatory response syn-
results weighted by the number of samples per patient (b).
drome.
a) Results counting each sample separately, LUMItestPCT® versus PCT-Q® The total number of samples measured by both tests
test (n = 167) is not identical with the total patient number
Increased Normal Total (n = 15). However, the study is focused upon the com-
LUMItestPCT® LUMItestPCT®
parison between two different tests in individual sam-
Increased PCT-Q® test 14 2 16
ples gained only from severely traumatized patients, i.e.,
Normal PCT-Q® test 24 127 151 from a comparable group. Thus, the number of samples
Total 38 129 167 measured by both tests in severely traumatized patients
is relevant, rather than the actual number of patients.
High procalcitonin levels were detected in 14 of 38 samples by the PCT-
Q® test. Normal procalcitonin levels were detected in 127 of 129 samples Since the total number of samples measured per patient
by the PCT-Q® test. varied, clustering of samples was taken into considera-
tion in the statistical analysis. At the increased procalci-
b) Results weighted by the number of samples per patient, LUMItestPCT®
versus PCT-Q® test tonin level (> 0.5 ng/ml), the total number of highly
Increased Normal Total
increased samples (> 2 ng/ml) was unfortunately very
LUMItestPCT® LUMItestPCT® small. Nevertheless, it should be pointed out that the
PCT-Q® test only picked up 36.8% of all increased pro-
Increased PCT-Q® test 1.8 0.3 2.1 calcitonin levels (50% of the highly and 34.4% of the
Normal PCT-Q® test 2.3 10.6 12.9 moderately increased procalcitonin levels). For the low
Total 4.1 10.9 15.0
procalcitonin category, it might have appeared reason-
To adjust for the different numbers of samples per patient, the values we- able to measure procalcitonin in healthy volunteers
re weighted by the reciprocal individual sample size. The results weighted using both the PCT-Q® test and the LUMItestPCT®.
by the number of samples per patient were similar to the results shown in
Table 1a, which counted each sample separately. However, we elected not to do so since the PCT-Q® test
is not sensitive enough to pick up procalcitonin in
Table 2. Sensitivity (44%) and specificity (97%) of the PCT-Q® test com- healthy volunteers.
pared to the LUMItestPCT® with raw (Raw CI) and simultaneous 95% Apart from the fact that the PCT-Q® test is semi-
confidence intervals (Sim CI). quantitative and immunochromatographic while the
LUMItestPCT® is quantitative and immunoluminomet-
Parameter Raw CI Sim CI
ric, there are principal differences between the two
Sensitivity (%) 44 8–69 6–72 tests, both with regard to cost and to handling. In theo-
Specificity (%) 97 90–100 89–100 ry, the LUMItestPCT® is roughly 25% cheaper per sin-
gle test than the PCT-Q® test. Furthermore, the
LUMItestPCT® takes twice as long to perform (1 h) as
test picked up normal procalcitonin levels in 127 (nor- the PCT-Q® test. In practice, however, the LUMItest-
mal LUMItestPCT® and normal PCT-Q® test) of 129 PCT® requires double measurements and standard
samples (Table 1a). The true value can be expected in curves as well as a luminometer. Furthermore, the
the range from 6% to 72% with a probability of 95% LUMItestPCT® requires experienced personnel since it
(Table 2). The specificity of the PCT-Q® test was 97%. is far more complicated to perform than the PCT-Q®
The true value can be expected in the range from 89% test. Thus, in practice, the LUMItestPCT® is only cheap-
to 100% with a probability of 95% (Table 2). The results er for laboratories with access to a luminometer and
weighted by the number of samples per patient (Table enough experienced personnel. Nevertheless, the PCT-
1b) were similar to the results counting each sample sep- Q® test, though quicker and very simple to perform, is
arately (Table 1a). also less accurate. We consider this lack of accuracy of
the PCT-Q® test a serious drawback in the trauma inten-
Discussion sive care unit.
The PCT-Q® test was less sensitive than the LUMItest Since the PCT-Q® test is highly specific, increased
PCT® at both the moderately increased procalcitonin procalcitonin readings can be considered reliable, i.e, it
levels (0.5–2 ng/ml) found in some multiple trauma is unlikely that the PCT-Q® test yields falsely increased

European Journal of Trauma 2003 · No. 2 © Urban & Vogel 83

Pelinka LE, et al. Quantitative vs Semiquantitative Procalcitonin Measurement
procalcitonin readings. However, normal procalci-
tonin readings should be evaluated with caution since
the PCT-Q® test is not highly sensitive. Interestingly,
we found that the PCT-Q® test, though yielding results
twice as quickly as the LUMItestPCT®, is sometimes
slower clinically, because it fails to pick up increased
procalcitonin as early as the LUMItestPCT®. Thus,
though the semiquantitative PCT-Q® test is twice as
quick as the quantitative LUMItestPCT®, we do not
consider the PCT-Q® test as suitable as the LUMItest
PCT® for acute diagnostic decisions in the trauma
intensive care unit. By contrast, a paper recently pub-
lished on clinical experiences with both tests [11] states
that the PCT-Q® test categorized 92% of the results
correctly and is thus suitable to support acute diagnos-
tic decisions. However, the clinical experience was
gathered from nontrauma patients who were suspect-
ed to have increased procalcitonin levels and were
selected randomly. Moreover, the authors used a cut-
off value of 2 ng/ml, while we differentiated between
low (< 0.5 ng/ml), increased (> 0.5–2 ng/ml), and high-
ly increased (> 2 ng/ml) procalcitonin. According to
the scale provided by the manufacturer, severe bacter-
ial infections, sepsis, and multiple organ failure show
increased procalcitonin readings > 2 ng/ml, but multi-
ple trauma readings are rarely increased over 0.5–2
ng/ml.
As pointed out previously, early detection of incipi-
ent sepsis is of utmost importance in the trauma inten-
sive care unit, in order to intensify therapy and/or initi-
ate surgical intervention as soon as possible. Valuable
time might be lost if incipient sepsis were overlooked or
underestimated due to falsely normal procalcitonin
readings.
Acknowledgments
The authors wish to thank Anna Khadem, MTA, for technical assis-
tance and are highly indebted to Heinz Petto, PhD, for valuable dis-
cussion and statistical evaluation.
84
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Correspondence Address
Linda E. Pelinka, MD
Ludwig Boltzmann Institute for
Experimental and Clinical Traumatology
Donaueschingenstraße 13
1200 Vienna
Austria
Phone (+43/1) 33110-464, Fax -460
e-mail: lindapel@via.at
European Journal of Trauma 2003 · No. 2 © Urban & Vogel