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Godijk NG, McDonald SA, Altorf-van der Kuil W, Schoffelen AF, Franz E, Bootsma MCJ. New methodology to assess the excess burden of antibiotic resistance using country-specific parameters: a case study regarding E. coli urinary tract infections. BMJ Open 2023; 13:e064335. [PMID: 38110375 DOI: 10.1136/bmjopen-2022-064335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES Antimicrobial resistant (AMR) infections are a major public health problem and the burden on population level is not yet clear. We developed a method to calculate the excess burden of resistance which uses country-specific parameter estimates and surveillance data to compare the mortality and morbidity due to resistant infection against a counterfactual (the expected burden if infection was antimicrobial susceptible). We illustrate this approach by estimating the excess burden for AMR (defined as having tested positive for extended-spectrum beta-lactamases) urinary tract infections (UTIs) caused by E. coli in the Netherlands in 2018, which has a relatively low prevalence of AMR E. coli, and in Italy in 2016, which has a relatively high prevalence. DESIGN Excess burden was estimated using the incidence-based disability-adjusted life-years (DALYs) measure. Incidence of AMR E. coli UTI in the Netherlands was derived from ISIS-AR, a national surveillance system that includes tested healthcare and community isolates, and the incidence in Italy was estimated using data reported in the literature. A systematic literature review was conducted to find country-specific parameter estimates for disability duration, risks of progression to bacteraemia and mortality. RESULTS The annual excess burden of AMR E. coli UTI was estimated at 3.89 and 99.27 DALY/100 0000 population and 39 and 2786 excess deaths for the Netherlands and Italy, respectively. CONCLUSIONS For the first time, we use country-specific and pathogen-specific parameters to estimate the excess burden of resistant infections. Given the large difference in excess burden due to resistance estimated for Italy and for the Netherlands, we emphasise the importance of using country-specific parameters describing the incidence and disease progression following AMR and susceptible infections that are pathogen specific, and unfortunately currently difficult to locate.
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Affiliation(s)
- Noortje Grejanne Godijk
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Scott A McDonald
- Centre for Infectious Disease Control, National Institute for Public Health & the Environment, Bilthoven, The Netherlands
| | - Wieke Altorf-van der Kuil
- Centre for Infectious Disease Control, National Institute for Public Health & the Environment, Bilthoven, The Netherlands
| | - Annelot F Schoffelen
- Centre for Infectious Disease Control, National Institute for Public Health & the Environment, Bilthoven, The Netherlands
| | - Eelco Franz
- Centre for Infectious Disease Control, National Institute for Public Health & the Environment, Bilthoven, The Netherlands
| | - Martin C J Bootsma
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Mathematics, Utrecht University, Utrecht, The Netherlands
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Lu X, Zhou B, Hu D, Ding Y. Emergency decompression for patients with ureteral stones and SIRS: a prospective randomized clinical study. Ann Med 2023; 55:965-972. [PMID: 36883206 PMCID: PMC10795631 DOI: 10.1080/07853890.2023.2169343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/11/2023] [Indexed: 03/09/2023] Open
Abstract
OBJECTIVE Patients with ureteral calculi and systemic inflammatory response syndrome (SIRS) often require emergency drainage, and percutaneous nephrostomy (PCN) and retrograde ureteral stent insertion (RUSI) are the most commonly used methods. Our study aimed to identify the best choice (PCN or RUSI) for these patients and to examine the risk factors for progression to urosepsis after decompression. METHODS A prospective, randomized clinical study was performed at our hospital from March 2017 to March 2022. Patients with ureteral stones and SIRS were enrolled and randomized to the PCN or RUSI group. Demographic information, clinical features and examination results were collected. RESULTS Patients (n = 150) with ureteral stones and SIRS were enrolled into our study, with 78 (52%) patients in the PCN group and 72 (48%) patients in the RUSI group. Demographic information was not significantly different between the groups. The final treatment of calculi was significantly different between the two groups (p < .001). After emergency decompression, urosepsis developed in 28 patients. Patients with urosepsis had a higher procalcitonin (p = .012) and blood culture positivity rate (p < .001) and more pyogenic fluids during primary drainage (p < .001) than patients without urosepsis. CONCLUSION PCN and RUSI were effective methods of emergency decompression in patients with ureteral stone and SIRS. Patients with pyonephrosis and a higher PCT should be carefully treated to prevent the progression to urosepsis after decompression.Key messageIn this study, we evaluate the best choice (PCN or RUSI) for patients who have ureteral stones and SIRS and to examine the risk factors for progression to urosepsis after decompression. This study found that PCN and RUSI were effective methods of emergency decompression. Pyonephrosis and higher PCT were risk factors for patients to develop to urosepsis after decompression.
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Affiliation(s)
- Xiaofei Lu
- Department of Urology, Xiang Yang No. 1 Peoples Hospital Affiliated Hospital of Hubei University of Medicine, Xiangyang, China
| | - Benzheng Zhou
- Department of Urology, Xiang Yang No. 1 Peoples Hospital Affiliated Hospital of Hubei University of Medicine, Xiangyang, China
| | - Dechao Hu
- Department of Urology, Xiang Yang No. 1 Peoples Hospital Affiliated Hospital of Hubei University of Medicine, Xiangyang, China
| | - Yanting Ding
- Department of Gynaecology and Obstetrics, Xiang Yang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
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Applying Diagnostic Stewardship to Proactively Optimize the Management of Urinary Tract Infections. Antibiotics (Basel) 2022; 11:antibiotics11030308. [PMID: 35326771 PMCID: PMC8944608 DOI: 10.3390/antibiotics11030308] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/05/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
A urinary tract infection is amongst the most common bacterial infections in the community and hospital setting and accounts for an estimated 1.6 to 2.14 billion in national healthcare expenditure. Despite its financial impact, the diagnosis is challenging with urine cultures and antibiotics often inappropriately ordered for non-specific symptoms or asymptomatic bacteriuria. In an attempt to limit unnecessary laboratory testing and antibiotic overutilization, several diagnostic stewardship initiatives have been described in the literature. We conducted a systematic review with a focus on the application of molecular and microbiological diagnostics, clinical decision support, and implementation of diagnostic stewardship initiatives for urinary tract infections. The most successful strategies utilized a bundled, multidisciplinary, and multimodal approach involving nursing and physician education and feedback, indication requirements for urine culture orders, reflex urine culture programs, cascade reporting, and urinary antibiograms. Implementation of antibiotic stewardship initiatives across the various phases of laboratory testing (i.e., pre-analytic, analytic, post-analytic) can effectively decrease the rate of inappropriate ordering of urine cultures and antibiotic prescribing in patients with clinically ambiguous symptoms that are unlikely to be a urinary tract infection.
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Seizilles de Mazancourt E, Vallée M, Sotto A, Le Goux C, Dihn A, Therby A, Boissier R, Savoie PH, Long JA, Bruyere F. [Infectious emergencies in urology]. Prog Urol 2021; 31:978-986. [PMID: 34420878 DOI: 10.1016/j.purol.2021.07.006] [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: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To report the nature, diagnosis and therapeutic strategy of infectious emergencies in urology. MATERIAL AND METHODS Bibliographic research from Pubmed, Embase, and Google scholar in July 2021. A synthesis of the guidelines of national infectious diseases societies. RESULTS Urosepsis and complicated urinary tract infection have a standardized definition. Diagnosis and therapeutic strategy are presented for upper tract urinary infection, male urinary infection, healthcare associated urinary infection, symptomatic canduria and urinary infections of the elderly. Appropriate antibiotherapy should be tailored to the degree of severity, bacterial ecosystem, patient characteristics et localization of the infection. CONCLUSION Urinary infections can be critical and require immediate care. Knowledge of the guidelines and of appropriate diagnosis and therapeutics strategy improve care which should be rapidly applied, and collegial.
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Affiliation(s)
- E Seizilles de Mazancourt
- Service d'urologie et de la transplantation, Hôpital Édouard-Herriot, hospices civils de Lyon, 69008 Lyon, France
| | - M Vallée
- Service d'urologie, CHRU Poitiers, 86000 Poitiers, France
| | - A Sotto
- Service de maladies infectieuses, CHU Nîmes, 30000 Nîmes, France
| | - C Le Goux
- Centre Alfred-Kastler, Hôpital privé Nord parisien, 95200 Sarcelles, France
| | - A Dihn
- Service de maladies infectieuses, CHU Garches, 92380 France
| | - A Therby
- Service de maladies infectieuses, CH Versailles, 78150 France
| | - R Boissier
- Hopital de la conception, Assistance publique Hôpitaux de Marseille, 13005, France
| | - P H Savoie
- Hôpital d'Instruction des Armées Saint-Anne, BP 600, 83190 Toulon cedex 09
| | - J A Long
- Service d'urologie, Centre hospitalier universitaire de Grenoble, 38000 France; TIMC-IMAG, CNRS 5525, France
| | - F Bruyere
- Service d'urologie, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours cedex, France.
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Prognostic Role of Serum Procalcitonin Measurement in Adult Patients Admitted to the Emergency Department with Fever. ANTIBIOTICS (BASEL, SWITZERLAND) 2021; 10:antibiotics10070788. [PMID: 34209605 PMCID: PMC8300691 DOI: 10.3390/antibiotics10070788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 01/08/2023]
Abstract
Background and Objectives. Fever is one of the most common presenting complaints in the Emergency Department (ED). This study aimed at evaluating the prognostic role of serum Procalcitonin (PCT) measurement among adult patients admitted to the ED with fever. Materials and Methods. This is a retrospective cross-sectional study including all consecutive patients admitted to ED with fever and subsequently hospitalized in a period of six-year (January 2014 to December 2019). Inclusion criteria were age > 18 years, fever (T ≥ 38 °C) or chills within 24 h from presentation to the ED as the main symptom, and availability of a PCT determination obtained <24 h since ED access. The primary endpoint was overall in-hospital mortality. Results. Overall, 6595 patients were included in the study cohort (3734 males, 55.6%), with a median age of 71 [58-81] years. Among these, based on clinical findings and quick sequential organ failure assessment (qSOFA), 422 were considered septic (36.2% deceased), and 6173 patients non-septic (16.2% deceased). After correction for baseline covariates, a PCT > 0.5 ng/mL was an independent risk factor for all-cause in-hospital death in both groups (HR 1.77 [1.27-2.48], and 1.80 [1.59-2.59], respectively). Conclusions. Among adult patients admitted with fever, the PCT assessment in ED could have reduced prognostic power for patients with a high suspicion of sepsis. On the other hand, it could be useful for sepsis rule-out for patients at low risk. In these latter patients, the prognostic role of PCT is higher for those with a final diagnosis of bloodstream infection.
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Clinical Outcome Predictive Value of Procalcitonin in Patients Suspected with Infection in the Emergency Department. Emerg Med Int 2021; 2021:2344212. [PMID: 34221509 PMCID: PMC8213466 DOI: 10.1155/2021/2344212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022] Open
Abstract
Procalcitonin (PCT) may be useful for early risk stratification in the emergency department (ED), but the transposition of published data to routine emergency practice is sometimes limited. An observational retrospective study was conducted in the adult ED of the Reims University Hospital (France). Over one year, 852 patients suspected of infection were included, of mean age 61.7 years (SD: 22.6), and 624 (73.2%) were hospitalized following ED visit. Overall, 82 (9.6%) patients died during their hospitalization with an odds ratio (OR) of 5.10 (95% CI: 2.19-11.87) for PCT ≥ 0.5, in multivariate logistic regression analyses. Moreover, 78 (9.2%) patients were admitted to an ICU, 74 (8.7%) had attributable bacteremia, and 56 (6.6%) evolved toward septic shock with an OR of 4.37 (2.08-9.16), 6.38 (2.67-15.24), and 6.38 (2.41-16.86), respectively, for PCT ≥ 0.5. The highest discriminatory values were found for patients with age <65 years, but PCT lost its discrimination power for in-hospital mortality in patients with a bronchopulmonary infection site or a temperature ≥37.8°C and for ICU admission in patients with severe clinical presentations. PCT could be helpful in risk stratification, but several limitations must be considered, including being sometimes outperformed by a simple clinical examination.
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Gornet M, Leroux P, Ramont L, De Ruffi S, Giordano Orsini G, Losset X, Kanagaratnam L, Gennai S. Lack of admission biomarkers' clinical utility in outcomes prediction in patients suspected with infection in the emergency department. Am J Emerg Med 2021; 47:109-114. [PMID: 33799140 DOI: 10.1016/j.ajem.2021.03.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Initial procalcitonin (PCT) levels may fail in mortality and septic shock prediction and raise cost-effectiveness issues. Since measurement of lactate, C-reactive protein (CRP), white blood cells and neutrophils is common in the emergency department (ED), we compared prediction abilities of these biomarkers to PCT. METHODS From January 1st to December 31st, 2018, an observational, single center, retrospective study was conducted in the adult ED of the Reims University Hospital (France). Endpoints were bacteremia, septic shock, and in-hospital mortality, related to the same ED visit. RESULTS Over one year, 459 patients suspected with infection were included, of mean age 60.4 years (SD: 22.0), with 50.8% male, and 364 (79.3%) were hospitalized following ED visit. Overall, 45 (9.8%) patients had a bacteremia, 39 (8.5%) a septic shock and 54 (11.8%) died during their hospitalization. PCT and CRP showed the best discrimination for bacteremia, with an area under curve (AUC) of 0.68 for PCT and 0.65 for CRP. PCT and lactate showed similar good discriminative power for septic shock, with an AUC of 0.78 for both, and poor discrimination for in-hospital mortality, with an AUC of 0.62 for PCT and 0.69 for lactate. Systolic blood pressure and pulse oximetry showed similar discrimination for septic shock as PCT or lactate, while they showed higher discrimination for in-hospital mortality than PCT. CONCLUSION Usual admission biomarkers lack clinical utility in predicting septic shock or in-hospital mortality. CRP and PCT are poorly efficient in predicting bacteremia.
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Affiliation(s)
- Marion Gornet
- Emergency Department, Reims University Hospital, 45 rue Cognacq-Jay, 51100 Reims, France
| | - Pierre Leroux
- Emergency Department, Reims University Hospital, 45 rue Cognacq-Jay, 51100 Reims, France
| | - Laurent Ramont
- Biochemistry Department, Reims University Hospital, 45 rue Cognacq-Jay, 51100 Reims, France; Université de Reims Champagne-Ardenne, SFR CAP-Santé (FED 4231), Laboratoire de Biochimie Médicale et Biologie Moléculaire, 51 rue Cognacq-Jay, 51100 Reims, France; CNRS UMR 7369, Matrice Extracellulaire et Dynamique Cellulaire-MEDyC, 51 rue Cognacq-Jay, 51100 Reims, France.
| | - Sebastien De Ruffi
- Emergency Department, Reims University Hospital, 45 rue Cognacq-Jay, 51100 Reims, France
| | - Guillaume Giordano Orsini
- Emergency Department, Reims University Hospital, 45 rue Cognacq-Jay, 51100 Reims, France; Université de Reims Champagne-Ardenne, UFR Médecine, 51 rue Cognacq-Jay, 51100 Reims, France.
| | - Xavier Losset
- Emergency Department, Reims University Hospital, 45 rue Cognacq-Jay, 51100 Reims, France.
| | - Lukshe Kanagaratnam
- Université de Reims Champagne-Ardenne, UFR Médecine, 51 rue Cognacq-Jay, 51100 Reims, France; Clinical Research Unit, Reims University Hospital, 45 rue Cognacq-Jay, 51100 Reims, France.
| | - Stéphane Gennai
- Emergency Department, Reims University Hospital, 45 rue Cognacq-Jay, 51100 Reims, France; Université de Reims Champagne-Ardenne, UFR Médecine, 51 rue Cognacq-Jay, 51100 Reims, France.
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Covino M, Gallo A, Montalto M, De Matteis G, Burzo ML, Simeoni B, Murri R, Candelli M, Ojetti V, Franceschi F. The Role of Early Procalcitonin Determination in the Emergency Departiment in Adults Hospitalized with Fever. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020179. [PMID: 33669753 PMCID: PMC7922631 DOI: 10.3390/medicina57020179] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Abstract
Background and Objectives: Fever is one of the most common presenting complaints in the Emergency Department (ED). The role of serum procalcitonin (PCT) determination in the ED evaluation of adults presenting with fever is still debated. The aim of this study was to evaluate if, in adults presenting to the ED with fever and then hospitalized, the early PCT determination could improve prognosis. Materials and Methods. This is a retrospective, mono-centric study, conducted over a 10-year period (2009-2018). We analyzed consecutive patients ≥18 years admitted to ED with fever and then hospitalized. According to quick sequential organ failure assessment (qSOFA) at admission, we compared patients that had a PCT determination vs. controls. Primary endpoint was overall in-hospital mortality; secondary endpoints were in-hospital length of stay, and mortality in patients with bloodstream infection and acute respiratory infections. Results. The sample included 12,062 patients, median age was 71 years and 55.1% were men. In patients with qSOFA ≥ 2 overall mortality was significantly lower if they had a PCT-guided management in ED, (20.5% vs. 26.5%; p = 0.046). In the qSOFA < 2 group the mortality was not significantly different in PCT patients, except for those with a final diagnosis of bloodstream infection. Conclusions. Among adults hospitalized with fever, the PCT evaluation at ED admission was not associated with better outcomes, with the possible exception of patients affected by bloodstream infections. However, in febrile patients presenting to the ED with qSOFA ≥ 2, the early PCT evaluation could improve the overall in-hospital survival.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
- Correspondence:
| | - Antonella Gallo
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (A.G.); (G.D.M.)
| | - Massimo Montalto
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (A.G.); (G.D.M.)
| | - Giuseppe De Matteis
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (A.G.); (G.D.M.)
| | - Maria Livia Burzo
- Emergency Department, Ospedale Generale M.G. Vannini, Istituto Figlie di San Camillo, 00177 Rome, Italy;
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
| | - Rita Murri
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
- Department of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Marcello Candelli
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
| | - Veronica Ojetti
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
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Covino M, Fransvea P, Rosa F, Cozza V, Quero G, Simeoni B, Gasbarrini A, Alfieri S, Franceschi F, Sganga G. Early Procalcitonin Assessment in the Emergency Department in Patients with Intra-Abdominal Infection: An Excess or a Need? Surg Infect (Larchmt) 2021; 22:787-796. [PMID: 33533675 DOI: 10.1089/sur.2020.373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Intra-abdominal infection (IAI) is a wide range of intra-abdominal disease. Management involves empirical therapy and source control. Procalcitonin (PCT) has been suggested to assist in defining individual infection status and delivering individualized therapy. The aim of this study was to investigate the effects on patient outcomes of an early procalcitonin (PCT) assessment (in the emergency department [ED]) in patients with IAI. Methods: This was a retrospective, mono-centric study evaluating consecutive patients admitted to the ED from 2015 to 2019 with diagnosis of IAI. According to whether there had been PCT determination in the ED, patients were divided into no ePCT determination (no-ePCT) and early PCT determination in the ED (ePCT). The primary endpoint was the intra-hospital mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay (LOS). The propensity score match (PSM) was generated using a logistic regression model on the baseline covariates considered to be potentially influencing the decision to determine PCT in the ED and confounding factors identified as significant at a preliminary statistical analysis with respect to in-hospital death. Results: A series of 3,429 patients were included. The ePCT group consisted to 768 (22.4%), whereas the no-ePCT group contained 2,661 patients (77.6%). When the PSM was matched to the two groups, no significant difference was observed. Considering patients with uncomplicated infections, the PCT determination was associated with a higher mortality rate. We found no significant differences regarding outcomes with the exception of LOS, which was slightly longer in the ePCT group. However, we observed a tendency toward a minor difference in the number of complications in the ePCT group, in particular a reduced rate of progression to sepsis. Conclusion: Early PCT determination could be irrelevant in IAIs. The PCT value may be cost-effective and possibly improve the prognosis in cIAIs. Further research is needed to understand the optimal use of PCT, including in combination with other emerging diagnostic tests.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Fausto Rosa
- Digestive Surgery, and Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Valerio Cozza
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery, and Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery, and Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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Rothe K, Spinner CD, Waschulzik B, Janke C, Schneider J, Schneider H, Braitsch K, Smith C, Schmid RM, Busch DH, Katchanov J. A diagnostic algorithm for detection of urinary tract infections in hospitalized patients with bacteriuria: The "Triple F" approach supported by Procalcitonin and paired blood and urine cultures. PLoS One 2020; 15:e0240981. [PMID: 33091046 PMCID: PMC7580978 DOI: 10.1371/journal.pone.0240981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/06/2020] [Indexed: 11/18/2022] Open
Abstract
For acute medicine physicians, distinguishing between asymptomatic bacteriuria (ABU) and clinically relevant urinary tract infections (UTI) is challenging, resulting in overtreatment of ABU and under-recognition of urinary-source bacteraemia without genitourinary symptoms (USB). We conducted a retrospective analysis of ED encounters in a university hospital between October 2013 and September 2018 who met the following inclusion criteria: Suspected UTI with simultaneous collection of paired urinary cultures and blood cultures (PUB) and determination of Procalcitonin (PCT). We sought to develop a simple algorithm based on clinical signs and PCT for the management of suspected UTI. Individual patient presentations were retrospectively evaluated by a clinical "triple F" algorithm (F1 ="fever", F2 ="failure", F3 ="focus") supported by PCT and PUB. We identified 183 ED patients meeting the inclusion criteria. We introduced the term UTI with systemic involvement (SUTI) with three degrees of diagnostic certainty: bacteremic UTI (24.0%; 44/183), probable SUTI (14.2%; 26/183) and possible SUTI (27.9%; 51/183). In bacteremic UTI, half of patients (54.5%; 24/44) presented without genitourinary symptoms. Discordant bacteraemia was diagnosed in 16 patients (24.6% of all bacteremic patients). An alternative focus was identified in 67 patients, five patients presented with S. aureus bacteremia. 62 patients were diagnosed with possible UTI (n = 20) or ABU (n = 42). Using the proposed "triple F" algorithm, dichotomised PCT of < 0.25 pg/ml had a negative predictive value of 88.7% and 96.2% for bacteraemia und accordant bacteraemia respectively. The application of the algorithm to our cohort could have resulted in 33.3% reduction of BCs. Using the diagnostic categories "possible" or "probable" SUTI as a trigger for initiation of antimicrobial treatment would have reduced or streamlined antimicrobial use in 30.6% and 58.5% of cases, respectively. In conclusion, the "3F" algorithm supported by PCT and PUB is a promising diagnostic and antimicrobial stewardship tool.
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Affiliation(s)
- Kathrin Rothe
- Institute for Medical Microbiology, Immunology and Hygiene, School of Medicine, Technical University of Munich, Munich, Germany
- * E-mail:
| | - Christoph D. Spinner
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Birgit Waschulzik
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Janke
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Jochen Schneider
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Heike Schneider
- Department of Clinical Chemistry and Pathobiochemistry, School of Medicine, Technical University of Munich, Munich, Germany
| | - Krischan Braitsch
- Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christopher Smith
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki, Japan
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roland M. Schmid
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dirk H. Busch
- Institute for Medical Microbiology, Immunology and Hygiene, School of Medicine, Technical University of Munich, Munich, Germany
- German Centre for Infection Research (DZIF), partner site Munich, Munich, Germany
| | - Juri Katchanov
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
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11
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Covino M, Piccioni A, Bonadia N, Onder G, Sabia L, Carbone L, Candelli M, Ojetti V, Murri R, Franceschi F. Early procalcitonin determination in the emergency department and clinical outcome of community-acquired pneumonia in old and oldest old patients. Eur J Intern Med 2020; 79:51-57. [PMID: 32409204 DOI: 10.1016/j.ejim.2020.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 03/11/2020] [Accepted: 04/27/2020] [Indexed: 02/05/2023]
Abstract
UNLABELLED We evaluated patients admitted through our ED for community-acquired pneumonia (CAP) to assess the relevance of an early procalcitonin (PCT) determination on patient's outcomes. METHODS We reviewed all patients admitted for CAP in a 10 years period (2008-2017). Patients were stratified according to age groups: (18-65 years; 65-84 years; and ≥85 years), CURB-65 score, need for ventilation, Sepsis-3 criteria at admission, enrollment period, blood culture in ED. In-hospital mortality rate and length of hospital stay (LOS) were compared between patients that had an early PCT determination in ED vs. patients admitted without. RESULTS Our study cohort consisted of 4056 CAP patients, age 76 [IQ range 64-84] years. We enrolled 1039 patients <65 years old, 2015 aged 65-84 years, and 1002 aged ≥85 years. Overall, the early PCT determination in ED was not associated to a reduced LOS (p=0.630), nor to a reduced mortality rate (p=0.134). However, in patients ≥ 85 years, the PCT determination in ED was associated with lower mortality in those with CURB-65 ≥ 2, and Charlson's score ≥ 2 (p=0.033 and p=0.002, respectively). CONCLUSIONS Although an early PCT assessment in ED was not associated with better outcomes in term of LOS and mortality in patients with CAP, our findings suggest that it might be associated with reduced mortality in patients ≥ 85 years with severe CAP or high comorbidity.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Francesco Vito 1, 00168, Roma, Italia.
| | - Andrea Piccioni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Francesco Vito 1, 00168, Roma, Italia
| | - Nicola Bonadia
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Francesco Vito 1, 00168, Roma, Italia
| | - Graziano Onder
- Department of Gerontology, Neuroscience and Orthopedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia; Università Cattolica del Sacro Cuore, Roma, Italia
| | - Luca Sabia
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Francesco Vito 1, 00168, Roma, Italia
| | - Luigi Carbone
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Francesco Vito 1, 00168, Roma, Italia
| | - Marcello Candelli
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Francesco Vito 1, 00168, Roma, Italia
| | - Veronica Ojetti
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Francesco Vito 1, 00168, Roma, Italia; Università Cattolica del Sacro Cuore, Roma, Italia
| | - Rita Murri
- Department of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italia; Università Cattolica del Sacro Cuore, Roma, Italia
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Francesco Vito 1, 00168, Roma, Italia; Università Cattolica del Sacro Cuore, Roma, Italia
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