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Póvoa P, Pitrowsky M, Guerreiro G, Pacheco MB, Salluh JIF. Biomarkers: Are They Useful in Severe Community-Acquired Pneumonia? Semin Respir Crit Care Med 2024; 45:200-206. [PMID: 38196062 DOI: 10.1055/s-0043-1777771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Community acquired pneumonia (CAP) is a prevalent infectious disease often requiring hospitalization, although its diagnosis remains challenging as there is no gold standard test. In severe CAP, clinical and radiologic criteria have poor sensitivity and specificity, and microbiologic documentation is usually delayed and obtained in less than half of sCAP patients. Biomarkers could be an alternative for diagnosis, treatment monitoring and establish resolution. Beyond the existing evidence about biomarkers as an adjunct diagnostic tool, most evidence comes from studies including CAP patients in primary care or emergency departments, and not only sCAP patients. Ideally, biomarkers used in combination with signs, symptoms, and radiological findings can improve clinical judgment to confirm or rule out CAP diagnosis, and may be valuable adjunctive tools for risk stratification, differentiate viral pneumonia and monitoring the course of CAP. While no single biomarker has emerged as an ideal one, CRP and PCT have gathered the most evidence. Overall, biomarkers offer valuable information and can enhance clinical decision-making in the management of CAP, but further research and validation are needed to establish their optimal use and clinical utility.
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Affiliation(s)
- Pedro Póvoa
- NOVA Medical School, Centre for Integrated Research in Health, New University of Lisbon, Lisbon, Portugal
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Centre for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Department of Intensive Care, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Melissa Pitrowsky
- Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
| | - Gonçalo Guerreiro
- Department of Intensive Care, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Mariana B Pacheco
- Medical School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Jorge I F Salluh
- Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
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Valenzuela-Sánchez F, Valenzuela-Méndez B, Rodríguez-Gutiérrez JF, Estella Á. Latest developments in early diagnosis and specific treatment of severe influenza infection. JOURNAL OF INTENSIVE MEDICINE 2024; 4:160-174. [PMID: 38681787 PMCID: PMC11043645 DOI: 10.1016/j.jointm.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Influenza pandemics are unpredictable recurrent events with global health, economic, and social consequences. The objective of this review is to provide an update on the latest developments in early diagnosis and specific treatment of the disease and its complications, particularly with regard to respiratory organ failure. Despite advances in treatment, the rate of mortality in the intensive care unit remains approximately 30%. Therefore, early identification of potentially severe viral pneumonia is extremely important to optimize treatment in these patients. The pathogenesis of influenza virus infection depends on viral virulence and host response. Thus, in some patients, it is associated with an excessive systemic response mediated by an authentic cytokine storm. This process leads to severe primary pneumonia and acute respiratory distress syndrome. Initial prognostication in the emergency department based on comorbidities, vital signs, and biomarkers (e.g., procalcitonin, ferritin, human leukocyte antigen-DR, mid-regional proadrenomedullin, and lactate) is important. Identification of these biomarkers on admission may facilitate clinical decision-making to determine early admission to the hospital or the intensive care unit. These decisions are reached considering pathophysiological circumstances that are associated with a poor prognosis (e.g., bacterial co-infection, hyperinflammation, immune paralysis, severe endothelial damage, organ dysfunction, and septic shock). Moreover, early implementation is important to increase treatment efficacy. Based on a limited level of evidence, all current guidelines recommend using oseltamivir in this setting. The possibility of drug resistance should also be considered. Alternative options include other antiviral drugs and combination therapies with monoclonal antibodies. Importantly, it is not recommended to use corticosteroids in the initial treatment of these patients. Furthermore, the implementation of supportive measures for respiratory failure is essential. Current recommendations are limited, heterogeneous, and not regularly updated. Early intubation and mechanical ventilation is the basic treatment for patients with severe respiratory failure. Prone ventilation should be promptly performed in patients with acute respiratory distress syndrome, while early tracheostomy should be considered in case of planned prolonged mechanical ventilation. Clinical trials on antiviral treatment and respiratory support measures specifically for these patients, as well as specific recommendations for different at-risk populations, are necessary to improve outcomes.
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Affiliation(s)
- Francisco Valenzuela-Sánchez
- Intensive Care Unit, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Haematology Department, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Centro de Investigación Biomédica en Red, Enfermedades respiratorias, CIBERES, Instituto de Salud Carlos III, Av. de Monforte de Lemos, Madrid, Spain
| | - Blanca Valenzuela-Méndez
- Department of Oncological Surgery, Institut du Cancer de Montpellier (ICM), Parc Euromédecine, 208 Av. des Apothicaires,Montpellier, France
| | | | - Ángel Estella
- Intensive Care Unit, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Department of Medicine, Faculty of Medicine, University of Cádiz, Calle Doctor Marañón, Cádiz, Spain
- Instituto de Investigación e Innovación Biomédica de Cádiz (INIBiCA), Avenida Ana de Viya 21, Cádiz, Spain
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Doubravská L, Htoutou Sedláková M, Fišerová K, Klementová O, Turek R, Langová K, Kolář M. Bacterial Community- and Hospital-Acquired Pneumonia in Patients with Critical COVID-19-A Prospective Monocentric Cohort Study. Antibiotics (Basel) 2024; 13:192. [PMID: 38391578 PMCID: PMC10886267 DOI: 10.3390/antibiotics13020192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024] Open
Abstract
The impact of bacterial pneumonia on patients with COVID-19 infection remains unclear. This prospective observational monocentric cohort study aims to determine the incidence of bacterial community- and hospital-acquired pneumonia (CAP and HAP) and its effect on mortality in critically ill COVID-19 patients admitted to the intensive care unit (ICU) at University Hospital Olomouc between 1 November 2020 and 31 December 2022. The secondary objectives of this study include identifying the bacterial etiology of CAP and HAP and exploring the capabilities of diagnostic tools, with a focus on inflammatory biomarkers. Data were collected from the electronic information hospital system, encompassing biomarkers, microbiological findings, and daily visit records, and subsequently evaluated by ICU physicians and clinical microbiologists. Out of 171 patients suffering from critical COVID-19, 46 (27%) had CAP, while 78 (46%) developed HAP. Critically ill COVID-19 patients who experienced bacterial CAP and HAP exhibited higher mortality compared to COVID-19 patients without any bacterial infection, with rates of 38% and 56% versus 11%, respectively. In CAP, the most frequent causative agents were chlamydophila and mycoplasma; Enterobacterales, which were multidrug-resistant in 71% of cases; Gram-negative non-fermenting rods; and Staphylococcus aureus. Notably, no strains of Streptococcus pneumoniae were detected, and only a single strain each of Haemophilus influenzae and Moraxella catarrhalis was isolated. The most frequent etiologic agents causing HAP were Enterobacterales and Gram-negative non-fermenting rods. Based on the presented results, commonly used biochemical markers demonstrated poor predictive and diagnostic accuracy. To confirm the diagnosis of bacterial CAP in our patient cohort, it was necessary to assess the initial values of inflammatory markers (particularly procalcitonin), consider clinical signs indicative of bacterial infection, and/or rely on positive microbiological findings. For HAP diagnostics, it was appropriate to conduct regular detailed clinical examinations (with a focus on evaluating respiratory functions) and closely monitor the dynamics of inflammatory markers (preferably Interleukin-6).
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Affiliation(s)
- Lenka Doubravská
- Department of Anaesthesiology, Resuscitation and Intensive Care, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Anaesthesiology, Resuscitation and Intensive Care, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Miroslava Htoutou Sedláková
- Department of Microbiology, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Kateřina Fišerová
- Department of Microbiology, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Olga Klementová
- Department of Anaesthesiology, Resuscitation and Intensive Care, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Anaesthesiology, Resuscitation and Intensive Care, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Radovan Turek
- Department of Anaesthesiology, Resuscitation and Intensive Care, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Kateřina Langová
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Milan Kolář
- Department of Microbiology, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
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Chen Z, Zhan Q, Huang L, Wang C. Coinfection and superinfection in ICU critically ill patients with severe COVID-19 pneumonia and influenza pneumonia: are the pictures different? Front Public Health 2023; 11:1195048. [PMID: 37711242 PMCID: PMC10497876 DOI: 10.3389/fpubh.2023.1195048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/03/2023] [Indexed: 09/16/2023] Open
Abstract
Background Similar to influenza, coinfections and superinfections are common and might result in poor prognosis. Our study aimed to compare the characteristics and risks of coinfections and superinfections in severe COVID-19 and influenza virus pneumonia. Methods The data of patients with COVID-19 and influenza admitted to the intensive care unit (ICU) were retrospectively analyzed. The primary outcome was to describe the prevalence and pathogenic distribution of coinfections/ICU-acquired superinfections in the study population. The secondary outcome was to evaluate the independent risk factors for coinfections/ICU-acquired superinfections at ICU admission. Multivariate analysis of survivors and non-survivors was performed to investigate whether coinfections/ICU-acquired superinfections was an independent prognostic factor. Results In the COVID-19 (n = 123) and influenza (n = 145) cohorts, the incidence of coinfections/ICU-acquired superinfections was 33.3%/43.9 and 35.2%/52.4%, respectively. The most common bacteria identified in coinfection cases were Enterococcus faecium, Pseudomonas aeruginosa, and Acinetobacter baumannii (COVID-19 cohort) and A. baumannii, P. aeruginosa, and Klebsiella pneumoniae (influenza cohort). A significant higher proportion of coinfection events was sustained by Aspergillus spp. [(22/123, 17.9% in COVID-19) and (18/145, 12.4% in influenza)]. The COVID-19 group had more cases of ICU-acquired A. baumannii, Corynebacterium striatum and K. pneumoniae. A. baumannii, P. aeruginosa, and K. pneumoniae were the three most prevalent pathogens in the influenza cases with ICU-acquired superinfections. Patients with APACHE II ≥18, CD8+ T cells ≤90/μL, and 50 < age ≤ 70 years were more susceptible to coinfections; while those with CD8+ T cells ≤90/μL, CRP ≥120 mg/L, IL-8 ≥ 20 pg./mL, blood glucose ≥10 mmol/L, hypertension, and smoking might had a higher risk of ICU-acquired superinfections in the COVID-19 group. ICU-acquired superinfection, corticosteroid administration for COVID-19 treatment before ICU admission, and SOFA score ≥ 7 were independent prognostic factors in patients with COVID-19. Conclusion Patients with COVID-19 or influenza had a high incidence of coinfections and ICU-acquired superinfections. The represent agents of coinfection in ICU patients were different from those in the general ward. These high-risk patients should be closely monitored and empirically treated with effective antibiotics according to the pathogen.
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Affiliation(s)
- Ziying Chen
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- State Key Laboratory of Respiratory Health and Multimorbidity, China-Japan Friendship Hospital, Beijing, China
- National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Qingyuan Zhan
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- State Key Laboratory of Respiratory Health and Multimorbidity, China-Japan Friendship Hospital, Beijing, China
- National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Linna Huang
- National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- State Key Laboratory of Respiratory Health and Multimorbidity, China-Japan Friendship Hospital, Beijing, China
- National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Chen Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- State Key Laboratory of Respiratory Health and Multimorbidity, China-Japan Friendship Hospital, Beijing, China
- National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Satjawattanavimol S, Teerapuncharoen K, Kaewlai R, Disayabutr S. Prevalence of early bacterial co-infection in hospitalized patients with COVID-19 pneumonia: a retrospective study. J Thorac Dis 2023; 15:3568-3579. [PMID: 37559639 PMCID: PMC10407494 DOI: 10.21037/jtd-22-1681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/26/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Identification of bacterial co-infection is crucial in determining outcomes of patients with coronavirus disease 2019 (COVID-19) pneumonia. The present study aims to evaluate the prevalence and associated factors of early bacterial co-infection in patients with COVID-19 pneumonia. METHODS The present study is a retrospective study. Patients with COVID-19 pneumonia, who were admitted to Siriraj Hospital between April 1 and August 31, 2021, were randomly enrolled and classified as the "Early bacterial co-infection" group, defined by an infection occurring within the first 48 hours after admission, and the "Unlikely early bacterial co-infection" group. RESULTS A total of 245 patients were enrolled. The prevalence of early bacterial co-infection was 15.5%. Chest X-rays showed characteristic findings for COVID-19 pneumonia in 37.6%. The median Brixia chest X-ray scores and C-reactive protein levels were significantly higher in the Early bacterial co-infection group. The most common causative pathogens included Staphylococcus aureus, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. Patients with early bacterial co-infection had a significantly higher all-cause mortality compared to the Unlikely early bacterial co-infection group (P=0.012). The Charlson Comorbidity Index ≥4, high level of respiratory support, and mass-liked or diffuse opacities on chest X-rays were independent factors associated with the early bacterial co-infection. CONCLUSIONS The prevalence of early bacterial co-infection in patients with COVID-19 pneumonia was low but it was associated with mortality. There is insufficient evidence to support the empirical use of antibiotics in these patients. A further prospective study is required to confirm the results of the present study.
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Affiliation(s)
- Silp Satjawattanavimol
- Division of Respiratory Disease and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Krittika Teerapuncharoen
- Division of Respiratory Disease and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rathachai Kaewlai
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supparerk Disayabutr
- Division of Respiratory Disease and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Saura O, Luyt CE. Procalcitonin as a biomarker to guide treatments for patients with lower respiratory tract infections. Expert Rev Respir Med 2023; 17:651-661. [PMID: 37639716 DOI: 10.1080/17476348.2023.2251394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Lower respiratory tract infections are amongst the main causes for hospital/intensive care unit admissions and antimicrobial prescriptions. In order to reduce antimicrobial pressure, antibiotic administration could be optimized through procalcitonin-based algorithms. AREAS COVERED In this review, we discuss the performances of procalcitonin for the diagnosis and the management of community-acquired and ventilator-associated pneumonia. We provide up-to-date evidence and deliver clear messages regarding the purpose of procalcitonin to reduce unnecessary antimicrobial exposure. EXPERT OPINION Antimicrobial pressure and resulting antimicrobial resistances are a major public health issue as well as a daily struggle in the management of patients with severe infectious diseases, especially in intensive care units where antibiotic exposure is high. Procalcitonin-guided antibiotic administration has proven its efficacy in reducing unnecessary antibiotic use in lower respiratory tract infections without excess in mortality, hospital length of stay or disease relapse. Procalcitonin-guided algorithms should be implemented in wards taking care of patients with severe infections. However, procalcitonin performances are different regarding the setting of the infection (community versus hospital-acquired infections) the antibiotic management (start or termination of antibiotic) as well as patient's condition (immunosuppressed or in shock) and we encourage the physicians to be aware of these limitations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM, UMRS_1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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Wang R, Zhang J, He M, Chen H, Xu J. Procalcitonin as a biomarker of nosocomial pneumonia in aneurysmal subarachnoid hemorrhage patients treated in neuro-ICU. Clin Neurol Neurosurg 2023; 231:107870. [PMID: 37421741 DOI: 10.1016/j.clineuro.2023.107870] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Nosocomial pneumonia commonly develops in aneurysmal subarachnoid hemorrhage (aSAH) patients and is associated with poor prognosis of these patients. This study is designed to verify the predictive value of procalcitonin (PCT) on nosocomial pneumonia in aSAH patients. METHODS 298 aSAH patients received treatments in the neuro-intensive care unit (NICU) of West China hospital were included. Logistic regression was conducted to verify the association between PCT level and nosocomial pneumonia and to construct a model for predicting pneumonia. Area under the receiver operating characteristic curve (AUC) were calculated to evaluate the accuracy of the single PCT and the constructed model. RESULTS 90 (30.2%) patients developed pneumonia during hospitalizations among included aSAH patients. Pneumonia group had higher procalcitonin level (p < 0.001) than non-pneumonia group. The mortality (p < 0.001), mRS (p < 0.001), length of ICU stay (p < 0.001), length of hospital stay (p < 0.001) were both higher or longer in pneumonia group. Multivariate logistic regression indicated WFNS (p = 0.001), acute hydrocephalus (p = 0.007), WBC (p = 0.021), PCT (p = 0.046) and C-reactive protein (CRP) (p = 0.031) were independently associated with the development of pneumonia in included patients. The AUC value of procalcitonin for predicting nosocomial pneumonia was 0.764. Composed of WFNS, acute hydrocephalus, WBC, PCT and CRP, the predictive model for pneumonia has higher AUC of 0.811. CONCLUSIONS PCT is an available and effective predictive marker of nosocomial pneumonia in aSAH patients. Composed of WFNS, acute hydrocephalus, WBC, PCT and CRP, our constructed predictive model is helpful for clinicians to evaluate the risk of nosocomial pneumonia and guide therapeutics in aSAH patients.
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Affiliation(s)
- Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jing Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Hongxu Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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The Role of Procalcitonin as an Antimicrobial Stewardship Tool in Patients Hospitalized with Seasonal Influenza. Antibiotics (Basel) 2023; 12:antibiotics12030573. [PMID: 36978440 PMCID: PMC10044820 DOI: 10.3390/antibiotics12030573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Up to 60% of the antibiotics prescribed to patients hospitalized with seasonal influenza are unnecessary. Procalcitonin (PCT) has the potential as an antimicrobial stewardship program (ASP) tool because it can differentiate between viral and bacterial etiology. We aimed to explore the role of PCT as an ASP tool in hospitalized seasonal influenza patients. Methods: We prospectively included 116 adults with seasonal influenza from two influenza seasons, 2018–2020. All data was obtained from a single clinical setting and analyzed by descriptive statistics and regression models. Results: In regression analyses, we found a positive association of PCT with 30 days mortality and the amount of antibiotics used. Influenza diagnosis was associated with less antibiotic use if the PCT value was low. Patients with a low initial PCT (<0.25 µg/L) had fewer hospital and intensive care unit (ICU) days and fewer positive chest X-rays. PCT had a negative predictive value of 94% for ICU care stay, 98% for 30 days mortality, and 88% for bacterial coinfection. Conclusion: PCT can be a safe rule-out test for bacterial coinfection. Routine PCT use in seasonal influenza patients with an uncertain clinical picture, and rapid influenza PCR testing, may be efficient as ASP tools.
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The Role of Biomarkers in Influenza and COVID-19 Community-Acquired Pneumonia in Adults. Antibiotics (Basel) 2023; 12:antibiotics12010161. [PMID: 36671362 PMCID: PMC9854478 DOI: 10.3390/antibiotics12010161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Pneumonia is a growing problem worldwide and remains an important cause of morbidity, hospitalizations, intensive care unit admission and mortality. Viruses are the causative agents in almost a fourth of cases of community-acquired pneumonia (CAP) in adults, with an important representation of influenza virus and SARS-CoV-2 pneumonia. Moreover, mixed viral and bacterial pneumonia is common and a risk factor for severity of disease. It is critical for clinicians the early identification of the pathogen causing infection to avoid inappropriate antibiotics, as well as to predict clinical outcomes. It has been extensively reported that biomarkers could be useful for these purposes. This review describe current evidence and provide recommendations about the use of biomarkers in influenza and SARS-CoV-2 pneumonia, focusing mainly on procalcitonin (PCT) and C-reactive protein (CRP). Evidence was based on a qualitative analysis of the available scientific literature (meta-analyses, randomized controlled trials, observational studies and clinical guidelines). Both PCT and CRP levels provide valuable information about the prognosis of influenza and SARS-CoV-2 pneumonia. Additionally, PCT levels, considered along with other clinical, radiological and laboratory data, are useful for early diagnosis of mixed viral and bacterial CAP, allowing the proper management of the disease and adequate antibiotics prescription. The authors propose a practical PCT algorithm for clinical decision-making to guide antibiotic initiation in cases of influenza and SARS-CoV-2 pneumonia. Further well-design studies are needed to validate PCT algorithm among these patients and to confirm whether other biomarkers are indeed useful as diagnostic or prognostic tools in viral pneumonia.
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Saura O, Chommeloux J, Levy D, Assouline B, Lefevre L, Luyt CE. Updates in the management of respiratory virus infections in ICU patients: revisiting the non-SARS-CoV-2 pathogens. Expert Rev Anti Infect Ther 2022; 20:1537-1550. [PMID: 36220790 DOI: 10.1080/14787210.2022.2134116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although viruses are an underestimated cause of community-acquired pneumonias (CAP) and hospital-acquired pneumonias (HAP)/ventilator-associated pneumonias (VAP) in intensive care unit (ICU) patients, they have an impact on morbidity and mortality. AREAS COVERED In this perspective article, we discuss the available data regarding the management of severe influenza CAP and herpesviridae HAP/VAP. We review diagnostic and therapeutic strategies in order to give clear messages and address unsolved questions. EXPERT OPINION Influenza CAP affects yearly thousands of people; however, robust data regarding antiviral treatment in the most critical forms are scarce. While efficacy of oseltamivir has been investigated in randomized controlled trials (RCT) in uncomplicated influenza, only observational data are available in ICU patients. Herpesviridae are an underestimated cause of HAP/VAP in ICU patients. Whilst incidence of herpesviridae identification in samples from lower respiratory tract of ICU patients is relatively high (from 20% to 50%), efforts should be made to differentiate local reactivation from true lung infection. Only few randomized controlled trials evaluated the efficacy of antiviral treatment in herpesviridae reactivation/infection in ICU patients and all were exploratory or negative. Further studies are needed to evaluate the impact of such treatment in specific populations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Juliette Chommeloux
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David Levy
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lucie Lefevre
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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Diagnostic Accuracy of Procalcitonin upon Emergency Department Admission during SARS-CoV-2 Pandemic. Antibiotics (Basel) 2022; 11:antibiotics11091141. [PMID: 36139922 PMCID: PMC9495046 DOI: 10.3390/antibiotics11091141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 01/08/2023] Open
Abstract
Highlights Abstract Introduction: Procalcitonin is a marker for bacterial diseases and has been used to guide antibiotic prescription. Procalcitonin accuracy, measured at admission, in patients with community-acquired pneumonia (CAP), is unknown in the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Objectives: To evaluate the diagnostic accuracy of procalcitonin to assess the need for antibiotic treatment in patients with CAP presenting to the emergency department during the SARS-CoV-2 pandemic. Methods: We performed a real-world diagnostic retrospective accuracy study of procalcitonin in patients admitted to the emergency department. Measures of diagnostic accuracy were calculated based on procalcitonin results compared to the reference standard of combined microbiological and radiological analysis. Sensitivity, specificity, positive and negative predictive values, and area under (AUC) the receiver-operating characteristic (ROC) curve were calculated in two analyses: first assessing procalcitonin ability to differentiate microbiologically proven bacteria from viral CAP and then clinically diagnosed bacterial CAP from viral CAP. Results: When using a procalcitonin threshold of 0.5 ng/mL to identify bacterial etiology within patients with CAP, we observed sensitivity and specificity of 50% and 64.1%, and 43% and 82.6%, respectively, in the two analyses. The positive and negative predictive values of a procalcitonin threshold of 0.5 ng/mL to identify patients for whom antibiotics should be advised were 46.4% and 79.7%, and 48.9% and 79% in the two analyses, respectively. The AUC for the two analyses was 0.60 (95% confidence interval [CI] 0.52–0.68) and 0.62 (95% CI, 0.55–0.69). Conclusions: Procalcitonin measured upon admission during the SARS-CoV-2 pandemic should not guide antibiotic treatment in patients with CAP.
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12
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Wrotek A, Wrotek O, Jackowska T. Low Levels of Procalcitonin Are Related to Decreased Antibiotic Use in Children Hospitalized Due to Influenza. Diagnostics (Basel) 2022; 12:diagnostics12051148. [PMID: 35626302 PMCID: PMC9140075 DOI: 10.3390/diagnostics12051148] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/23/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Procalcitonin increases in bacterial infections, which are often suspected (though rarely confirmed) in paediatric influenza. We retrospectively verified procalcitonin’s usefulness in antibiotic guidance in children hospitalized due to laboratory-confirmed influenza. The ROC curve analysis evaluated procalcitonin’s performance in terms of antibiotic implementation or continuation in patients who were naive or had been receiving antibiotic treatment prior to hospital admission. We also assessed the procalcitonin’s usefulness to predict lower-respiratory-tract infections (LRTI), the presence of radiologically confirmed pneumonia, an intensive care unit transfer and a fatal outcome. Multiple regression models were built to verify the previously reported procalcitonin cut-off values. The study enrolled 371 children (median age 33 months). The AUC (area under the curve) for antibiotic implementation reached 0.66 (95%CI: 0.58–0.73) and 0.713 (95%CI: 0.6–0.83) for antibiotic continuation; optimal cut-offs (0.4 and 0.23 ng/mL, respectively) resulted in a negative predictive value (NPV) of 79.7% (95%CI: 76.2–82.9%) and 54.6% (95%CI: 45.8–63%), respectively. The use of 0.25 ng/mL as a reference decreased the odds of antibiotic treatment by 67% (95%CI: 43–81%) and 91% (95%CI: 56–98%), respectively. Procalcitonin showed lower AUC for the prediction of LRTI and pneumonia (0.6, 95%CI: 0.53–0.66, and 0.63, 95%CI: 0.56–0.7, respectively), with a moderately high NPV in the latter case (83%, 95%CI: 79.3–86.1%). Procalcitonin use may decrease the antibiotic frequency in hospitalized influenza cases both in terms of antibiotic administration and continuation. Procalcitonin concentrations may suggest bacterial suprainfections at lower concentrations than in adults, and a focus on its rule-out value is of special interest.
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Affiliation(s)
- August Wrotek
- Department of Pediatrics, Centre of Postgraduate Medical Education, Marymoncka 99/103, 01-813 Warsaw, Poland
- Department of Pediatrics, Bielanski Hospital, Cegłowska 80, 01-809 Warsaw, Poland
- Correspondence: (A.W.); (T.J.); Tel.: +48-864-1167 (T.J.)
| | - Oliwia Wrotek
- Student Research Group at the Bielanski Hospital, 01-809 Warsaw, Poland;
| | - Teresa Jackowska
- Department of Pediatrics, Centre of Postgraduate Medical Education, Marymoncka 99/103, 01-813 Warsaw, Poland
- Department of Pediatrics, Bielanski Hospital, Cegłowska 80, 01-809 Warsaw, Poland
- Correspondence: (A.W.); (T.J.); Tel.: +48-864-1167 (T.J.)
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13
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Plasma Levels of Mid-Regional Proadrenomedullin Accurately Identify H1N1pdm09 Influenza Virus Patients with Risk of Intensive Care Admission and Mortality in the Emergency Department. J Pers Med 2022; 12:jpm12010084. [PMID: 35055399 PMCID: PMC8777718 DOI: 10.3390/jpm12010084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/24/2021] [Accepted: 12/28/2021] [Indexed: 12/19/2022] Open
Abstract
Early identification of severe viral pneumonia in influenza virus A (H1N1pdm09) patients is extremely important for prompt admission to the ICU. The objective is to evaluate the usefulness of MR-proadrenomedullin (MR-proADM) compared to C reactive protein (CRP), procalcitonin (PCT), and ferritin in the prognosis of influenza A pneumonia. This prospective, observational, multicenter study included one hundred thirteen patients with confirmed influenza virus A (H1N1pdm09) admitted to an Emergency Department and ICUs of six hospitals in Spain. Measurements and Main Results: one-hundred thirteen patients with confirmed influenza virus A (H1N1pdm09) were enrolled. Seventy-five subjects (mortality 29.3%) with severe pneumonia caused by influenza A H1N1pdm09 virus (H1N1vIPN) were compared with 38 controls (CG).The median MR-proADM levels at hospital admission were 1.2 nmol/L (IQR (0.8–2.6) vs. 0.5 nmol/L (IQR 0.2–0.9) in the CG (p = 0.01), and PCT levels were 0.43 μg/L (IQR 0.2–1.2) in the H1N1vIPN group and 0.1 μg/L (IQR 0.1–0.2) in the CG (p < 0.01). CRP levels at admission were 15.5 mg/dL(IQR 9.2–24.9) in H1N1vIPN and 8.6 mg/dL(IQR 3–17.3) in the CG (p < 0.01). Ferritin levels at admission were 558.1 ng/mL(IQR 180–1880) in H1N1vIPN and 167.7 ng/mL(IQR 34.8–292.9) in the CG (p < 0.01). A breakpoint for hospital admission of MR-proADM of 1.1 nmol/L showed a sensitivity of 55% and a specificity of 90% (AUC-ROC0.822). Non-survivors showed higher MR-proADM levels: median of 2.5 nmol/L vs. 0.9 nmol/L among survivors (p < 0.01). PCT, CRP, and ferritin levels also showed significant differences in predicting mortality. The MR-proADM AUC-ROC for mortality was 0.853 (p < 0.01). In a Cox proportional hazards model, MR-proADM levels > 1.2 nmol/L at hospital admission were significant predictive factors for ICU and 90-day mortality (HR: 1.3). Conclusions: the initial MR-proADM, ferritin, CRP, and PCT levels effectively determine adverse outcomes and risk of ICU admission and mortality in patients with influenza virus pneumonia. MR-proADM has the highest potency for survival prediction.
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14
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Abstract
Influenza infection causes severe illness in 3 to 5 million people annually, with up to an estimated 650,000 deaths per annum. As such, it represents an ongoing burden to health care systems and human health. Severe acute respiratory infection can occur, resulting in respiratory failure requiring intensive care support. Herein we discuss diagnostic approaches, including development of CLIA-waived point of care tests that allow rapid diagnosis and treatment of influenza. Bacterial and fungal coinfections in severe influenza pneumonia are associated with worse outcomes, and we summarize the approach and treatment options for diagnosis and treatment of bacterial and Aspergillus coinfection. We discuss the available drug options for the treatment of severe influenza, and treatments which are no longer supported by the evidence base. Finally, we describe the supportive management and ventilatory approach to patients with respiratory failure as a result of severe influenza in the intensive care unit.
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Affiliation(s)
- Liam S O'Driscoll
- Department of Intensive Care Medicine, St. James's University Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, St. James's University Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland.,Respiratory Medicine, Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
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15
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Pázmány P, Soós A, Hegyi P, Dohos D, Kiss S, Szakács Z, Párniczky A, Garami A, Péterfi Z, Molnár Z. Inflammatory Biomarkers Are Inaccurate Indicators of Bacterial Infection on Admission in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease-A Systematic Review and Diagnostic Accuracy Network Meta-Analysis. Front Med (Lausanne) 2021; 8:639794. [PMID: 34869399 PMCID: PMC8636902 DOI: 10.3389/fmed.2021.639794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 10/21/2021] [Indexed: 01/02/2023] Open
Abstract
Introduction: The value of inflammatory biomarkers in the diagnosis of bacterial infection induced acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is currently unclear. Our objective was to investigate the diagnostic accuracy of on-admission inflammatory biomarkers in differentiating bacterial origin in AECOPD. Methods: Systematic literature search was performed to include cross-sectional studies on AECOPD patients with microbiological culture results as gold standard, and at least one on-admission inflammatory biomarker determined from serum: C-reactive protein (CRP), procalcitonin (PCT), neutrophil/lymphocyte ratio, eosinophil percentage, CD64index; or sputum: neutrophil elastase, tumor necrosis factor alfa, interleukin-1-beta (IL-1b), interleukin-8, sputum color, as index tests. We ranked index tests by superiority indices in a network meta-analysis and also calculated pooled sensitivity and specificity. Results: Altogether, 21 eligible articles reported data on 2,608 AECOPD patients (44% bacterial). Out of the 14 index tests, sputum IL-1b showed the highest diagnostic performance with a pooled sensitivity of 74% (CI: 26–97%) and specificity of 65% (CI: 19–93%). Pooled sensitivity for CRP and PCT were: 67% (CI: 54–77%) and 54% (CI: 39–69%); specificity 62% (CI: 52–71%) and 71% (CI: 59–79%), respectively. Conclusion: Admission inflammatory biomarkers are inaccurate indicators of bacterial infection in AECOPD. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/#myprospero, identifier: 42020161301.
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Affiliation(s)
- Piroska Pázmány
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Department of General Medicine and Pulmonology, Heim Pál National Institute for Pediatrics, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Alexandra Soós
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.,János Szentágothai Research Center, University of Pécs, Pécs, Hungary.,Centre for Translational Medicine, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Dóra Dohos
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Szabolcs Kiss
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Szakács
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,János Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Andrea Párniczky
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.,Department of Gastroenterology, Heim Pál National Institute for Pediatrics, Budapest, Hungary
| | - András Garami
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Zoltán Péterfi
- Department of Internal Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Molnár
- Medical School, Institute for Translational Medicine, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.,Centre for Translational Medicine, Semmelweis University, Faculty of Medicine, Budapest, Hungary.,Department of Anesthesiology and Intensive Therapy, Medical Faculty, Poznan University for Medical Sciences, Poznan, Poland.,Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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16
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Xu HG, Tian M, Pan SY. Clinical utility of procalcitonin and its association with pathogenic microorganisms. Crit Rev Clin Lab Sci 2021; 59:93-111. [PMID: 34663176 DOI: 10.1080/10408363.2021.1988047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In this review, we summarize the relationship of PCT with pathogens, evaluate the clinical utility of PCT in the diagnosis of clinical diseases, condition monitoring and evaluation, and guiding medical decision-making, and explore current knowledge on the mechanisms by which pathogens cause changes in PCT levels. The lipopolysaccharides of the microorganisms stimulate cytokine production in host cells, which in turn stimulates production of serum PCT. Pathogens have different virulence mechanisms that lead to variable host inflammatory responses, and differences in the specific signal transduction pathways result in variable serum PCT concentrations. The mechanisms of signal transduction have not been fully elucidated. Further studies are necessary to ascertain the PCT fluctuation range of each pathogen. PCT levels are helpful in distinguishing between certain pathogens, in deciding if antibiotics are indicated, and in monitoring response to antibiotics.
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Affiliation(s)
- Hua-Guo Xu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Meng Tian
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shi-Yang Pan
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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17
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Duan S, Gu X, Fan G, Zhou F, Zhu G, Cao B. C-reactive protein or procalcitonin combined with rhinorrhea for discrimination of viral from bacterial infections in hospitalized adults in non-intensive care units with lower respiratory tract infections. BMC Pulm Med 2021; 21:308. [PMID: 34583675 PMCID: PMC8478003 DOI: 10.1186/s12890-021-01672-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Whether procalcitonin (PCT) or C-reactive protein (CRP) combined with certain clinical characteristics can better distinguish viral from bacterial infections remains unclear. The aim of the study was to assess the ability of PCT or CRP combined with clinical characteristics to distinguish between viral and bacterial infections in hospitalized non-intensive care unit (ICU) adults with lower respiratory tract infection (LRTI). METHODS This was a post-hoc analysis of a randomized clinical trial previously conducted among LRTI patients. The ability of PCT, CRP and PCT or CRP combined with clinical symptoms to discriminate between viral and bacterial infection were assessed by portraying receiver operating characteristic (ROC) curves among patients with only a viral or a typical bacterial infection. RESULTS In total, 209 infected patients (viral 69%, bacterial 31%) were included in the study. When using CRP or PCT to discriminate between viral and bacterial LRTI, the optimal cut-off points were 22 mg/L and 0.18 ng/mL, respectively. When the optimal cut-off for CRP (≤ 22 mg/L) or PCT (≤ 0.18 ng/mL) combined with rhinorrhea was used to discriminate viral from bacterial LRTI, the AUCs were 0.81 (95% CI: 0.75-0.87) and 0.80 (95% CI: 0.74-0.86), which was statistically significantly better than when CRP or PCT used alone (p < 0.001). When CRP ≤ 22 mg/L, PCT ≤ 0.18 ng/mL and rhinorrhea were combined, the AUC was 0.86 (95% CI: 0.80-0.91), which was statistically significantly higher than when CRP (≤ 22 mg/L) or PCT (≤ 0.18 ng/mL) was combined with rhinorrhea (p = 0.011 and p = 0.021). CONCLUSIONS Either CRP ≤ 22 mg/L or PCT ≤ 0.18 ng/mL combined with rhinorrhea could help distinguish viral from bacterial infections in hospitalized non-ICU adults with LRTI. When rhinorrhea was combined together, discrimination ability was further improved.
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Affiliation(s)
- Shengchen Duan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoying Gu
- Department of Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
- National Clinical Research Center of Respiratory Diseases, Beijing, China
| | - Guohui Fan
- Department of Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
- National Clinical Research Center of Respiratory Diseases, Beijing, China
| | - Fei Zhou
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Guangfa Zhu
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bin Cao
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China.
- National Clinical Research Center of Respiratory Diseases, Beijing, China.
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Beijing, China.
- Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.
- Tsinghua University-Peking University Joint Center for Life Sciences, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
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18
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Voiriot G, Fartoukh M, Durand-Zaleski I, Berard L, Rousseau A, Armand-Lefevre L, Verdet C, Argaud L, Klouche K, Megarbane B, Patrier J, Richard JC, Reignier J, Schwebel C, Souweine B, Tandjaoui-Lambiotte Y, Simon T, Timsit JF. Combined use of a broad-panel respiratory multiplex PCR and procalcitonin to reduce duration of antibiotics exposure in patients with severe community-acquired pneumonia (MULTI-CAP): a multicentre, parallel-group, open-label, individual randomised trial conducted in French intensive care units. BMJ Open 2021; 11:e048187. [PMID: 34408046 PMCID: PMC8375718 DOI: 10.1136/bmjopen-2020-048187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION At the time of the worrying emergence and spread of bacterial resistance, reducing the selection pressure by reducing the exposure to antibiotics in patients with community-acquired pneumonia (CAP) is a public health issue. In this context, the combined use of molecular tests and biomarkers for guiding antibiotics discontinuation is attractive. Therefore, we have designed a trial comparing an integrated approach of diagnosis and treatment of severe CAP to usual care. METHODS AND ANALYSIS The multiplex PCR and procalcitonin to reduce duration of antibiotics exposure in patients with severe-CAP (MULTI-CAP) trial is a multicentre (n=20), parallel-group, superiority, open-label, randomised trial. Patients are included if adult admitted to intensive care unit for a CAP. Diagnosis of pneumonia is based on clinical criteria and a newly appeared parenchymal infiltrate. Immunocompromised patients are excluded. Subjects are randomised (1:1 ratio) to either the intervention arm (experimental strategy) or the control arm (usual strategy). In the intervention arm, the microbiological diagnosis combines a respiratory multiplex PCR (mPCR) and conventional microbiological investigations. An algorithm of early antibiotic de-escalation or discontinuation is recommended, based on mPCR results and the procalcitonin value. In the control arm, only conventional microbiological investigations are performed and antibiotics de-escalation remains at the clinician's discretion. The primary endpoint is the number of days alive without any antibiotic from the randomisation to day 28. Based on our hypothesis of 2 days gain in the intervention arm, we aim to enrol a total of 450 patients over a 30-month period. ETHICS AND DISSEMINATION The MULTI-CAP trial is conducted according to the principles of the Declaration of Helsinki, is registered in Clinical Trials and has been approved by the Committee for Protection of Persons and the National French Drug Safety Agency. Written informed consents are obtained from all the patients (or representatives). The results will be disseminated through educational institutions, submitted to peer-reviewed journals for publication and presented at medical congresses. TRIAL REGISTRATION NUMBER NCT03452826; Pre-results.
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Affiliation(s)
- Guillaume Voiriot
- Service de Médecine Intensive Réanimation, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Muriel Fartoukh
- Service de Médecine Intensive Réanimation, Assistance Publique-Hopitaux de Paris, Paris, France
| | | | - Laurence Berard
- Unité de Recherche Clinique de l'Est Parisien, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Alexandra Rousseau
- Unité de Recherche Clinique de l'Est Parisien, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Laurence Armand-Lefevre
- Département de Microbiologie, Hôpital Bichat, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Charlotte Verdet
- Département de Microbiologie, Hôpital Saint-Antoine, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Laurent Argaud
- Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Université de Lyon, Lyon, France
| | - Kada Klouche
- Intensive Care Medicine Department, Universite de Montpellier, Montpellier, France
| | - Bruno Megarbane
- Service de Médecine Intensive Réanimation, Hôpital Lariboisière, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Juliette Patrier
- Service de Réanimation Infectieuse, Hôpital Bichat, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive Réanimation, Hôpital de la Croix-Rousse, Université de Lyon, Lyon, France
| | - Jean Reignier
- Médecine intensive réanimation, CHU Nantes, Nantes, Pays de la Loire, France
| | - Carole Schwebel
- Service de Médecine Intensive Réanimation, CHU Grenoble Alpes, Grenoble, Auvergne-Rhone-Alpes, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, CHU Gabriel-Montpied, Clermont-Ferrand, France
| | - Yacine Tandjaoui-Lambiotte
- Service de Réanimation médico-chirurgicale, Hôpital Avicennes, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Tabassome Simon
- Clinical Research Platform (URC-CRB-CRC), Assistance Publique-Hôpitaux de Paris, Saint Antoine Hospital, Paris, France
- Clinical Pharmacology-Research Platform, Université Pierre et Marie Curie, Paris, France
| | - Jean-François Timsit
- Service de Réanimation Infectieuse, Hôpital Bichat, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
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19
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Garay OU, Guiñazú G, Cornistein W, Farina J, Valentini R, Levy Hara G. Budget impact analysis of using procalcitonin to optimize antimicrobial treatment for patients with suspected sepsis in the intensive care unit and hospitalized lower respiratory tract infections in Argentina. PLoS One 2021; 16:e0250711. [PMID: 33930050 PMCID: PMC8087000 DOI: 10.1371/journal.pone.0250711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic use represents a major global threat. Sepsis and bacterial lower respiratory tract infections (LRTIs) have been linked to antimicrobial resistance, carrying important consequences for patients and health systems. Procalcitonin-guided algorithms may represent helpful tools to reduce antibiotic overuse but the financial burden is unclear. The aim of this study was to estimate the healthcare and budget impact in Argentina of using procalcitonin-guided algorithms to guide antibiotic prescription. METHODS A decision tree was used to model health and cost outcomes for the Argentinean health system, over a one-year duration. Patients with suspected sepsis in the intensive care unit and hospitalized patients with LRTI were included. Model parameters were obtained from a focused, non-systematic, local and international bibliographic search, and validated by a panel of local experts. Deterministic and probabilistic sensitivity analyses were performed to analyze the uncertainty of parameters. RESULTS The model predicted that using procalcitonin-guided algorithms would result in 734.5 [95% confidence interval (CI): 1,105.2;438.8] thousand fewer antibiotic treatment days, 7.9 [95% CI: 18.5;8.5] thousand antibiotic-resistant cases avoided, and 5.1 [95% CI: 6.7;4.2] thousand fewer Clostridioides difficile cases. In total, this would save $422.4 US dollars (USD) [95% CI: $935;$267] per patient per year, meaning cost savings of $83.0 [95% CI: $183.6;$57.7] million USD for the entire health system and $0.4 [95% CI: $0.9;$0.3] million USD for a healthcare provider with 1,000 cases per year of sepsis and LRTI patients. The sensitivity analysis showed that the probability of cost-saving for the sepsis patient group was lower than for the LRTI patient group (85% vs. 100%). CONCLUSIONS Healthcare and financial benefits can be obtained by implementing procalcitonin-guided algorithms in Argentina. Although we found results to be robust on an aggregate level, some caution must be used when focusing only on sepsis patients in the intensive care unit.
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Affiliation(s)
- Osvaldo Ulises Garay
- Market Access and Medical Affairs, Roche Diagnostics, Buenos Aires, Argentina
- * E-mail:
| | - Gonzalo Guiñazú
- Ricardo Gutiérrez Children’s Hospital, Buenos Aires, Argentina
| | | | - Javier Farina
- Hospital Cuenca Alta Néstor Kirchner, Buenos Aires, Argentina
| | | | - Gabriel Levy Hara
- Unit of Infectious Diseases, Hospital Carlos G Durand, Buenos Aires, Argentina
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20
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Mason CY, Kanitkar T, Richardson CJ, Lanzman M, Stone Z, Mahungu T, Mack D, Wey EQ, Lamb L, Balakrishnan I, Pollara G. Exclusion of bacterial co-infection in COVID-19 using baseline inflammatory markers and their response to antibiotics. J Antimicrob Chemother 2021; 76:1323-1331. [PMID: 33463683 PMCID: PMC7928909 DOI: 10.1093/jac/dkaa563] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/22/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND COVID-19 is infrequently complicated by bacterial co-infection, but antibiotic prescriptions are common. We used community-acquired pneumonia (CAP) as a benchmark to define the processes that occur in bacterial pulmonary infections, testing the hypothesis that baseline inflammatory markers and their response to antibiotic therapy could distinguish bacterial co-infection from COVID-19. METHODS Retrospective cohort study of CAP (lobar consolidation on chest radiograph) and COVID-19 (PCR detection of SARS-CoV-2) patients admitted to Royal Free Hospital (RFH) and Barnet Hospital (BH), serving as independent discovery and validation cohorts. All CAP and >90% COVID-19 patients received antibiotics on hospital admission. RESULTS We identified 106 CAP and 619 COVID-19 patients at RFH. Compared with COVID-19, CAP was characterized by elevated baseline white cell count (WCC) [median 12.48 (IQR 8.2-15.3) versus 6.78 (IQR 5.2-9.5) ×106 cells/mL, P < 0.0001], C-reactive protein (CRP) [median 133.5 (IQR 65-221) versus 86.0 (IQR 42-160) mg/L, P < 0.0001], and greater reduction in CRP 48-72 h into admission [median ΔCRP -33 (IQR -112 to +3.5) versus +14 (IQR -15.5 to +70.5) mg/L, P < 0.0001]. These observations were recapitulated in the independent validation cohort at BH (169 CAP and 181 COVID-19 patients). A multivariate logistic regression model incorporating WCC and ΔCRP discriminated CAP from COVID-19 with AUC 0.88 (95% CI 0.83-0.94). Baseline WCC >8.2 × 106 cells/mL or falling CRP identified 94% of CAP cases, and excluded bacterial co-infection in 46% of COVID-19 patients. CONCLUSIONS We propose that in COVID-19, absence of both elevated baseline WCC and antibiotic-related decrease in CRP can exclude bacterial co-infection and facilitate antibiotic stewardship efforts.
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Affiliation(s)
- Claire Y Mason
- Department of Infection, Royal Free London NHS Trust, London, UK
| | - Tanmay Kanitkar
- Department of Infection, Royal Free London NHS Trust, London, UK
| | | | - Marisa Lanzman
- Department of Pharmacy, Royal Free London NHS Trust, London, UK
| | - Zak Stone
- Department of Pharmacy, Royal Free London NHS Trust, London, UK
| | - Tabitha Mahungu
- Department of Infection, Royal Free London NHS Trust, London, UK
| | - Damien Mack
- Department of Infection, Royal Free London NHS Trust, London, UK
| | - Emmanuel Q Wey
- Department of Infection, Royal Free London NHS Trust, London, UK
- Division of Infection & Immunity, University College London, London, UK
| | - Lucy Lamb
- Department of Infection, Royal Free London NHS Trust, London, UK
- Academic Department of Defence Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - Gabriele Pollara
- Department of Infection, Royal Free London NHS Trust, London, UK
- Division of Infection & Immunity, University College London, London, UK
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21
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Bourgoin P, Soliveres T, Barbaresi A, Loundou A, Belkacem IA, Arnoux I, Bernot D, Loosveld M, Morange PE, Michelet P, Malergue F, Markarian T. CD169 and CD64 could help differentiate bacterial from CoVID-19 or other viral infections in the Emergency Department. Cytometry A 2021; 99:435-445. [PMID: 33491921 PMCID: PMC8014466 DOI: 10.1002/cyto.a.24314] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 01/16/2023]
Abstract
The identification of a bacterial, viral, or even noninfectious cause is essential in the management of febrile syndrome in the emergency department (ED), especially in epidemic contexts such as flu or CoVID-19. The aim was to assess discriminative performances of two biomarkers, CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), using a new flow cytometry procedure, in patients presenting with fever to the ED during epidemics. Eighty five adult patients presenting with potential infection were included during the 2019 flu season in the ED of La Timone Hospital. They were divided into four diagnostic outcomes according to their clinical records: no-infection, bacterial infection, viral infection and co-infection. Seventy six patients with confirmed SARS-CoV-2 infection were also compared to 48 healthy volunteers. For the first cohort, 38 (45%) patients were diagnosed with bacterial infections, 11 (13%) with viral infections and 29 (34%) with co-infections. mCD169 was elevated in patients with viral infections, with a majority of Flu A virus or Respiratory Syncytial Virus, while nCD64 was elevated in subjects with bacterial infections, with a majority of Streptococcus pneumoniae and Escherichia coli. nCD64 and mCD169 showed 90% and 80% sensitivity, and 78% and 91% specificity, respectively, for identifying patients with bacterial or viral infections. When studied in a second cohort, mCD169 was elevated in 95% of patients with SARS-CoV-2 infections and remained at normal level in 100% of healthy volunteers. nCD64 and mCD169 have potential for accurately distinguishing bacterial and acute viral infections. Combined in an easy and rapid flow cytometry procedure, they constitute a potential improvement for infection management in the ED, and could even help for triage of patients during emerging epidemics.
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Affiliation(s)
- Pénélope Bourgoin
- Department of Research and Development, Beckman Coulter Life Sciences-Immunotech, Marseille, France.,Aix Marseille University, INSERM, INRAE, Marseille, France
| | - Thomas Soliveres
- Department of Emergency Medicine and Intensive Care, Timone University Hospital, APHM, Marseille, France
| | - Alexandra Barbaresi
- Department of Emergency Medicine and Intensive Care, Timone University Hospital, APHM, Marseille, France
| | - Anderson Loundou
- Department of Public Health, EA3279 Self-Perceived Health Assessment Research Unit, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Inès Ait Belkacem
- Department of Research and Development, Beckman Coulter Life Sciences-Immunotech, Marseille, France.,UMR 7280, Marseille-Luminy Immunology Center (CIML), Marseille, France
| | - Isabelle Arnoux
- Department of Hematology Laboratory, Timone University Hospital, APHM, Marseille, France
| | - Denis Bernot
- Department of Hematology Laboratory, Timone University Hospital, APHM, Marseille, France
| | - Marie Loosveld
- Department of Hematology Laboratory, Timone University Hospital, APHM, Marseille, France
| | - Pierre-Emmanuel Morange
- Aix Marseille University, INSERM, INRAE, Marseille, France.,Department of Hematology Laboratory, Timone University Hospital, APHM, Marseille, France
| | - Pierre Michelet
- Aix Marseille University, INSERM, INRAE, Marseille, France.,Department of Emergency Medicine and Intensive Care, Timone University Hospital, APHM, Marseille, France
| | - Fabrice Malergue
- Department of Research and Development, Beckman Coulter Life Sciences-Immunotech, Marseille, France
| | - Thibaut Markarian
- Aix Marseille University, INSERM, INRAE, Marseille, France.,Department of Emergency Medicine and Intensive Care, Timone University Hospital, APHM, Marseille, France
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22
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Kamat IS, Ramachandran V, Eswaran H, Guffey D, Musher DM. Procalcitonin to Distinguish Viral From Bacterial Pneumonia: A Systematic Review and Meta-analysis. Clin Infect Dis 2021; 70:538-542. [PMID: 31241140 DOI: 10.1093/cid/ciz545] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/23/2019] [Indexed: 12/21/2022] Open
Abstract
Because of the diverse etiologies of community-acquired pneumonia (CAP) and the limitations of current diagnostic modalities, serum procalcitonin levels have been proposed as a novel tool to guide antibiotic therapy. Outcome data from procalcitonin-guided therapy trials have shown similar mortality, but the essential question is whether the sensitivity and specificity of procalcitonin levels enable the practitioner to distinguish bacterial pneumonia, which requires antibiotic therapy, from viral pneumonia, which does not. In this meta-analysis of 12 studies in 2408 patients with CAP that included etiologic diagnoses and sufficient data to enable analysis, the sensitivity and specificity of serum procalcitonin were 0.55 (95% confidence interval [CI], .37-.71; I2 = 95.5%) and 0.76 (95% CI, .62-.86; I2 = 94.1%), respectively. Thus, a procalcitonin level is unlikely to provide reliable evidence either to mandate administration of antibiotics or to enable withholding such treatment in patients with CAP.
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Affiliation(s)
- Ishan S Kamat
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Harish Eswaran
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Daniel M Musher
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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23
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Bacterial and viral co-infections in patients with severe SARS-CoV-2 pneumonia admitted to a French ICU. Ann Intensive Care 2020; 10:119. [PMID: 32894364 PMCID: PMC7475952 DOI: 10.1186/s13613-020-00736-x] [Citation(s) in RCA: 186] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background Data on the prevalence of bacterial and viral co-infections among patients admitted to the ICU for acute respiratory failure related to SARS-CoV-2 pneumonia are lacking. We aimed to assess the rate of bacterial and viral co-infections, as well as to report the most common micro-organisms involved in patients admitted to the ICU for severe SARS-CoV-2 pneumonia. Patients and methods In this monocenter retrospective study, we reviewed all the respiratory microbiological investigations performed within the first 48 h of ICU admission of COVID-19 patients (RT-PCR positive for SARS-CoV-2) admitted for acute respiratory failure. Results From March 13th to April 16th 2020, a total of 92 adult patients (median age: 61 years, 1st–3rd quartiles [55–70]; males: n = 73/92, 79%; baseline SOFA: 4 [3–7] and SAPS II: 31 [21–40]; invasive mechanical ventilation: n = 83/92, 90%; ICU mortality: n = 45/92, 49%) were admitted to our 40-bed ICU for acute respiratory failure due to SARS-CoV-2 pneumonia. Among them, 26 (28%) were considered as co-infected with a pathogenic bacterium at ICU admission with no co-infection related to atypical bacteria or viruses. The distribution of the 32 bacteria isolated from culture and/or respiratory PCRs was as follows: methicillin-sensitive Staphylococcus aureus (n = 10/32, 31%), Haemophilus influenzae (n = 7/32, 22%), Streptococcus pneumoniae (n = 6/32, 19%), Enterobacteriaceae (n = 5/32, 16%), Pseudomonas aeruginosa (n = 2/32, 6%), Moraxella catarrhalis (n = 1/32, 3%) and Acinetobacter baumannii (n = 1/32, 3%). Among the 24 pathogenic bacteria isolated from culture, 2 (8%) and 5 (21%) were resistant to 3rd generation cephalosporin and to amoxicillin–clavulanate combination, respectively. Conclusions We report on a 28% rate of bacterial co-infection at ICU admission of patients with severe SARSCoV-2 pneumonia, mostly related to Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Enterobacteriaceae. In French patients with confirmed severe SARSCoV-2 pneumonia requiring ICU admission, our results encourage the systematic administration of an empiric antibiotic monotherapy with a 3rd generation cephalosporin, with a prompt de-escalation as soon as possible. Further larger studies are needed to assess the real prevalence and the predictors of co-infection together with its prognostic impact on critically ill patients with severe SARS-CoV-2 pneumonia.
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24
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Gautam S, Cohen AJ, Stahl Y, Valda Toro P, Young GM, Datta R, Yan X, Ristic NT, Bermejo SD, Sharma L, Restrepo MI, Dela Cruz CS. Severe respiratory viral infection induces procalcitonin in the absence of bacterial pneumonia. Thorax 2020; 75:974-981. [PMID: 32826284 DOI: 10.1136/thoraxjnl-2020-214896] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Procalcitonin expression is thought to be stimulated by bacteria and suppressed by viruses via interferon signalling. Consequently, during respiratory viral illness, clinicians often interpret elevated procalcitonin as evidence of bacterial coinfection, prompting antibiotic administration. We sought to evaluate the validity of this practice and the underlying assumption that viral infection inhibits procalcitonin synthesis. METHODS We conducted a retrospective cohort study of patients hospitalised with pure viral infection (n=2075) versus bacterial coinfection (n=179). The ability of procalcitonin to distinguish these groups was assessed. In addition, procalcitonin and interferon gene expression were evaluated in murine and cellular models of influenza infection. RESULTS Patients with bacterial coinfection had higher procalcitonin than those with pure viral infection, but also more severe disease and higher mortality (p<0.001). After matching for severity, the specificity of procalcitonin for bacterial coinfection dropped substantially, from 72% to 61%. In fact, receiver operating characteristic curve analysis showed that procalcitonin was a better indicator of multiple indices of severity (eg, organ failures and mortality) than of coinfection. Accordingly, patients with severe viral infection had elevated procalcitonin. In murine and cellular models of influenza infection, procalcitonin was also elevated despite bacteriologic sterility and correlated with markers of severity. Interferon signalling did not abrogate procalcitonin synthesis. DISCUSSION These studies reveal that procalcitonin rises during pure viral infection in proportion to disease severity and is not suppressed by interferon signalling, in contrast to prior models of procalcitonin regulation. Applied clinically, our data suggest that procalcitonin represents a better indicator of disease severity than bacterial coinfection during viral respiratory infection.
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Affiliation(s)
- Samir Gautam
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Avi J Cohen
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Yannick Stahl
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Patricia Valda Toro
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grant M Young
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rupak Datta
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xiting Yan
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nicholas T Ristic
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Santos D Bermejo
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lokesh Sharma
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marcos I Restrepo
- Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health, San Antonio, Texas, USA.,Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Charles S Dela Cruz
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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25
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Bourgoin P, Lediagon G, Arnoux I, Bernot D, Morange PE, Michelet P, Malergue F, Markarian T. Flow cytometry evaluation of infection-related biomarkers in febrile subjects in the emergency department. Future Microbiol 2020; 15:189-201. [PMID: 32065550 DOI: 10.2217/fmb-2019-0256] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: In an Emergency Department (ED), the etiological identification of infected subjects is essential. 13 infection-related biomarkers were assessed using a new flow cytometry procedure. Materials & methods: If subjects presented with febrile symptoms at the ED, 13 biomarkers' levels, including CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), were tested and compared with clinical records. Results: Among 50 subjects, 78% had bacterial infections and 8% had viral infections. nCD64 showed 82% sensitivity and 91% specificity for identifying subjects with bacterial infections. mCD169, HLA-ABC ratio and HLA-DR on monocytes had high values in subjects with viral infections. Conclusion: Biomarkers showed promising performances to improve the ED's infectious stratification.
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Affiliation(s)
- Pénélope Bourgoin
- Department of Research & Development, Beckman Coulter Life Sciences-Immunotech, 130 Avenue de Lattre de Tassigny, 13009 Marseille, France.,C2VN INSERM-INRA, Aix-Marseille University, 27 Boulevard Jean Moulin, 13385 Marseille, France
| | - Guillaume Lediagon
- Adult Emergency Unit, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Isabelle Arnoux
- Hematology Laboratory, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Denis Bernot
- Hematology Laboratory, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Pierre-Emmanuel Morange
- C2VN INSERM-INRA, Aix-Marseille University, 27 Boulevard Jean Moulin, 13385 Marseille, France.,Hematology Laboratory, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Pierre Michelet
- Adult Emergency Unit, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Fabrice Malergue
- Department of Research & Development, Beckman Coulter Life Sciences-Immunotech, 130 Avenue de Lattre de Tassigny, 13009 Marseille, France
| | - Thibaut Markarian
- Adult Emergency Unit, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
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26
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Gregoriano C, Heilmann E, Molitor A, Schuetz P. Role of procalcitonin use in the management of sepsis. J Thorac Dis 2020; 12:S5-S15. [PMID: 32148921 DOI: 10.21037/jtd.2019.11.63] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Important aspects of sepsis management include early diagnosis as well as timely and specific treatment in the first few hours of triage. However, diagnosis and differentiation from non-infectious causes often cause uncertainties and potential time delays. Correct use of antibiotics still represents a major challenge, leading to increased risk for opportunistic infections, resistances to multiple antimicrobial agents and toxic side effects, which in turn increase mortality and healthcare costs. Optimized procedures for reliable diagnosis and management of antibiotic therapy has great potential to improve patient care. Herein, biomarkers have been shown to improve infection diagnosis, help in early risk stratification and provide prognostic information which helps optimizing therapeutic decisions ("antibiotic stewardship"). In this context, the use of the blood infection marker procalcitonin (PCT) has gained much attention. There is still no gold standard for the detection of sepsis and use of conventional diagnostic approaches are restricted by some limitations. Therefore, additional tests are necessary to enable early and reliable diagnosis. PCT has good discriminatory properties to differentiate between bacterial and viral inflammations with rapidly available results. Further, PCT adds to risk stratification and prognostication, which may influence appropriate use of health-care resources and therapeutic options. PCT kinetics over time also improves the monitoring of critically ill patients with sepsis and thus influences decisions regarding de-escalation of antibiotics. Most importantly, PCT helps in guiding antibiotic use in patients with respiratory infection and sepsis by limiting initiation and by shortening treatment duration. To date, PCT is the best studied biomarker regarding antibiotic stewardship. Still, further research is needed to understand optimal use of PCT, also in combination with other remerging diagnostic tests for most efficient sepsis care.
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Affiliation(s)
- Claudia Gregoriano
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Eva Heilmann
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Alexandra Molitor
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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27
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Torres A, Loeches IM, Sligl W, Lee N. Severe flu management: a point of view. Intensive Care Med 2020; 46:153-162. [PMID: 31912206 PMCID: PMC7095473 DOI: 10.1007/s00134-019-05868-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022]
Abstract
Annual flu seasons are typically characterized by changes in types and subtypes of influenza, with variations in terms of severity. Despite remarkable improvements in the prevention and management of patients with suspected or laboratory-confirmed diagnosis of influenza, annual seasonal influenza continues to be associated with a high morbidity and mortality. Admission to the intensive care unit is required for patients with severe forms of seasonal influenza infection, with primary pneumonia being present in most of the cases. This review summarizes the most recent knowledge on the diagnosis and treatment strategies in critically ill patients with influenza, focused on diagnostic testing methods, antiviral therapy, use of corticosteroids, antibacterial and antifungal therapy, and supportive measures. The review focuses on diagnostic testing methods, antiviral therapy, use of corticosteroids, antibacterial and antifungal therapy, supportive measures and relevant existing evidence, in order to provide the non-expert clinician a useful overview. An enhanced understanding of current diagnostic and treatment aspects of influenza infection can contribute to improve outcomes and reduce mortality among ICU patients with influenza.
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Affiliation(s)
- Antoni Torres
- Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), C/Villarroel 170, 08036, Barcelona, Spain.
| | - Ignacio-Martin- Loeches
- Service of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red, Enfermedades Respiratorias (CIBERES), C/Villarroel 170, 08036, Barcelona, Spain.,Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - Wendy Sligl
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Nelson Lee
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
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28
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Bourgoin P, Soliveres T, Ahriz D, Arnoux I, Meisel C, Unterwalder N, Morange PE, Michelet P, Malergue F, Markarian T. Clinical research assessment by flow cytometry of biomarkers for infectious stratification in an Emergency Department. Biomark Med 2019; 13:1373-1386. [PMID: 31617736 DOI: 10.2217/bmm-2019-0214] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aim: Management of patients with infections within the Emergency Department (ED) is challenging for practitioners, as the identification of infectious causes remains difficult with current techniques. A new combination of two biomarkers was tested with a new rapid flow cytometry technique. Materials & methods: Subjects from the ED were tested for their CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169) levels and results were compared to their clinical records. Results: Among 139 patients, 29% had confirmed bacterial infections and 5% viral infections. nCD64 and mCD169 respectively showed 88 and 86% sensitivity and 90 and 100% specificity for identifying subjects in bacterial or viral conditions. Conclusion: This point-of-care technique could allow better management of patients in the ED.
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Affiliation(s)
- Pénélope Bourgoin
- Department of Research & Development, Beckman Coulter Life Sciences-Immunotech, 130 Avenue de Lattre de Tassigny, 13009 Marseille, France.,C2VN Department, INSERM-INRA, Aix-Marseille University, 27 Boulevard Jean Moulin, 13385 Marseille, France
| | - Thomas Soliveres
- Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Dalia Ahriz
- Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Isabelle Arnoux
- Hematology Laboratory Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Christian Meisel
- Department of Medical Immunology, Charité - University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.,Department of Immunology, Labor Berlin - Charité Vivantes GmbH, Sylter Strasse 2, 13353 Berlin, Germany
| | - Nadine Unterwalder
- Department of Immunology, Labor Berlin - Charité Vivantes GmbH, Sylter Strasse 2, 13353 Berlin, Germany
| | - Pierre-Emmanuel Morange
- C2VN Department, INSERM-INRA, Aix-Marseille University, 27 Boulevard Jean Moulin, 13385 Marseille, France.,Hematology Laboratory Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Pierre Michelet
- Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Fabrice Malergue
- Department of Research & Development, Beckman Coulter Life Sciences-Immunotech, 130 Avenue de Lattre de Tassigny, 13009 Marseille, France
| | - Thibaut Markarian
- Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
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29
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Abstract
Biomarkers are increasingly used in patients with serious infections in the critical care setting to complement clinical judgment and interpretation of other diagnostic and prognostic tests. The main purposes of such blood markers are (1) to improve infection diagnosis (i.e., differentiation between bacterial vs. viral vs. fungal vs. noninfectious), (2) to help in the early risk stratification and thus provide prognostic information regarding the risk for mortality and other adverse outcomes, and (3) to optimize antibiotic tailoring to individual needs of patients ("antibiotic stewardship").Especially in critically ill patients, in whom sepsis is a major cause of morbidity and mortality, rapid diagnosis is desirable to start timely and specific treatment.Besides some biomarkers, such as procalcitonin, which is well established and has shown positive effects in regard to utilization of antimicrobials and clinical outcomes, there is a growing number of novel markers from different pathophysiological pathways, where the final proof of an added value to clinical judgment and ultimately clinical benefit to patients is still lacking.Without a doubt, the addition of blood biomarkers to clinical medicine has had a strong impact on the way we care for patients today. Recent trials show that as an adjunct to other clinical and laboratory parameters these markers provide important information about risks for bacterial infection and resolution of infection. Moreover, biomarkers can help to optimize management of patients with serious illness in the intensive care unit, thereby offering more individualized treatment courses with overall improvements in clinical outcomes.
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Affiliation(s)
- Eva Heilmann
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Claudia Gregoriano
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Switzerland
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30
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Outcome prediction using the Mortality in Emergency Department Sepsis score combined with procalcitonin for influenza patients. Med Clin (Barc) 2019; 153:411-417. [PMID: 31174861 DOI: 10.1016/j.medcli.2019.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 02/19/2019] [Accepted: 03/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Severe influenza is often associated with bacterial coinfection and can trigger sepsis, which increases the severity, complexity and mortality of the disease. To determine an effective method for predicting 28-day mortality of emergency department (ED) patients with influenza, we investigated the Mortality in Emergency Department Sepsis (MEDS) score, procalcitonin (PCT) and other relevant biomarkers. METHODS We conducted a retrospective, observational, monocentric study, and the endpoint was 28-day mortality. Independent predictors were identified and a new combination predictive model was created both by logistic regression, and the model was evaluated by a receiver operating characteristic (ROC) curve. RESULTS A total of 364 consecutive ED admitted patients with influenza were enrolled and 45 patients died within 28 days. For predicting 28-day mortality, the MEDS score and PCT were independent predictors with adjusted odds ratio of 1.318 (95% CI 1.206-1.439) and 1.038 (95% CI 1.010-1.065), and with AUCs of 0.817 (95% CI 0.756-0.878) and 0.793 (95% CI 0.725-0.861), respectively. The new combination of the MEDS score with PCT significantly improved the efficacy for predicting 28-day mortality with an AUC of 0.857 (95% CI 0.809-0.905), and was superior to the SOFA score with an AUC of 0.837 (95% CI 0.779-0.894). CONCLUSION The MEDS score and PCT, especially when combined, perform well for predicting mortality of ED admitted patients with influenza.
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Klugman KP, Madhi SA, Ginsburg AS, Rodgers GL. The role of bacterial vaccines in the prevention of influenza mortality. LANCET GLOBAL HEALTH 2019; 6:e1268-e1269. [PMID: 30420025 DOI: 10.1016/s2214-109x(18)30445-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/15/2018] [Indexed: 12/26/2022]
Affiliation(s)
| | - Shabir A Madhi
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Department of Science and National Research Foundation, Vaccine Preventable Diseases, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Daoud A, Laktineh A, Macrander C, Mushtaq A, Soubani AO. Pulmonary complications of influenza infection: a targeted narrative review. Postgrad Med 2019; 131:299-308. [PMID: 30845866 DOI: 10.1080/00325481.2019.1592400] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Severe influenza infection represents a leading cause of global morbidity and mortality. Several clinical syndromes that involve a number of organs may be associated with Influenza infection. However, lower respiratory complications remain the most common and serious sequel of influenza infection. These include influenza pneumonia, superinfection with bacteria and fungi, exacerbation of underlying lung disease and ARDS. This review analyzes the available literature on the epidemiology and clinical considerations of these conditions. It also provides an overview of the effects of type of influenza, antiviral therapy, vaccination and other therapies on the outcome of these complications.
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Affiliation(s)
- Asil Daoud
- a Division of Pulmonary, Critical Care and Sleep Medicine , Wayne State University, School of Medicine , Detroit , MI , USA
| | - Amir Laktineh
- a Division of Pulmonary, Critical Care and Sleep Medicine , Wayne State University, School of Medicine , Detroit , MI , USA
| | - Corey Macrander
- a Division of Pulmonary, Critical Care and Sleep Medicine , Wayne State University, School of Medicine , Detroit , MI , USA
| | - Ammara Mushtaq
- a Division of Pulmonary, Critical Care and Sleep Medicine , Wayne State University, School of Medicine , Detroit , MI , USA
| | - Ayman O Soubani
- a Division of Pulmonary, Critical Care and Sleep Medicine , Wayne State University, School of Medicine , Detroit , MI , USA
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MacIntyre CR, Chughtai AA, Barnes M, Ridda I, Seale H, Toms R, Heywood A. The role of pneumonia and secondary bacterial infection in fatal and serious outcomes of pandemic influenza a(H1N1)pdm09. BMC Infect Dis 2018; 18:637. [PMID: 30526505 PMCID: PMC6286525 DOI: 10.1186/s12879-018-3548-0] [Citation(s) in RCA: 205] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 11/23/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of this study was to estimate the prevalence of pneumonia and secondary bacterial infections during the pandemic of influenza A(H1N1)pdm09. METHODS A systematic review was conducted to identify relevant literature in which clinical outcomes of pandemic influenza A(H1N1)pdm09 infection were described. Published studies (between 01/01/2009 and 05/07/2012) describing cases of fatal or hospitalised A(H1N1)pdm09 and including data on bacterial testing or co-infection. RESULTS Seventy five studies met the inclusion criteria. Fatal cases with autopsy specimen testing were reported in 11 studies, in which any co-infection was identified in 23% of cases (Streptococcus pneumoniae 29%). Eleven studies reported bacterial co-infection among hospitalised cases of A(H1N1)2009pdm with confirmed pneumonia, with a mean of 19% positive for bacteria (Streptococcus pneumoniae 54%). Of 16 studies of intensive care unit (ICU) patients, bacterial co-infection identified in a mean of 19% of cases (Streptococcus pneumoniae 26%). The mean prevalence of bacterial co-infection was 12% in studies of hospitalised patients not requiring ICU (Streptococcus pneumoniae 33%) and 16% in studies of paediatric patients hospitalised in general or pediatric intensive care unit (PICU) wards (Streptococcus pneumoniae 16%). CONCLUSION We found that few studies of the 2009 influenza pandemic reported on bacterial complications and testing. Of studies which did report on this, secondary bacterial infection was identified in almost one in four patients, with Streptococcus pneumoniae the most common bacteria identified. Bacterial complications were associated with serious outcomes such as death and admission to intensive care. Prevention and treatment of bacterial secondary infection should be an integral part of pandemic planning, and improved uptake of routine pneumococcal vaccination in adults with an indication may reduce the impact of a pandemic.
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Affiliation(s)
- Chandini Raina MacIntyre
- Biosecurity Program, The Kirby Institute, UNSW Medicine, University of New South Wales, Sydney, NSW 2052 Australia
| | - Abrar Ahmad Chughtai
- School of Public Health and Community Medicine, Faculty of Medicine, UNSW Medicine, the University of New South Wales, Samuels Building, Room 209, Sydney, NSW 2052 Australia
| | - Michelle Barnes
- School of Public Health and Community Medicine, Faculty of Medicine, UNSW Medicine, the University of New South Wales, Samuels Building, Room 209, Sydney, NSW 2052 Australia
| | - Iman Ridda
- School of Public Health and Community Medicine, Faculty of Medicine, UNSW Medicine, the University of New South Wales, Samuels Building, Room 209, Sydney, NSW 2052 Australia
| | - Holly Seale
- School of Public Health and Community Medicine, Faculty of Medicine, UNSW Medicine, the University of New South Wales, Samuels Building, Room 209, Sydney, NSW 2052 Australia
| | - Renin Toms
- School of Public Health and Community Medicine, Faculty of Medicine, UNSW Medicine, the University of New South Wales, Samuels Building, Room 209, Sydney, NSW 2052 Australia
| | - Anita Heywood
- School of Public Health and Community Medicine, Faculty of Medicine, UNSW Medicine, the University of New South Wales, Samuels Building, Room 209, Sydney, NSW 2052 Australia
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Li Z, He L, Li S, He W, Zha C, Ou W, Hou Q, Wang W, Sun X, Liang H. Combination of procalcitonin and C-reactive protein levels in the early diagnosis of bacterial co-infections in children with H1N1 influenza. Influenza Other Respir Viruses 2018; 13:184-190. [PMID: 30443990 PMCID: PMC6379630 DOI: 10.1111/irv.12621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 11/08/2018] [Accepted: 11/13/2018] [Indexed: 12/22/2022] Open
Abstract
Objective This study evaluated the diagnostic value of measuring the levels of procalcitonin (PCT) and C‐reactive protein (CRP) to differentiate children co‐infected with H1N1 influenza and bacteria from children infected with H1N1 influenza alone. Methods Consecutive patients (children aged < 5 years) with laboratory‐confirmed H1N1 influenza who were hospitalized or received outpatient care from a tertiary‐care hospital in Canton, China, between January 1, 2012, and September 1, 2017, were included in the present study. Laboratory results, including serum PCT and CRP levels, white blood cell (WBC) counts, and bacterial cultures, were analyzed. The predictive value of the combination of biomarkers versus any of the biomarkers alone for diagnosing bacterial co‐infections was evaluated using logistic regression analyses. Results Significantly higher PCT (1.46 vs 0.21 ng/mL, P < 0.001) and CRP (19.20 vs 5.10 mg/dL, P < 0.001) levels were detected in the bacterial co‐infection group than in the H1N1 infection‐alone group. Using PCT or CRP levels alone, the areas under the curves (AUCs) for predicting bacterial co‐infections were 0.801 (95% CI, 0.772‐0.855) and 0.762 (95% CI, 0.722‐0.803), respectively. Using a combination of PCT and CRP, the logistic regression‐based model, Logit(P) = −1.912 + 0.546 PCT + 0.087 CRP, showed significantly greater accuracy (AUC: 0.893, 95% CI: 0.842‐0.934) than did the other three biomarkers. Conclusions The combination of PCT and CRP levels could provide a useful method of distinguishing bacterial co‐infections from an H1N1 influenza infection alone in children during the early disease phase. After further validation, the flexible model derived here could assist clinicians in decision‐making processes.
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Affiliation(s)
- Zhihao Li
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Liya He
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Shuhua Li
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Waner He
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Caihui Zha
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wanxing Ou
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Qiaozhen Hou
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Weiying Wang
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xin Sun
- Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Abstract
Procalcitonin (PCT) is a quickly measurable marker, assumed to have high sensitivity and specificity for sepsis and infection. A literature search was conducted to evaluate PCT ability as a diagnostic and prognostic tool in infectious processes and its ability to monitor the antibiotic therapy. PCT level is increased in bacterial and fungal infections, but not in viral infections, with a significantly higher level in patients with bacteremia compared with uninfected patients (2.5 vs. 0.3 ng/mL; P < 0.0001). A PCT value of ≤0.1 ng/mL discards bacteremia and microbiological tests (negative predictive value of 96.3%), >0.1 ng/mL needs microbiological tests, and >1.0 ng/mL is indicative of bacteremia. Antibiotic treatment algorithms guided by PCT decreased the need for antibiotic treatment in approximately 50%. PCT is a promising test in clinical practice to decide the introduction of antibiotic therapy in addition to the existing tools, without neglecting the clinical assessment, with a significant decrease in costs.
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Rozencwajg S, Bréchot N, Schmidt M, Hékimian G, Lebreton G, Besset S, Franchineau G, Nieszkowska A, Leprince P, Combes A, Luyt CE. Co-infection with influenza-associated acute respiratory distress syndrome requiring extracorporeal membrane oxygenation. Int J Antimicrob Agents 2017; 51:427-433. [PMID: 29174419 DOI: 10.1016/j.ijantimicag.2017.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/09/2017] [Accepted: 11/12/2017] [Indexed: 12/19/2022]
Abstract
The co-infection frequency and impact among influenza-associated acute respiratory distress syndrome (ARDS) patients requiring extracorporeal membrane oxygenation (ECMO) are not known. This retrospective observational analysis concerned data prospectively collected from patients admitted to our medical intensive care unit (ICU) who received ECMO support for influenza-associated ARDS between 2009-2016. Co-infection was defined as occurring within 48 h following ICU admission. Among the 77 ARDS patients requiring ECMO support, 39 (51%) developed co-infections, with Staphylococcus aureus [18 (46%) of the co-infected patients] being the most prevalent pathogen. Panton-Valentin leukocidin (PVL)-producing S. aureus was isolated from 10 patients (56% of S. aureus co-infections and 26% of all co-infections). Co-infected patients were comparable with those without co-infection, except for BMI, initial disease severity and antibiotic treatment prior to admission. Co-infection was associated with higher in-ICU mortality (62% vs. 29%; P = 0.006) and with fewer ECMO-free days [median (IQR) 0 (0-19) vs. 23 (0-46); P = 0.004] and fewer mechanical ventilation-free days [0 (0-0) vs. 6 (0-35); P = 0.003] on Day 60. Multivariable analysis retained age >49 years, pre-ECMO Simplified Acute Physiology Score (SAPS) II score >70 and co-infection as independent predictors of hospital mortality. In conclusion, co-infection is frequent in ECMO-treated patients with influenza-associated ARDS, affecting ca. 50%, and is independently associated with poor outcome. Staphylococcus aureus was the most frequently identified pathogen, with a high rate of PVL-positive S. aureus. Whether specific therapy targeting PVL-producing S. aureus should be given remains to be determined.
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Affiliation(s)
- Sacha Rozencwajg
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Nicolas Bréchot
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Schmidt
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Guillaume Hékimian
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Lebreton
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sébastien Besset
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Franchineau
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ania Nieszkowska
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pascal Leprince
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alain Combes
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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Hadfield J, Bennett L. Determining best outcomes from community-acquired pneumonia and how to achieve them. Respirology 2017; 23:138-147. [PMID: 29150897 DOI: 10.1111/resp.13218] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 10/12/2017] [Accepted: 10/19/2017] [Indexed: 12/12/2022]
Abstract
Community-acquired pneumonia (CAP) is a common acute medical illness with a standard, effective treatment that was introduced before the evidenced-based medicine era. Mortality rates have improved in recent decades but improvements have been minimal when compared to other conditions such as acute coronary syndromes. The standardized approach to treatment makes CAP a target for comparative performance and outcome measures. While easy to collect, simplistic outcomes such as mortality, readmission and length of stay are difficult to interpret as they can be affected by subjective choices and health care resources. Proposed clinical- and patient-reported outcomes are discussed below and include measures such as the time to clinical stability (TTCS) and patient satisfaction, which can be compared between health institutions. Strategies to improve these outcomes include use of a risk stratification tool, local antimicrobial guidelines with antibiotic stewardship and care bundles to include early administration of antibiotics and early mobilization.
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Affiliation(s)
- Jane Hadfield
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Lesley Bennett
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, WA, Australia
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Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department. Med Clin (Barc) 2017; 148:501-510. [PMID: 28391994 DOI: 10.1016/j.medcli.2017.02.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/08/2017] [Accepted: 02/16/2017] [Indexed: 01/10/2023]
Abstract
Between all patients treated in the Emergency Department (ED), 1.35% are diagnosed with community-acquired pneumonia (CAP). CAP is the main cause of death due to infectious disease (10-14%) and the most frequent reason of sepsis-septic shock in the ED. In the last decade, the search for objective tools to help establishing an early diagnosis, bacterial aetiology, severity, suspicion of bacteremia and the prognosis of mortality has increased. Biomarkers have shown their usefulness in this matter. Procalcitonin (obtains the highest accuracy for CAP diagnosis, bacterial aetiology and the presence of bacteremia), lactate (biomarker of hypoxia and tissue hypoperfusion) and proadrenomedullin (which has the greatest accuracy to predict mortality which in combination with the prognostic severity scales obtains even better results). The aim of this review is to highlight recently published scientific evidence and to compare the utility and prognostic accuracy of the biomarkers in CAP patients treated in the ED.
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Samsudin I, Vasikaran SD. Clinical Utility and Measurement of Procalcitonin. Clin Biochem Rev 2017; 38:59-68. [PMID: 29332972 PMCID: PMC5759088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Procalcitonin (PCT), regarded as a biomarker specific for bacterial infections, is used in a variety of clinical settings including primary care, emergency department and intensive care. PCT measurement aids in the diagnosis of sepsis and to guide and monitor antibiotic therapy. This article gives a brief overview of PCT and its use in guiding antibiotic therapy in various clinical settings, as well as its limitations. PCT performance in comparison with other biomarkers of infection in particular CRP is also reviewed. Owing to its greater availability, CRP has been widely used as a biomarker of infection and sepsis. PCT is often reported to be more superior to CRP, being more specific for sepsis and bacterial infection. PCT starts to rise earlier and returns to normal concentration more rapidly than CRP, allowing for an earlier diagnosis and better monitoring of disease progression.
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Affiliation(s)
- Intan Samsudin
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Murdoch, WA 6150, Australia
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor 43400, Malaysia
| | - Samuel D Vasikaran
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Murdoch, WA 6150, Australia
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Canavaggio P, Boutolleau D, Goulet H, Riou B, Hausfater P. Procalcitonin for clinical decisions on influenza-like illness in emergency department during influenza a(H1N1)2009 pandemic. Biomarkers 2017; 23:10-13. [PMID: 28010128 DOI: 10.1080/1354750x.2016.1276626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE We aimed to determine whether serum procalcitonin (PCT) values could help in identifying flu in patient admitted to the emergency department (ED) with influenza-like illness (ILI) during influenza A(H1N1)2009 pandemic. METHODS An observational retrospective cohort study was performed in a referral ED for emerging infectious diseases. All patients tested for influenza A(H1N1)2009 by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) and procalcitonin between June 2009 and January 2010 were analyzed. PCT was studied for its negative predictive value of bacterial infection. Patients PCT-/RT-PCR + were considered as true positive. RESULTS On the 80 patients included, 16 were positive for influenza A(H1N1)2009 RT-PCR, all but one of them had low PCT concentrations. Conversely, 19 (30%) of the 64 patients with negative RT-PCR had elevated PCT concentrations. For a PCT threshold <0.25 μg/L, sensitivity was 0.94, specificity 0.30, positive predictive value 0.25 and negative predictive value 0.95 for the diagnosis of flu. CONCLUSION In the context of an influenza pandemic, serum PCT measurement may be useful for clinical decisions in the ED as most of RT-PCR confirmed patients have low PCT values. Patients with PCT above 0.25 μg/L are unlikely to have a unique diagnosis of flu.
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Affiliation(s)
- P Canavaggio
- a Department of Emergency , Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris (APHP) , Paris , France
| | - D Boutolleau
- b Virology Laboratory , Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris (APHP) , Paris , France.,c Sorbonne Universités UPMC-Univ Paris06, INSERM U1135, CIMI , Paris , France
| | - H Goulet
- a Department of Emergency , Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris (APHP) , Paris , France
| | - B Riou
- a Department of Emergency , Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris (APHP) , Paris , France.,d Sorbonne Universités UPMC-Univ Paris06, GRC-14 BIOSFAST, UMRS INSERM 1166 , Paris , France
| | - P Hausfater
- a Department of Emergency , Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris (APHP) , Paris , France.,d Sorbonne Universités UPMC-Univ Paris06, GRC-14 BIOSFAST, UMRS INSERM 1166 , Paris , France
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Kapasi AJ, Dittrich S, González IJ, Rodwell TC. Host Biomarkers for Distinguishing Bacterial from Non-Bacterial Causes of Acute Febrile Illness: A Comprehensive Review. PLoS One 2016; 11:e0160278. [PMID: 27486746 PMCID: PMC4972355 DOI: 10.1371/journal.pone.0160278] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/15/2016] [Indexed: 12/17/2022] Open
Abstract
Background In resource limited settings acute febrile illnesses are often treated empirically due to a lack of reliable, rapid point-of-care diagnostics. This contributes to the indiscriminate use of antimicrobial drugs and poor treatment outcomes. The aim of this comprehensive review was to summarize the diagnostic performance of host biomarkers capable of differentiating bacterial from non-bacterial infections to guide the use of antibiotics. Methods Online databases of published literature were searched from January 2010 through April 2015. English language studies that evaluated the performance of one or more host biomarker in differentiating bacterial from non-bacterial infection in patients were included. Key information extracted included author information, study methods, population, pathogens, clinical information, and biomarker performance data. Study quality was assessed using a combination of validated criteria from the QUADAS and Lijmer checklists. Biomarkers were categorized as hematologic factors, inflammatory molecules, cytokines, cell surface or metabolic markers, other host biomarkers, host transcripts, clinical biometrics, and combinations of markers. Findings Of the 193 citations identified, 59 studies that evaluated over 112 host biomarkers were selected. Most studies involved patient populations from high-income countries, while 19% involved populations from low- and middle-income countries. The most frequently evaluated host biomarkers were C-reactive protein (61%), white blood cell count (44%) and procalcitonin (34%). Study quality scores ranged from 23.1% to 92.3%. There were 9 high performance host biomarkers or combinations, with sensitivity and specificity of ≥85% or either sensitivity or specificity was reported to be 100%. Five host biomarkers were considered weak markers as they lacked statistically significant performance in discriminating between bacterial and non-bacterial infections. Discussion This manuscript provides a summary of host biomarkers to differentiate bacterial from non-bacterial infections in patients with acute febrile illness. Findings provide a basis for prioritizing efforts for further research, assay development and eventual commercialization of rapid point-of-care tests to guide use of antimicrobials. This review also highlights gaps in current knowledge that should be addressed to further improve management of febrile patients.
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Affiliation(s)
- Anokhi J. Kapasi
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Iveth J. González
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
| | - Timothy C. Rodwell
- Foundation for Innovative New Diagnostics (FIND), Campus Biotech Building B2 Level 0, 9 Chemin des Mines, 1202, Geneva, Switzerland
- * E-mail:
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Klein EY, Monteforte B, Gupta A, Jiang W, May L, Hsieh YH, Dugas A. The frequency of influenza and bacterial coinfection: a systematic review and meta-analysis. Influenza Other Respir Viruses 2016; 10:394-403. [PMID: 27232677 PMCID: PMC4947938 DOI: 10.1111/irv.12398] [Citation(s) in RCA: 317] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2016] [Indexed: 12/19/2022] Open
Abstract
Aim Coinfecting bacterial pathogens are a major cause of morbidity and mortality in influenza. However, there remains a paucity of literature on the magnitude of coinfection in influenza patients. Method A systematic search of MeSH, Cochrane Library, Web of Science, SCOPUS, EMBASE, and PubMed was performed. Studies of humans in which all individuals had laboratory confirmed influenza, and all individuals were tested for an array of common bacterial species, met inclusion criteria. Results Twenty‐seven studies including 3215 participants met all inclusion criteria. Common etiologies were defined from a subset of eight articles. There was high heterogeneity in the results (I2 = 95%), with reported coinfection rates ranging from 2% to 65%. Although only a subset of papers were responsible for observed heterogeneity, subanalyses and meta‐regression analysis found no study characteristic that was significantly associated with coinfection. The most common coinfecting species were Streptococcus pneumoniae and Staphylococcus aureus, which accounted for 35% (95% CI, 14%–56%) and 28% (95% CI, 16%–40%) of infections, respectively; a wide range of other pathogens caused the remaining infections. An assessment of bias suggested that lack of small‐study publications may have biased the results. Conclusions The frequency of coinfection in the published studies included in this review suggests that although providers should consider possible bacterial coinfection in all patients hospitalized with influenza, they should not assume all patients are coinfected and be sure to properly treat underlying viral processes. Further, high heterogeneity suggests additional large‐scale studies are needed to better understand the etiology of influenza bacterial coinfection.
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Affiliation(s)
- Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA.,Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | | | | | - Wendi Jiang
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Larissa May
- Department of Emergency Medicine, The George Washington University, Washington, DC, USA
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Andrea Dugas
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
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Personalized medicine in severe influenza. Eur J Clin Microbiol Infect Dis 2016; 35:893-7. [PMID: 26936615 PMCID: PMC7101819 DOI: 10.1007/s10096-016-2611-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 02/11/2016] [Indexed: 12/17/2022]
Abstract
Existing therapies against infectious diseases may only be effective in limited subpopulations during specific phases of diseases, incorporating theranostics, and there is a clear need to individualize different therapeutic approaches depending on the host. Influenza A virus infection evolves into a severe respiratory failure in some young adult patients, related to an exaggerated inflammatory response. Mortality rates remain high despite antiviral treatment and aggressive respiratory support. The influenza A virus (IAV) infection will induce a proinflammatory innate immune response through recognition of viral RNA by Toll-like receptor (TLR) 7 and retinoic acid-inducible gene 1 (RIG-I) molecules by nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB route). Anti-inflammatory therapies focused on modulating this inflammatory response to “all patients” have not been satisfactory. Steroids should be avoided because they do not improve survival and promote superinfections. Since clinical judgment has often been proven inadequate, interest in the use of biomarkers to monitor host response and to assess severity and complications is growing. It is well known that, if used appropriately, these can be helpful tools to predict not only severity but also mortality. We need more biomarkers that predict host response: it is time to change lactate measurement to proteomics and transcriptomics. Theranostics describes an approach covering both diagnosis and coupled therapy. Death is usually a fatal complication of a dysregulated immune response more than the acute virulence of the infectious agent. Future research demonstrating the usefulness of adjunctive therapy in a subset of critically ill patients with IAV pneumonia is an unmet clinical need.
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Rodríguez AH, Avilés-Jurado FX, Díaz E, Schuetz P, Trefler SI, Solé-Violán J, Cordero L, Vidaur L, Estella Á, Pozo Laderas JC, Socias L, Vergara JC, Zaragoza R, Bonastre J, Guerrero JE, Suberviola B, Cilloniz C, Restrepo MI, Martín-Loeches I, Cobo P, Martins J, Carbayo C, Robles-Musso E, Cárdenas A, Fierro J, Fernández DO, Sierra R, Huertos MJ, Carmona Pérez ML, Pozo Laderas JC, Guerrero R, Robles JC, León ME, Gómez AB, Márquez E, Rodríguez-Carvajal M, Estella Á, Pomares J, Ballesteros JL, Romero OM, Fernández Y, Lobato F, Prieto JF, Albofedo-Sánchez J, Martínez P, de la Torre MV, Nieto M, Sola EC, Díaz Castellanos MA, Soler GS, Leyba CO, Garnacho-Montero J, Hinojosa R, Fernández E, Loza A, León C, López SG, Arenzana A, Ocaña D, Navarrete I, Beryanaki MZ, Sánchez I, Pérez Alé M, Poullet Brea AM, Machado Casas JF, Serón C, Avellanas ML, Lander A, de Arellano SGR, Lacueva MM, Luque P, Serrano EP, Martín Lázaro JF, Polo CS, Cia IG, Bartolomé BJ, Nuñez CL, González I, Tomás Marsilla JI, Andrés CJ, Ibañes PG, Aguilar PA, Montón JM, Regil PD, Iglesias L, González CP, Fernández BQ, Iglesias LM, Soria LV, Escudero RY, Revuelta MDRM, Quiroga, García-Rodríguez Á, Cuadrado MM, Balán Mariño AL, Socias L, Ibánez P, Borges-Sa M, Socias A, Del Castillo A, Marcos RJ, Muñoz C, Bonell JM, Amestarán I, López MAG, Pàmies CV, Bonell Goytisolo JM, Morales Carbonero JA, Bonell Goytisolo JM, Morales Carbonero JA, Senoff RP, López de Medrano MG, Ruiz-Santana S, Díaz JJ, Ramírez CS, Sisón M, Hernández D, Trujillo A, Regalado L, Fndez SR, Lorente L, Rivero JC, Mora Quintero ML, Martín M, Martínez S, Cáceres J, Sanchez Palacio M, Marcos, García Rodríguez D, Leria MR, Suberviola B, Ugarte P, García-López F, Iniesta RS, Alonso AÁ, Padilla A, Palacios BM, Grande MLG, Martín Rodríguez MC, Adbel-Hadi Álvarez H, Ambros Checa A, Hernández HM, Albaya A, Obregón AS, Crespo CM, Estrella CA, Benito Puncel C, Oyargue EQ, Canabal A, Marina L, López de Toro I, Simón A, Añón JM, López Messa JB, López Pueyo MJ, del valle Sergio Ossa Echeverri OM, Ferreras Z, Ballesteros Herraez JC, Macias S, Berezo JÁ, Varela JB, Schweizer PB, Salamanca AG, Lomas LT, Anzález AO, Cicuéndez Avila R, Francisco Javier PG, Terrero AÁ, Ezpeleta FT, Sala C, López O, Paez Z, García Á, Carriedo Ule D, Crespo MR, Rebolledo JP, Andrés NH, Zirena ACC, García BR, López Messa JB, del Valle Ortiz M, Echeverri SO, Catalán RM, Ferrer M, Torres A, Cilloniz C, Ansorregui SB, Cabré L, Baeza I, Rovira A, Álvarez-Lerma F, Vázquez A, Nolla J, Fernández F, Cervelló JR, Iglesia R, Mañéz R, Ballús J, Granada RM, Vallés J, Díaz E, Ortíz M, Guía C, Martín-Loeches I, Páez J, Almirall J, Balanzo X, Güell E, Yebenes JC, Rello J, Arnau E, Pérez M, Laborda C, Souto J, Lagunes L, Catalán I, Sirvent JM, de Arbina NL, Serra AB, Sánchez A, Cuenca; SM, Badía M, Baseda-Garrido B, Valverdú-Vidal M, Barcenilla F, Palomar M, Nuvials X, Benedicto PG, Campo FR, Esteban M, Luna J, Eixarch GM, Diago AP, Nava JM, González de Molina J, Trenado J, Ferrer R, Josic Z, Casanovas M, Gurri F, Rodríguez P, Rodríguez A, Claverias L, Trefler S, Bodí M, Magret M, Ferri C, Díaz RM, Mesalles E, Arméstar F, de Mendoza D, Fernández CL, Berrade JJ, Saris AB, Pechkova M, Jiménez CM, Gil SP, Juliá-Narváez J, Marcos MR, Mallqui VF, Santiago Triviño MA, García PM, Fernández-Zapata A, Recio T, Arrascaeta A, García-Ramos MJ, Gallego E, Rodrigo ES, Bueno F, Díaz M, Pérez NG, Hormigo DL, Delgado JDJ, Frutos P, Rivera Pinna M, Cordero ML, Pastor JA, Álvarez-Rocha L, Ceniceros Barros A, Pedreira AV, Vila D, González CF, Pérez JB, Piquer MO, Merayo E, López-Ciudad VJ, Cañones JC, Vilaboy E, Chao JV, Cid López FS, Cortés PV, Pérez Veloso MA, Saborido EM, Pardavila EA, Montes AO, González RJ, Freita S, Alemparte E, Ortega A, López AM, Canabal J, Ferres E, Pérez JB, Piquer MO, Ramos SF, Cendón LL, Casal VG, Adrio SV, Fernández EM, Prado SG, Franco AV, Monzón JL, Goñi F, Del Nogal Sáez F, Navalpotro MB, Abad RD, Lasierra JLF, García-Torrejón MC, Pérez–Calvo C, López D, Arnaiz L, Sánchez-Alonso S, Velayos C, del Río F, González MÁ, Nieto M, Cesteros CS, Martín MC, Molina JM, Montejo JC, Catalán M, Albert P, de Pablo A, Guerrero JE, Zurita; M, Peyrat JB, Cámara MD, Cerdá E, Alvarez M, Pey C, Riestra EM, Martinez-Fidalgo C, Rodríguez M, Palencia E, Caballero R, Vaquero C, Mariscal F, García S, Cepeda R, Carrasco N, Prieto I, Liétor A, Ramos R, Casas RC, Cuesta CS, Sánchez Alonso S, Galván B, Figueira JC, Soriano MC, Martín BC, Caballero AR, Galdós P, Moreno BB, Alcántara Carmona S, del Cabo F, Hermosa C, Gordo F, Algora A, Paredes A, Carmona TG, Cambroner J, Ramos EL, de Zárate YO, Gómez-Rosado S, Lodo MM, Garrobo NF, Hernández SÁ, Honrubia T, Prado López LM, Esteban A, Lorente J, Nin N, Sotomayor CJ, Arnaiz L, Silvero EM, de la Reguera EMF, de la Casa Monje RM, Serrano FM, Trasmonte Martínez MV, Martín Delgado MC, Martínez S, Abad FF, Navalon IC, Velis MV, Martínez M, Martínez Baño D, Andreu E, Butí SM, Rueda BG, García F, Fernández NL, Para LH, Freire AO, Nvarro Ruiz MR, Romero CH, Maraví-Poma E, Urra IJ, Redin LM, Tellería A, Insansti J, Garcia NA, Macaya L, Palanco JL, González N, Marco P, Vidaur L, Salas E, Udabe RS, Santamaría B, Rodríguez T, Vergara JC, Amiano JRI, Santos IG, Manzano A, Arenal CC, Olaechea PM, Hernández HM, López AM, San Miguel FF, Blanquer J, Carbonell N, Franco JF, Valero RR, Belenger A, Altaba S, Álvarez–Sánchez B, Robles JC, Francisco JS, Sánchez MR, Picos SA, Llanes AA, Gutiérrez EH, Zapata AF, Sánchez-Miralles Á, Antón Pascual JL, Bonastre J, Palamo M, Cebrian J, Cuñat J, Sahuquillo MG, Romero B, Pallé SB, de León Belmar J, Zaragoza R, Tormo C, Chinesta SS, Paricio V, Marques A, Sánchez-Morcillo S, Tormo S, Latour J, García MÁ, Palomo M, Royo FT, Hinojosa PM, Sánchez Pino MS, Ribes CM, Luis RG, Ribas A. Procalcitonin (PCT) levels for ruling-out bacterial coinfection in ICU patients with influenza: A CHAID decision-tree analysis. J Infect 2016; 72:143-51. [DOI: 10.1016/j.jinf.2015.11.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 11/12/2015] [Accepted: 11/28/2015] [Indexed: 01/22/2023]
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Yang M, Gao H, Chen J, Xu X, Tang L, Yang Y, Liang W, Yu L, Sheng J, Li L. Bacterial coinfection is associated with severity of avian influenza A (H7N9), and procalcitonin is a useful marker for early diagnosis. Diagn Microbiol Infect Dis 2015; 84:165-9. [PMID: 26639228 DOI: 10.1016/j.diagmicrobio.2015.10.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 08/01/2015] [Accepted: 10/24/2015] [Indexed: 10/22/2022]
Abstract
Patients contracting avian influenza A (H7N9) often develop severe disease. However, information on the contribution of bacterial coinfection to the severity of H7N9 is limited. We retrospectively studied 83 patients with confirmed H7N9 infection from April 2013 to February 2014. The severity of patients with bacterial coinfection and markers for early diagnosis of bacterial coinfection in H7N9 were analyzed. We found Staphylococcus aureus was the most prevalent pathogen. Higher Acute Physiology and Chronic Health Evaluation II score, shock, renal replacement treatment, mechanical ventilation, and extracorporeal membrane oxygenation treatment were more frequently observed in patients with bacterial coinfection. Procalcitonin is more sensitive than C-reactive protein in determining bacterial coinfection in H7N9 patients. In conclusion, H7N9 infection patients with bacterial coinfection had a more severe condition. Elevated procalcitonin is an accurate marker for diagnosing bacterial coinfection in H7N9 patients, thus enabling earlier antibiotic therapy.
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Affiliation(s)
- Meifang Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Hainv Gao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Jiajia Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Xiaowei Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Lingling Tang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Yida Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Weifeng Liang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Liang Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Jifang Sheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.
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Hasvold J, Sjoding M, Pohl K, Cooke C, Hyzy RC. The role of human metapneumovirus in the critically ill adult patient. J Crit Care 2015; 31:233-7. [PMID: 26572580 DOI: 10.1016/j.jcrc.2015.09.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 09/01/2015] [Accepted: 09/05/2015] [Indexed: 02/03/2023]
Abstract
PURPOSE The purpose of the study is to describe the role of human metapneumovirus (hMPV) infection in critical illness and acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS We collected clinical and demographic information from a retrospective chart review, comparing patients with and without an intensive care unit (ICU) admission. Among patients admitted to the ICU, we assessed whether hMPV was "unlikely," "possibly," or "likely" the reason for ICU admission, based on a prespecified definition, and whether the patient met criteria for ARDS. RESULTS We identified 128 hospitalized adults with hMPV infection. Forty hospitalized patients (31%) with hMPV infection required admission to the ICU. Among patients cared for in the ICU, hMPV was "possibly" the reason for ICU admission in 55% of patients and "likely" the reason in 38%. Forty-eight percent of ICU patients met criteria for ARDS. Although most patients admitted to the ICU had significant comorbidities or were immunosuppressed, 6 patients requiring ICU admission had more minor comorbidities and no underlying immunosuppression. CONCLUSIONS Although most patients hospitalized with hMPV had chronic cardiac or pulmonary disease, hMPV can also be associated serious respiratory illness and ARDS in adult patients without significant comorbidities or immunosuppression.
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Affiliation(s)
- Jennifer Hasvold
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
| | - Michael Sjoding
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kyle Pohl
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Colin Cooke
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes & Policy, Institute for Healthcare Innovation & Policy, University of Michigan, Ann Arbor, MI
| | - Robert C Hyzy
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Cillóniz C, Civljak R, Nicolini A, Torres A. Polymicrobial community-acquired pneumonia: An emerging entity. Respirology 2015; 21:65-75. [PMID: 26494527 DOI: 10.1111/resp.12663] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/21/2015] [Accepted: 07/28/2015] [Indexed: 12/13/2022]
Abstract
Polymicrobial aetiology in community-acquired pneumonia (CAP) is more common than previously recognized. This growing new entity can influence inflammation, host immunity and disease outcomes in CAP patients. However, the true incidence is complicated to determine and probably underestimated due mainly to many cases going undetected, particularly in the outpatient setting, as the diagnostic yield is restricted by the sensitivity of currently available microbiologic tests and the ability to get certain types of clinical specimens. The observed rate of polymicrobial cases may also lead to new antibiotic therapy considerations. In this review, we discuss the pathogenesis, microbial interactions in pneumonia, epidemiology, biomarkers and antibiotic therapy for polymicrobial CAP.
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Affiliation(s)
- Catia Cillóniz
- Department of Pneumology, Thorax Institute, Hospital Clinic of Barcelona-August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona (UB)-SGR 911-, Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Rok Civljak
- University of Zagreb School of Medicine, 'Dr. Fran Mihaljevic' University Hospital for Infectious Diseases, Zagreb, Croatia
| | | | - Antoni Torres
- Department of Pneumology, Thorax Institute, Hospital Clinic of Barcelona-August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona (UB)-SGR 911-, Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
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Pros and cons of using biomarkers versus clinical decisions in start and stop decisions for antibiotics in the critical care setting. Intensive Care Med 2015; 41:1739-51. [PMID: 26194026 DOI: 10.1007/s00134-015-3978-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 07/09/2015] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Patients in the intensive care unit (ICU) frequently receive prolonged or even unnecessary antibiotic therapy, which selects for antibiotic-resistant bacteria. Over the last decade there has been great interest in biomarkers, particularly procalcitonin, to reduce antibiotic exposure. METHODS In this narrative review, we discuss the value of biomarkers and provide additional information beyond clinical evaluation in order to be clinically useful and review the literature on sepsis biomarkers outside the neonatal period. Both benefits and limitations of biomarkers for clinical decision-making are reviewed. RESULTS Several randomized controlled trials (RCTs) have shown the safety and efficacy of procalcitonin to discontinue antibiotic therapy in patients with severe sepsis or septic shock. In contrast, there is limited utility of procalcitonin for treatment initiation or withholding therapy initially. In addition, an algorithm using procalcitonin for treatment escalation has been ineffective and is probably associated with poorer outcomes. Little data from interventional studies are available for other biomarkers for antibiotic stewardship, except for C-reactive protein (CRP), which was recently found to be similarly effective and safe as procalcitonin in a randomized controlled trial. We finally briefly discuss biomarker-unrelated approaches to reduce antibiotic duration in the ICU, which have shown that even without biomarker guidance, most patients with sepsis can be treated with relatively short antibiotic courses of approximately 7 days. CONCLUSIONS In summary, there is an ongoing unmet need for biomarkers which can reliably and early on identify patients who require antibiotic therapy, distinguish between responders and non-responders and help to optimize antibiotic treatment decisions among critically ill patients. Available evidence needs to be better incorporated in clinical decision-making.
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Sepsis: From Pathophysiology to Individualized Patient Care. J Immunol Res 2015; 2015:510436. [PMID: 26258150 PMCID: PMC4518174 DOI: 10.1155/2015/510436] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/24/2015] [Accepted: 07/02/2015] [Indexed: 12/13/2022] Open
Abstract
Sepsis has become a major health economic issue, with more patients dying in hospitals due to sepsis related complications compared to breast and colorectal cancer together. Despite extensive research in order to improve outcome in sepsis over the last few decades, results of large multicenter studies were by-and-large very disappointing. This fiasco can be explained by several factors, but one of the most important reasons is the uncertain definition of sepsis resulting in very heterogeneous patient populations, and the lack of understanding of pathophysiology, which is mainly based on the imbalance in the host-immune response. However, this heroic research work has not been in vain. Putting the results of positive and negative studies into context, we can now approach sepsis in a different concept, which may lead us to new perspectives in diagnostics and treatment. While decision making based on conventional sepsis definitions can inevitably lead to false judgment due to the heterogeneity of patients, new concepts based on currently gained knowledge in immunology may help to tailor assessment and treatment of these patients to their actual needs. Summarizing where we stand at present and what the future may hold are the purpose of this review.
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Tong SYC, Davis JS, Eichenberger E, Holland TL, Fowler VG. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev 2015; 28:603-61. [PMID: 26016486 PMCID: PMC4451395 DOI: 10.1128/cmr.00134-14] [Citation(s) in RCA: 2650] [Impact Index Per Article: 294.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.
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Affiliation(s)
- Steven Y C Tong
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Joshua S Davis
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Emily Eichenberger
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Thomas L Holland
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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