Ability of procalcitonin to distinguish between bacterial and nonbacterial infection in severe acute exacerbation of chronic obstructive pulmonary syndrome in the ICU

Chronic obstructive pulmonary disease and the airway microbiome: A review for clinicians

Chronic obstructive pulmonary disease (COPD) is a complex heterogeneous disease characterized by progressive airflow limitation and chronic inflammation. The progressive development and long-term repeated acute exacerbation of COPD make many patients still unable to control the deterioration of the disease after active treatment, and even eventually lead to death. An increasing number of studies have shown that the occurrence and development of COPD are closely related to the composition and changes of airway microbiome. This article reviews the interaction between COPD and airway microbiome, the potential mechanisms of interaction, and the treatment methods related to microbiome. We elaborated the internal correlation between airway microbiome and different stages of COPD, inflammatory endotypes, glucocorticoid and antibiotic treatment, analyze the pathophysiological mechanisms such as the "vicious cycle" hypothesis, abnormal inflammation-immune response of the host and the "natural selection" of COPD to airway microbiome, introduce the treatment of COPD related to microbiome and emphasize the predictive value of airway microbiome for the progression, exacerbation and prognosis of COPD, as well as the guiding role for clinical management of patients, in order to provide a new perspective for exploring the pathogenesis of COPD, and also provide clues and guidance for finding new treatment targets.

Comparative Characterization of Procalcitonin (Sensitivity, Specificity, Predictability, and Cut-Off Reference Values) as a Marker of Inflammation in Odontogenic Abscesses of the Head and Neck in the Female Population

Introduction Odontogenic abscesses of the head and neck can lead to serious complications and even end in death. This requires healthcare professionals to have a good knowledge of all the markers of inflammation that can be used in their diagnosis and treatment. Such markers that we use in our daily medical practice are leukocytes (WBC), neutrophils (Neu), and C-reactive protein (CRP). Somehow, in the background is procalcitonin (PCT), which has not been studied in detail in this type of purulent infection. The aim of the present study is to investigate and analyze PCT in odontogenic purulent infections of the head and neck in the female population and to compare it with already proven markers of inflammation such as CRP, WBC, and Neu. For the first time in the literature, as per our knowledge, the sensitivity, specificity, and predictability of PCT were determined when using it as an independent indicator of inflammation, and its cut-off reference values were determined in women with odontogenic abscesses of the head and neck. Materials and methods This is a prospective study, in which the CRP, WBC, Neu, and PCT of 30 women with odontogenic abscesses of the head and neck with a mean age of 47 (18-81) years were examined and analyzed. As a control group, we included 30 healthy women with a mean age of 48 (18-80) years, in whom there was no anamnestic and physical evidence of the presence of any infection in the last three months. The four markers were measured for the control group too. Results In the clinical group of women with odontogenic abscesses of the head and neck, the average values of CRP, WBC, Neu, and PCT were significantly higher (p<0.0001) compared to the same in the control group of healthy women; CRP: 95.46±76.41 mg/l vs. 0.63±0.37 mg/l, WBC: 10.44±2.97x103/L vs. 6.5±1.49x103/L, Neu: 7.92±2.93x103/L vs. 4.03±1.07x103/L, PCT: 0.74±0.69 ng/ml vs. 0.14±0.08 ng/ml. Discussion PCT, as well as CRP, WBC, and Neu, increases its plasma concentration in women with odontogenic abscesses of the head and neck and is extremely well positively correlated with them, with a high correlation with CRP and a significant correlation with WBC and Neu. In addition, PCT has a number of advantages over the other markers; it begins to increase its plasma concentration faster, reaches its maximum plasma concentration faster, normalizes its concentration faster after the infection subsides, and increases its blood level only in bacterial infection genesis. Conclusions PCT as a marker of inflammation not only positively correlates well with CRP, WBC, and Neu but also, with its advantages over them, it appears to be the most accurate indicator in the diagnosis, treatment, and follow-up of odontogenic head and neck abscesses in the near future; not only in women but also in the male and children's population. Its sensitivity, specificity, and predictability as an independent indicator of inflammation are 80%, 76.7%, and 83%, respectively, and its cut-off value of 0.225 ng/ml is lower than the generally accepted 0.5 ng/ml.

Reduced Reliability of Procalcitonin (PCT) as a Biomarker of Bacterial Superinfection: Concerns about PCT-Driven Antibiotic Stewardship in Critically Ill COVID-19 Patients-Results from a Retrospective Observational Study in Intensive Care Units

BACKGROUND

The aim of this study was to assess whether procalcitonin levels is a diagnostic tool capable of accurately identifying sepsis and ventilator-associated pneumonia (VAP) even in critically ill COVID-19 patients.

METHODS

In this retrospective, observational study, all critically ill COVID-19 patients who survived for ≥2 days in a single university hospital and had at least one serum procalcitonin (PCT) value and associated blood culture and/or culture from a lower respiratory tract specimen available were eligible for the study.

RESULTS

Over the research period, 184 patients were recruited; 67 VAP/BSI occurred, with an incidence rate of 21.82 episodes of VAP/BSI (95% CI: 17.18-27.73) per 1000 patient-days among patients who were included. At the time of a positive microbiological culture, an average PCT level of 1.25-3.2 ng/mL was found. Moreover, also in subjects without positive cultures, PCT was altered in 21.7% of determinations, with an average value of 1.04-5.5 ng/mL. Both PCT and PCT-72 h were not linked to a diagnosis of VAP/BSI in COVID-19 patients, according to the multivariable GEE models (aOR 1.13, 95% CI 0.51-2.52 for PCT; aOR 1.32, 95% CI 0.66-2.64 for PCT-72 h).

CONCLUSION

Elevated PCT levels might not always indicate bacterial superinfections or coinfections in a severe COVID-19 setting.

Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the ICU: An Observational Study From the OUTCOMEREA Database, 1997-2018

OBJECTIVES

Our aim was to describe changes in the management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) by ICUs and patient outcomes.

DESIGN

We extracted data from the OutcomeRea database concerning patients admitted for AECOPD between 1997 and 2018. We analyzed trends in the use of ventilatory support, corticosteroid therapy, antibiotic therapy, and patient survival.

SETTING

ICUs at 32 French sites.

PATIENTS

One thousand eight hundred sixteen patients in the database had a diagnosis of AECOPD.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Over time, there was a reduction in the prescription of corticosteroids and antibiotics. In a time-series analysis, these changes in practice were not linked with ICU mortality. The proportion of patients treated with invasive mechanical ventilation (IMV) also gradually declined (from 51% between 1997 and 2002 to 35% between 2013 and 2018) with an association between decrease in IMV use and reduction in ICU mortality in a time series analysis. Rates of noninvasive ventilation (NIV) failure decreased with an increase in NIV use to support weaning from IMV. There was a reduction in the median ICU length of stay (from 8 d in 1997-2002 to 4 d in 2013-2018) and in the median total duration of hospitalization (from 23 d in 1997-2002 to 14 d in 2013-2018). We observed an improvement in prognosis, with decreases in overall hospital mortality (from 24% between 1997 and 2002 to 15% between 2013 and 2018), ICU mortality (from 14% between 1997 and 2002 to 10% between 2013 and 2018), and 90-day mortality (from 41% between 1997 and 2002 to 22% between 2013 and 2018).

CONCLUSIONS

The length of stay and mortality of patients with AECOPD admitted to ICUs has decreased over the last 20 years, with a wider use of NIV and a reduction in antibiotic and corticosteroid prescriptions.

Early antibiotic therapy is associated with a lower probability of successful liberation from mechanical ventilation in patients with severe acute exacerbation of chronic obstructive pulmonary disease

Background

While antibiotic therapy is advocated to improve outcomes in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) whenever mechanical ventilation is required, the evidence relies on small studies carried out before the era of widespread antibiotic resistance. Furthermore, the impact of systematic antibiotic therapy on successful weaning from mechanical ventilation was never investigated accounting for the competitive risk of death. The aim of the study was to assess whether early antibiotic therapy (eABT) increases successful mechanical ventilation weaning probability as compared to no eABT, in patients with AECOPD without pneumoniae, using multivariate competitive risk regression.

Methods

Retrospective analysis of patients admitted in 2 intensive care units (ICU) from 2012 to 2020 for AECOPD without pneumonia and requiring mechanical ventilation. eABT was defined as any anti-bacterial chemotherapy introduced during the first 24 h after ICU admission. The primary outcomes were the adjusted subdistribution hazard ratio (SHR) of the probability of being successfully weaned from mechanical ventilation (i.e. non-invasive and invasive ventilation) according to eABT status and accounting for the competitive risk of death.

Results

Three hundred and ninety-one patients were included, of whom 66% received eABT. eABT was associated with a lower probability of successful liberation from mechanical ventilation when accounting for the competing risk of death in multivariate analyses (SHR 0.71 [95% confidence interval, 0.57–0.89], p < 0.01), after adjustment with covariates of disease severity. This association was present in all subgroups except in patients under invasive mechanical ventilation on ICU day-1, in patients with ICU day-1 worst PaCO₂ > 74 torr (median value) and in patients with a documented bacterial bronchitis at ICU admission. Ventilator-free days at day 28, ICU-free days at day 28 and invasive mechanical ventilation-free days at day 28, were significantly lower in the eABT group, while there was no significant difference in mortality at day 28 between patients who received eABT and those who did not.

Conclusions

eABT was independently associated with a lower probability of being successfully weaned from mechanical ventilation, suggesting that the clinician decision to overrule systematic administration of eABT was not associated with a detectable harm in AECOPD ICU patients without pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01060-2.

IL-6 and IL-10 Are Associated With Gram-Negative and Gram-Positive Bacteria Infection in Lymphoma

To investigate the Th1/Th2 cytokine profile in patients with lymphoma during the myelosuppression stage of infection. 52 patients with gram-negative bacterial infection (G- group), 49 patients with gram-positive bacterial infection (G+ group), 51 uninfected patients with lymphoma (uninfected group) and 20 healthy controls (healthy group) were enrolled in this study. We evaluated the quantification of Th1/Th2 cytokines with flow cytometry bead assay (CBA) in the sera to explore a rapid diagnostic method to determine the type of infection and anti-infective effect. The levels of procalcitonin (PCT) were also detected simultaneously. The four groups did not differ with regard to IL-2 and IL-4 (P>0.05). The IFN-γ and TNF-α levels of patients with lymphoma were higher than those of healthy controls (P<0.05). There was significantly upregulated IL-6 and IL-10 expression in the G- group (P<0.001). A similar trend was reflected in the IL-6 of the G+ group, which was significantly increased (P<0.001). However, no significant upregulation was observed for IL-10 in the G+ group. According to the different degrees of increased IL-6 and IL-10 levels, We proposed to use the G- Bacterial Infection Cytokine Profile (G- BICP) and the G+ Bacterial Infection Cytokine Profile (G+ BICP) for the first time to differentiate between Gram-negative and Gram-positive (G-/G+) bacterial infection in adults with lymphoma in the myelosuppression stage after chemotherapy. The IL-6, IL-10 and PCT in the G- group and the IL-6, PCT in the G+ group were significantly decreased at day 4 and day 8 compared with those at day 1. IL-6 and IL-10 are closely associated with the severity and treatment efficacy in adults with lymphomas who develop infections after chemotherapy and can help distinguish between G- and G+ bacterial infections at an early stage.