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Pan T, Guo X, Yang D, Ding J, Chen C. Expression and significance of procalcitonin, leukotriene B4, serum amyloid A, and C-reactive protein in children with different types of pneumonia: An observational study. Medicine (Baltimore) 2024; 103:e37817. [PMID: 38728486 PMCID: PMC11081565 DOI: 10.1097/md.0000000000037817] [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: 11/23/2023] [Accepted: 03/15/2024] [Indexed: 05/12/2024] Open
Abstract
This study aimed to investigate the expression and significance of serum procalcitonin (PCT), leukotriene B4 (LTB4), Serum amyloid A (SAA), and C-reactive protein (CRP) in children with different types of pneumonia caused by different pathogenic infections. One hundred and one children with pneumonia admitted to The Fifth People Hospital of Zhuhai from July 2019 to June 2020 were enrolled and divided into 38 cases in the bacterial group, 30 cases in the mycoplasma group, and 33 cases in the virus group according to the different types of pathogens. The patients were divided into 42 cases in the noncritical group, 33 cases in the critical group, and 26 cases in the very critical group according to the pediatric clinical illness score (PCIS), and 30 healthy children were selected as the control group during the same period. Comparison of serum PCT, SAA: bacterial group > mycoplasma group > viral group > control group with significant differences (P < .05). Receiver operator characteristic (ROC) analysis showed that the area under the curves (AUCs) of serum PCT, LTB4, SAA, and CRP for the diagnosis of bacterial pneumonia were 1.000, 0.531, 0.969, and 0.833, respectively, and the AUCs for the diagnosis of mycoplasma pneumonia were 0.653, 0.609, 0.547, and 0.652, respectively, and the AUCs for the diagnosis of viral pneumonia were 0.888, 0.570, 0.955, and 1.000, respectively. Comparison of serum PCT, LTB4, SAA: very critical group > critical group > noncritical group > control group, with significant differences (P < .05). Serum PCT, LTB4, and SAA were negatively correlated with PCIS score by Pearson analysis (P < .05). Serum PCT and SAA showed diagnostic value for bacterial pneumonia, and serum SAA and CRP showed diagnostic value for viral pneumonia; serum PCT, LTB4, and SAA correlate with severity of disease and show higher expression with worsening of the condition.
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Affiliation(s)
- Tinghui Pan
- Department of Paediatrics, The Fifth People’s Hospital of Zhuhai, Zhuhai, Guangdong, China
| | - Xiwen Guo
- Department of Human Anatomy and Histology & Embryology, Zunyi Medical University, Zhuhai Campus, Zhuhai, Guangdong, China
| | - Dehui Yang
- Department of Paediatrics, The Fifth People’s Hospital of Zhuhai, Zhuhai, Guangdong, China
| | - Jundong Ding
- Department of Paediatrics, The Fifth People’s Hospital of Zhuhai, Zhuhai, Guangdong, China
| | - Chengxian Chen
- Department of Neuromedicine, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
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2
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Kwa ALH, Aninda Sidharta BR, Son DN, Zirpe K, Periyasamy P, Plongla R, Swaminathan S, Loho T, Van Giap V, Apisarnthanarak A. Clinical utility of procalcitonin in implementation of procalcitonin-guided antibiotic stewardship in the South-East Asia and India: evidence and consensus-based recommendations. Expert Rev Anti Infect Ther 2024; 22:45-58. [PMID: 38112181 DOI: 10.1080/14787210.2023.2296066] [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: 05/29/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION The South-East Asian (SEA) region and India are highly susceptible to antibiotic resistance, which is caused due to lack of antimicrobial stewardship (AMS) knowledge, uncontrolled use of antibiotics, and poor infection control. Nonadherence to national/local guidelines, developed to combat antimicrobial resistance, is a major concern. A virtual advisory board was conducted to understand the current AMS standards and challenges in its implementation in these regions. AREAS COVERED Procalcitonin (PCT)-guided antibiotic use was discussed in various clinical conditions across initiation, management, and discontinuation stages. Most experts strongly recommended using PCT-driven antibiotic therapy among patients with lower respiratory tract infections, sepsis, and COVID-19. However, additional research is required to understand the optimal use of PCT in patients with organ transplantation and cancer patients with febrile neutropenia. Implementation of the solutions discussed in this review can help improve PCT utilization in guiding AMS in these regions and reducing challenges. EXPERT OPINION Experts strongly support the inclusion of PCT in AMS. They believe that PCT in combination with other clinical data to guide antibiotic therapy may result in more personalized and precise targeted antibiotic treatment. The future of PCT in antibiotic treatment is promising and may result in effective utilization of this biomarker.
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Affiliation(s)
- Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital; Emerging Infectious Diseases Program, Duke-National University of Singapore Medical School, Singapore, Singapore
| | | | - Do Ngoc Son
- Center for Critical Care Medicine, Bach Mai Hospital; Hanoi Medical University; School of Medicine and Pharmacy, Hanoi National University, Hanoi, Vietnam
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, India
| | - Petrick Periyasamy
- Infectious Diseases Unit, Medical Department, Hospital Canselor Tuanku Muhriz UKM, Kuala Lumpur, Malaysia
| | - Rongpong Plongla
- Division of Infectious Diseases, Department of Medicine and Center of Excellence in Antimicrobial Resistance and Stewardship; Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Tonny Loho
- Department of Clinical Pathology, Medistra Hospital; Medicine and Health Sciences, Universitas Kristen Krida Wacana, Jakarta, Indonesia
| | - Vu Van Giap
- Training and Direction of Healthcare Activities Center; Internal Medicine Department, Hanoi Medical University; Vietnam Respiratory Society; Vietnam Society of Sleep Medicine; Respiratory Center, Bach Mai Hospital, Hanoi, Vietnam
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Bessat C, Boillat-Blanco N, Albrich WC. The potential clinical value of pairing procalcitonin and lung ultrasonography to guide antibiotic therapy in patients with community-acquired pneumonia: a narrative review. Expert Rev Respir Med 2023; 17:919-927. [PMID: 37766614 DOI: 10.1080/17476348.2023.2254232] [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: 05/20/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Lower respiratory tract infections (LRTIs) are among the most frequent infections and are prone to inappropriate antibiotic treatments. This results from a limited accuracy of diagnostic tools in identifying bacterial pneumonia. Lung ultrasound (LUS) has excellent sensitivity and specificity in diagnosing pneumonia. Additionally, elevated procalcitonin (PCT) levels correlate with an increased likelihood of bacterial infection. LUS and PCT appear to be complementary in identifying patients with bacterial pneumonia who are likely to benefit from antibiotics. AREAS COVERED This narrative review aims to summarize the current evidence for LUS to diagnose pneumonia, for PCT to guide antibiotic therapy and the clinical value of pairing both tools. EXPERT OPINION LUS has excellent diagnostic accuracy for pneumonia in different settings, regardless of the examiner's experience. PCT guidance safely reduces antibiotic prescription in LRTIs. The combination of both tools has demonstrated an enhanced accuracy in the diagnosis of pneumonia, including CAP in the ED and VAP in the ICU, but randomized controlled studies need to validate the clinical impact of a combined approach.
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Affiliation(s)
- Cécile Bessat
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Werner C Albrich
- Division of Infectious Diseases & Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
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4
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Chambliss AB, Patel K, Colón-Franco JM, Hayden J, Katz SE, Minejima E, Woodworth A. AACC Guidance Document on the Clinical Use of Procalcitonin. J Appl Lab Med 2023; 8:598-634. [PMID: 37140163 DOI: 10.1093/jalm/jfad007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Procalcitonin (PCT), a peptide precursor of the hormone calcitonin, is a biomarker whose serum concentrations are elevated in response to systemic inflammation caused by bacterial infection and sepsis. Clinical adoption of PCT in the United States has only recently gained traction with an increasing number of Food and Drug Administration-approved assays and expanded indications for use. There is interest in the use of PCT as an outcomes predictor as well as an antibiotic stewardship tool. However, PCT has limitations in specificity, and conclusions surrounding its utility have been mixed. Further, there is a lack of consensus regarding appropriate timing of measurements and interpretation of results. There is also a lack of method harmonization for PCT assays, and questions remain regarding whether the same clinical decision points may be used across different methods. CONTENT This guidance document aims to address key questions related to the use of PCT to manage adult, pediatric, and neonatal patients with suspected sepsis and/or bacterial infections, particularly respiratory infections. The document explores the evidence for PCT utility for antimicrobial therapy decisions and outcomes prediction. Additionally, the document discusses analytical and preanalytical considerations for PCT analysis and confounding factors that may affect the interpretation of PCT results. SUMMARY While PCT has been studied widely in various clinical settings, there is considerable variability in study designs and study populations. Evidence to support the use of PCT to guide antibiotic cessation is compelling in the critically ill and in some lower respiratory tract infections but is lacking in other clinical scenarios, and evidence is also limited in the pediatric and neonatal populations. Interpretation of PCT results requires guidance from multidisciplinary care teams of clinicians, pharmacists, and clinical laboratorians.
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Affiliation(s)
- Allison B Chambliss
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Khushbu Patel
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Joshua Hayden
- Department of Laboratories, Norton Healthcare, Louisville, KY, United States
| | - Sophie E Katz
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Emi Minejima
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, United States
| | - Alison Woodworth
- Department of Pathology and Laboratory Medicine, University of Kentucky Medical Center, Lexington, KY, United States
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5
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Shojaei M, Chen UI, Midic U, Thair S, Teoh S, McLean A, Sweeney TE, Thompson M, Liesenfeld O, Khatri P, Tang B. Multisite validation of a host response signature for predicting likelihood of bacterial and viral infections in patients with suspected influenza. Eur J Clin Invest 2023; 53:e13957. [PMID: 36692131 DOI: 10.1111/eci.13957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/08/2022] [Accepted: 01/05/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Indiscriminate use of antimicrobials and antimicrobial resistance is a public health threat. IMX-BVN-1, a 29-host mRNA classifier, provides two separate scores that predict likelihoods of bacterial and viral infections in patients with suspected acute infections. We validated the performance of IMX-BVN-1 in adults attending acute health care settings with suspected influenza. METHOD We amplified 29-host response genes in RNA extracted from blood by NanoString nCounter. IMX-BVN-1 calculated two scores to predict probabilities of bacterial and viral infections. Results were compared against the infection status (no infection; highly probable/possible infection; confirmed infection) determined by clinical adjudication. RESULTS Amongst 602 adult patients (74.9% ED, 16.9% ICU, 8.1% outpatients), 7.6% showed in-hospital mortality and 15.5% immunosuppression. Median IMX-BVN-1 bacterial and viral scores were higher in patients with confirmed bacterial (0.27) and viral (0.62) infections than in those without bacterial (0.08) or viral (0.21) infection, respectively. The AUROC distinguishing bacterial from nonbacterial illness was 0.81 and 0.87 when distinguishing viral from nonviral illness. The bacterial top quartile's positive likelihood ratio (LR) was 4.38 with a rule-in specificity of 88%; the bacterial bottom quartile's negative LR was 0.13 with a rule-out sensitivity of 96%. Similarly, the viral top quartile showed an infinite LR with rule-in specificity of 100%; the viral bottom quartile had a LR of 0.22 and a rule-out sensitivity of 85%. CONCLUSION IMX-BVN-1 showed high accuracy for differentiating bacterial and viral infections from noninfectious illness in patients with suspected influenza. Clinical utility of IMX-BVN will be validated following integration into a point of care system.
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Affiliation(s)
- Maryam Shojaei
- Department of Medicine, Sydney Medical School Nepean, Nepean Hospital, University of Sydney, Penrith, New South Wales, Australia.,Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia.,Centre for Immunology and Allergy Research, Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Uan-I Chen
- Inflammatix, Inc., Sunnyvale, California, USA
| | - Uros Midic
- Inflammatix, Inc., Sunnyvale, California, USA
| | | | - Sally Teoh
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia
| | - Anthony McLean
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia
| | | | | | | | | | - Benjamin Tang
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia.,Centre for Immunology and Allergy Research, Westmead Institute for Medical Research, Westmead, New South Wales, Australia
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6
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Yousuf S, Rzewuska M, Duncan E, Ramsay C. Identification of outcomes reported for hospital antimicrobial stewardship interventions using a systematic review of reviews. JAC Antimicrob Resist 2023; 5:dlac127. [PMID: 36601549 PMCID: PMC9806591 DOI: 10.1093/jacamr/dlac127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/25/2022] [Indexed: 01/03/2023] Open
Abstract
Background Randomized trials of hospital antimicrobial stewardship (AMS) interventions aimed to optimize antimicrobial use contribute less to the evidence base due to heterogeneity in outcome selection and reporting. Developing a core outcome set (COS) for these interventions can be a way to address this problem. The first step in developing a COS is to identify and map all outcomes. Objectives To identify outcomes reported in systematic reviews of hospital AMS interventions. Methods Cochrane Database of Systematic Reviews, MEDLINE and Embase were searched for systematic reviews published up until August 2019 of interventions relevant to reducing unnecessary antimicrobial use for inpatient populations in secondary care hospitals. The methodological quality of included reviews was assessed using AMSTAR-2, A (revised) MeaSurement Tool to Assess systematic Reviews. Extracted outcomes were analysed using deductive and inductive thematic analysis. A list of overarching (unique) outcomes reflects the outcomes identified within the systematic reviews. Results Forty-one systematic reviews were included. Thirty-three (81%) systematic reviews were of critically low or low quality. A long list of 1739 verbatim outcomes was identified and categorized under five core areas of COMET (Core Outcome Measures in Effectiveness Trials) taxonomy: 'resources use' (45%), 'physiological/clinical' (27%), 'life impact' (16%), 'death' (8%) and 'adverse events' (4%). A total of 421 conceptually different outcomes were identified and grouped into 196 overarching outcomes. Conclusions There is significant heterogeneity in outcomes reported for hospital AMS interventions. Reported outcomes do not cover all domains of the COMET framework and may miss outcomes relevant to patients (e.g. emotional, social functioning, etc.). The included systematic reviews lacked methodological rigour, which warrants further improvements.
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Affiliation(s)
- Shazia Yousuf
- Corresponding author. E-mail: ; @shaziaYousuf11, @RzewuskaM, @EilidhMDuncan, @ProfRamsay
| | - Magdalena Rzewuska
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK
| | - Eilidh Duncan
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK
| | - Craig Ramsay
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK
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7
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Schuetz P. How to best use procalcitonin to diagnose infections and manage antibiotic treatment. Clin Chem Lab Med 2022; 61:822-828. [PMID: 36317790 DOI: 10.1515/cclm-2022-1072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022]
Abstract
Abstract
Objectives
Procalcitonin (PCT) is a host-response biomarker that has shown clinical value for assessing the likelihood of bacterial infections and guiding antibiotic treatment. Identifying situations where PCT can improve clinical care is therefore highly important.
Methods
The aim of this narrative review is to discuss strategies for the usage and integration of PCT into clinical routine, based on the most recent clinical evidence.
Results
Although PCT should not be viewed as a traditional diagnostic marker, it can help differentiate bacterial from non-bacterial infections and inflammation states – particularly in respiratory illness. Several trials have found that PCT-guided antibiotic stewardship reduces antibiotic exposure and associated side-effects among patients with respiratory infection and sepsis. Studies have demonstrated that patient-specific decisions regarding antibiotic usage is highly complex. Factors to consider include: the clinical situation (with a focus on the pretest probability for bacterial infection), the acuity and severity of presentation, as well as PCT test results. Low PCT levels help rule out bacterial infection in patients with both low pretest probability for bacterial infection and low-risk general condition. In high-risk individuals and/or high pretest probability for infection, empiric antibiotic treatment is mandatory. Subsequent monitoring of PCT helps track the resolution of infection and guide decisions regarding early termination of antibiotic treatment.
Conclusions
PCT possesses high potential to improve decision-making regarding antibiotic treatment – when combined with careful patient assessment, evidence-based clinical algorithms, and continuous notification and regular feedback from all antibiotic stewardship stakeholders. Medical Journals such as Clinical Chemistry and Laboratory Medicine (CCLM) have played a critical role in reviewing and dissemination the high-quality evidence about assays for PCT measurement, observational research regarding association with outcomes among different populations, and interventional research proofing its effectiveness for patient care.
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Affiliation(s)
- Philipp Schuetz
- Department of Internal Medicine , Kantonsspital Aarau , Aarau , Switzerland
- University of Basel , Basel , Switzerland
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8
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Atallah CJ, Panossian VS, Atallah NJ, Roberts MB, Mansour MK. Extra-pulmonary applications of procalcitonin: an updated literature review. Expert Rev Mol Diagn 2022; 22:537-544. [PMID: 35757858 DOI: 10.1080/14737159.2022.2094705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION : Procalcitonin (PCT) is a biomarker with established performance in the differentiation between bacterial and viral infections, predominantly in pulmonary infections, as well as the diagnosis and prognosis of bacterial sepsis. However, the role of PCT in extra-pulmonary infections is not well described. AREAS COVERED : We reviewed the role of PCT in commonly experienced extra-pulmonary infections including meningitis, diabetic foot infection, prosthetic joint infection, osteomyelitis, and skin and soft tissue infection. PubMed and Medline online libraries were searched, from 2013 till 2022, for relevant articles. EXPERT OPINION : For meningitis, PCT could distinguish bacterial from viral meningitis. PCT distinguished septic arthritis from different types of arthritis but had variable performance in discriminating septic arthritis from crystal arthropathy. For periprosthetic joint infections, results were inconclusive. PCT had a potential role in diagnosis of more complex infections such as osteomyelitis and diabetic foot infections, but further studies are needed for a definitive cutoff. In skin and soft tissue infections, PCT performance was more variable requiring further investigation to define cutoff for the discrimination of cellulitis from necrotizing fasciitis. We find that PCT performed best for meningitis and helps in the reduction of unnecessary antibiotic treatment, but has variable outcomes with other extra-pulmonary infections.
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Affiliation(s)
| | - Vahe S Panossian
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Natalie J Atallah
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew B Roberts
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Mansour
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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9
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Patel N, Adams C, Brunetti L, Bargoud C, Teichman AL, Choron RL. Evaluation of Procalcitonin's Utility to Predict Concomitant Bacterial Pneumonia in Critically Ill COVID-19 Patients. J Intensive Care Med 2022; 37:1486-1492. [PMID: 35711161 PMCID: PMC9207592 DOI: 10.1177/08850666221108636] [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] [Indexed: 11/20/2022]
Abstract
Background: Historically, procalcitonin(PCT) has been used as a
predictor of bacterial infection and to guide antibiotic therapy in hospitalized
patients. The purpose of this study was to determine PCT's diagnostic utility in
predicting secondary bacterial pneumonia in critically ill patients with severe
COVID-19 pneumonia. Methods: A retrospective cohort study was
conducted in COVID-19 adults admitted to the ICU between March 2020, and March
2021. All included patients had a PCT level within 72 h of presentation and
serum creatinine of <1.5mg/dL. A PCT threshold of 0.5ng/mL was used to
compare patients with high( ≥ 0.5ng/mL) versus low(< 0.5ng/mL) PCT. Bacterial
pneumonia was defined by positive respiratory culture. A receiver operating
characteristics (ROC) curve was utilized to evaluate PCT as a diagnostic test
for bacterial pneumonia, with an area under the curve(AUC) threshold of 0.7 to
signify an accurate diagnostic test. A multivariable model was constructed to
identify variables associated with in-hospital mortality. Results:
There were 165 patients included: 127 low PCT versus 38 high PCT. There was no
significant difference in baseline characteristics, vital signs, severity of
disease, or outcomes among low versus high PCT groups (all
p > 0.05). While there was no difference in bacterial
pneumonia in low versus high groups (34(26.8%) versus 12(31.6%),
p = 0.562), more patients in the high PCT
group had bacteremia (19(15%) versus 11(28.9%),
p = 0.050). Sensitivity was 26.1% and
specificity was 78.2% for PCT to predict bacterial pneumonia coinfection in ICU
patients with COVID-19 pneumonia. ROC yielded an AUC 0.54
(p = 0.415). After adjusting for LDH>350U/L and creatinine
in multivariable regression, PCT did not enhance performance of the regression
model. Conclusions: PCT offers little to no predictive utility in
diagnosing concomitant bacterial pneumonia in critically ill patients with
COVID-19 nor in predicting increased severity of disease or worse outcomes
including mortality.
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Affiliation(s)
- Nandini Patel
- 15484Ernest Mario School of Pharmacy, Piscataway, NJ 08854, USA
| | - Christopher Adams
- 15484Ernest Mario School of Pharmacy, Piscataway, NJ 08854, USA.,43982Robert Wood Johnson University Hospital Somerset, Somerville, NJ 08876, USA
| | - Luigi Brunetti
- 15484Ernest Mario School of Pharmacy, Piscataway, NJ 08854, USA.,43982Robert Wood Johnson University Hospital Somerset, Somerville, NJ 08876, USA
| | | | - Amanda L Teichman
- 43982Robert Wood Johnson University Hospital Somerset, Somerville, NJ 08876, USA.,43982Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Rachel L Choron
- 43982Robert Wood Johnson University Hospital Somerset, Somerville, NJ 08876, USA.,43982Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
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10
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Ross M, Henao R, Burke TW, Ko ER, McClain MT, Ginsburg GS, Woods CW, Tsalik EL. A comparison of host response strategies to distinguish bacterial and viral infection. PLoS One 2021; 16:e0261385. [PMID: 34905580 PMCID: PMC8670660 DOI: 10.1371/journal.pone.0261385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/29/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Compare three host response strategies to distinguish bacterial and viral etiologies of acute respiratory illness (ARI). METHODS In this observational cohort study, procalcitonin, a 3-protein panel (CRP, IP-10, TRAIL), and a host gene expression mRNA panel were measured in 286 subjects with ARI from four emergency departments. Multinomial logistic regression and leave-one-out cross validation were used to evaluate the protein and mRNA tests. RESULTS The mRNA panel performed better than alternative strategies to identify bacterial infection: AUC 0.93 vs. 0.83 for the protein panel and 0.84 for procalcitonin (P<0.02 for each comparison). This corresponded to a sensitivity and specificity of 92% and 83% for the mRNA panel, 81% and 73% for the protein panel, and 68% and 87% for procalcitonin, respectively. A model utilizing all three strategies was the same as mRNA alone. For the diagnosis of viral infection, the AUC was 0.93 for mRNA and 0.84 for the protein panel (p<0.05). This corresponded to a sensitivity and specificity of 89% and 82% for the mRNA panel, and 85% and 62% for the protein panel, respectively. CONCLUSIONS A gene expression signature was the most accurate host response strategy for classifying subjects with bacterial, viral, or non-infectious ARI.
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Affiliation(s)
- Melissa Ross
- Duke University School of Medicine, Durham, NC, United States of America
| | - Ricardo Henao
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, United States of America
| | - Thomas W. Burke
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Emily R. Ko
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Duke Regional Hospital, Durham, NC, United States of America
| | - Micah T. McClain
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Medical Service, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Geoffrey S. Ginsburg
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Christopher W. Woods
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Medical Service, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Ephraim L. Tsalik
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Emergency Medicine Service, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
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11
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Skjøt-Arkil H, Heltborg A, Lorentzen MH, Cartuliares MB, Hertz MA, Graumann O, Rosenvinge FS, Petersen ERB, Østergaard C, Laursen CB, Skovsted TA, Posth S, Chen M, Mogensen CB. Improved diagnostics of infectious diseases in emergency departments: a protocol of a multifaceted multicentre diagnostic study. BMJ Open 2021; 11:e049606. [PMID: 34593497 PMCID: PMC8487181 DOI: 10.1136/bmjopen-2021-049606] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The major obstacle in prescribing an appropriate and targeted antibiotic treatment is insufficient knowledge concerning whether the patient has a bacterial infection, where the focus of infection is and which bacteria are the agents of the infection. A prerequisite for the appropriate use of antibiotics is timely access to accurate diagnostics such as point-of-care (POC) testing.The study aims to evaluate diagnostic tools and working methods that support a prompt and accurate diagnosis of hospitalised patients suspected of an acute infection. We will focus on the most common acute infections: community-acquired pneumonia (CAP) and acute pyelonephritis (APN). The objectives are to investigate (1) patient characteristics and treatment trajectory of the different acute infections, (2) diagnostic and prognostic accuracy of infection markers, (3) diagnostic accuracy of POC urine flow cytometry on diagnosing and excluding bacteriuria, (4) how effective the addition of POC analysis of sputum to the diagnostic set-up for CAP is on antibiotic prescriptions, (5) diagnostic accuracy of POC ultrasound and ultralow dose (ULD) computerized tomography (CT) on diagnosing CAP, (6) diagnostic accuracy of specialist ultrasound on diagnosing APN, (7) diagnostic accuracy of POC ultrasound in diagnosing hydronephrosis in patients suspected of APN. METHODS AND ANALYSIS It is a multifaceted multicentre diagnostic study, including 1000 adults admitted with suspicion of an acute infection. Participants will, within the first 24 hours of admission, undergo additional diagnostic tests including infection markers, POC urine flow cytometry, POC analysis of sputum, POC and specialist ultrasound, and ULDCT. The primary reference standard is an assigned diagnosis determined by a panel of experts. ETHICS, DISSEMINATION AND REGISTRATION Approved by Regional Committees on Health Research Ethics for Southern Denmark, Danish Data Protection Agency and clinicaltrials.gov. Results will be presented in peer-reviewed journals, and positive, negative and inconclusive results will be published. TRIAL REGISTRATION NUMBERS NCT04661085, NCT04681963, NCT04667195, NCT04652167, NCT04686318, NCT04686292, NCT04651712, NCT04645030, NCT04651244.
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Affiliation(s)
- Helene Skjøt-Arkil
- Emergency Department, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Anne Heltborg
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Department of Internal Medicine, University Hospital of Southern Denmark, Sønderborg, Denmark
| | - Morten Hjarnø Lorentzen
- Emergency Department, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Mariana Bichuette Cartuliares
- Emergency Department, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Mathias Amdi Hertz
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Ole Graumann
- Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | | | - Eva Rabing Brix Petersen
- Blood Samples, Biochemistry and Immunology, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Claus Østergaard
- Department of Clinical Microbiology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Christian B Laursen
- Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Thor Aage Skovsted
- Blood Samples, Biochemistry and Immunology, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Stefan Posth
- Department of Clinical Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Emergency Department, Odense University Hospital, Odense, Denmark
| | - Ming Chen
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Department of Microbiology, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Christian Backer Mogensen
- Emergency Department, University Hospital of Southern Denmark, Aabenraa, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
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12
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DeSear KE, Thompson-Leduc P, Van Schooneveld TC, Kirson N, Chritton JJ, Ie S, Cheung HC, Ou S, Zimmer L, Schuetz P. Decreased antibiotic exposure using a procalcitonin protocol for respiratory infections and sepsis in US community hospitals (ProCommunity). Curr Med Res Opin 2021; 37:727-733. [PMID: 33617362 DOI: 10.1080/03007995.2021.1893675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Antibiotic overuse leading to antimicrobial resistance is a global public health concern. Clinical trials have demonstrated that procalcitonin-based decision-making for antibiotic therapy can safely decrease inappropriate antibiotic use in patients with respiratory infections and sepsis, but real-world data are scarce. This study sought to assess the impact of a procalcitonin-based antibiotic stewardship program (protocol plus education) on antibiotic use in community hospitals. METHODS An observational, retrospective, matched cohort study was conducted. Eligible patients treated in hospitals with a procalcitonin-based protocol plus education (Procalcitonin cohort hospitals) were matched to patients admitted to facilities without procalcitonin testing (Control cohort hospitals) using a 1:2 ratio. The Control hospitals were facilities where procalcitonin testing was not available on site. Patient matching was based on: (1) age, (2) gender, (3) admission diagnosis code using groupings of the International Classification of Diseases, 10th Revision, (4) whether patients were admitted to the intensive care unit, and (5) whether a blood culture test was performed. Procalcitonin cohort hospitals implemented a quality improvement initiative, where procalcitonin was available, used regularly, and clinicians (physicians and pharmacists) were educated on its use. RESULTS After adjustment, patients in the Procalcitonin cohort had 1.47 fewer antibiotic days (9.1 vs. 8.5 days, 95%CI: -2.72; -0.22, p = .021). There was no difference in length of stay or adverse clinical outcomes except for increase in acute kidney injury (odds ratio = 1.26, 95%CI: 1.01; 1.58, p = .038). CONCLUSIONS Patients with respiratory infections and sepsis in hospitals utilizing a procalcitonin-based protocol coupled with education received fewer days of antibiotic therapy.
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Affiliation(s)
| | | | | | | | | | - Sue Ie
- Community Health Systems PSC, LLC, Franklin, TN, USA
| | | | - Susan Ou
- Analysis Group, Inc, Boston, MA, USA
| | | | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau and faculty at the University of Basel, Basel, Switzerland
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13
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Lippi G, Salvagno GL, Gelati M, Pucci M, Lo Cascio C, Demonte D, Faggian D, Plebani M. Two-center comparison of 10 fully-automated commercial procalcitonin (PCT) immunoassays. Clin Chem Lab Med 2020; 58:77-84. [PMID: 31539351 DOI: 10.1515/cclm-2019-0888] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/30/2019] [Indexed: 01/08/2023]
Abstract
Background This two-center study was designed to verify comparability of procalcitonin (PCT) values among 10 different commercial immunoassays. Methods A total number of 176 routine lithium-heparin plasma samples were divided in identical aliquots and simultaneously analyzed with 10 different PCT immunoassays, including Kryptor BRAHMS PCT sensitive, Abbott Architect BRAHMS PCT, Beckman Coulter Access PCT (on Access and DXI), BioMérieux Vidas BRAHMS PCT, Diasorin Liaison BRAHMS PCT, Fujirebio Lumipulse G BRAHMS PCT, Roche BRAHMS PCT (on Cobas E801), Diazyme PCT (on Roche Cobas C702) and SNIBE Maglumi PCT. Results Highly significant correlation was always found across multiple comparisons, with correlation coefficients comprised between 0.918 and 0.997 (all p < 0.001). Bland and Altman plots analysis revealed highly variable bias among immunoassays, ranging between ±0.2% and ±38.6%. Diazyme PCT on Roche Cobas C702 and SNIBE Maglumi PCT displayed the larger overestimation, whilst PCT values were underestimated by Cobas BRAHAMS PCT. The agreement was always >80% (all p < 0.001), but varied largely across multiple comparisons, ranging between 90%-99% at 0.1 μg/L, 81%-99% at 0.25 μg/L, 83%-100% at 0.5 μg/L, 94%-100% at 2.0 μg/L and 90%-99% at 10 μg/L, respectively. The larger disagreement was observed comparing Diazyme PCT and Maglumi PCT with the other methods. Conclusions Although we found acceptable correlation among 10 commercial PCT immunoassays, the limited agreement at clinical decision thresholds remains a major issue, especially at lower end of PCT concentration, thus potentially contributing to jeopardize the clinical value of this biomarker.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Gian Luca Salvagno
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Matteo Gelati
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Mairi Pucci
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Claudia Lo Cascio
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Davide Demonte
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
| | - Diego Faggian
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
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14
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DeSear KE, Thompson-Leduc P, Kirson N, Chritton JJ, Ie S, Van Schooneveld TC, Cheung HC, Ou S, Schuetz P. ProCommunity: procalcitonin use in real-world US community hospital settings. Curr Med Res Opin 2020; 36:1529-1532. [PMID: 32643964 DOI: 10.1080/03007995.2020.1793748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Procalcitonin (PCT) is a biomarker that may help providers optimize antibiotic (AB) therapy. Numerous clinical trials have demonstrated the utility of PCT-guided decision algorithms in treating lower respiratory tract infections and sepsis, but evidence from real-world studies is limited. This study sought to evaluate the effects of PCT on select clinical outcomes in community hospitals. METHODS An observational, retrospective, case-control study was conducted. Hospitals from a large US hospital system were categorized into "treatment" and "control" hospitals. Treatment hospitals were those with in-house PCT testing, a pharmacy team tasked with PCT testing follow-up and results in the patient's electronic medical records alongside a recommendation on AB treatment. Control hospitals either did not have PCT testing available in house or sent out tests to a laboratory or neighboring facility. Patients from treatment hospitals were matched 1:1 to patients from control hospitals based on admission diagnosis code, sex, age and whether an intensive care unit admission was observed. Clinical outcomes included number of days of AB treatment, length of stay, 30 day readmissions, mortality and acute kidney injury. Comparisons were conducted using multivariable regressions accounting for clustering at the hospital level. RESULTS Patients from treatment hospitals had significantly shorter hospital stays (-0.68 days, 95% CI: -1.26, -0.09; p = .02). A reduction in days of AB treatment (-1.50 days, 95% CI: -3.27, 0.27; p = .10) was observed, but did not reach statistical significance. CONCLUSION These findings suggest that PCT, along with specific treatment recommendations, may lead to shortened hospital stays with no adverse outcome on patient safety.
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Affiliation(s)
| | | | | | | | - Sue Ie
- Community Health Systems PSC LLC, Franklin, TN, USA
| | | | | | - Susan Ou
- Analysis Group Inc., Boston, MA, USA
| | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau and Faculty at the University of Basel, Aarau, Switzerland
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15
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Ito A, Ishida T, Tachibana H, Arita M, Yamazaki A, Washio Y. Utility of procalcitonin for differentiating cryptogenic organising pneumonia from community-acquired pneumonia. Clin Chem Lab Med 2020; 57:1632-1637. [PMID: 31120857 DOI: 10.1515/cclm-2019-0175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/23/2019] [Indexed: 11/15/2022]
Abstract
Background This study aimed to investigate the usefulness of inflammatory biomarkers such as white blood cell (WBC) count, C-reactive protein (CRP) and procalcitonin (PCT) for differentiating cryptogenic organising pneumonia (COP) from community-acquired pneumonia (CAP). Methods COP patients hospitalised in Kurashiki Central Hospital between January 2010 and December 2017 whose WBC counts and CRP and PCT levels were measured were investigated retrospectively, and their results were compared with those of hospitalised CAP patients who were prospectively enrolled between October 2010 and November 2017. Definite COP was defined by specific histopathological findings, and possible COP was defined as a consolidation shadow on chest computed tomography and lymphocyte dominance in bronchoalveolar lavage fluid in the absence of specific histopathological findings or lung specimens. The discriminatory abilities of WBC counts, CRP and PCT were evaluated by receiver operating characteristic (ROC) curve analysis. Results There were 56 patients in the entire COP group, 35 (61.4%) with definite COP, and 914 CAP patients. All three biomarkers were significantly lower in COP than in CAP. The AUC value of PCT in all COP patients was 0.79, significantly higher than of both CRP (AUC 0.59, p < 0.001) and WBC (AUC 0.69, p = 0.048). In definite COP patients, the AUC value of PCT was 0.79, which was also significantly higher than of both WBC (AUC 0.64, p = 0.006) and CRP (AUC 0.64, p = 0.001). Conclusions PCT is a more useful biomarker for differentiating COP from CAP than WBC count or CRP. However, PCT should be used as an adjunct to clinical presentation and radiological findings.
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Affiliation(s)
- Akihiro Ito
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Miwa, Kurashiki 710-8602, Japan, Phone: +81 86 422 0210, Fax: +81 86 421 3424
| | - Tadashi Ishida
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiromasa Tachibana
- Department of Respiratory Medicine, National Hospital Organization, Minami Kyoto Hospital, Joyo, Japan
| | - Machiko Arita
- Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Kurashiki, Japan
| | - Akio Yamazaki
- Department of Respiratory Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Yasuyoshi Washio
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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16
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Plata-Menchaca EP, Ferrer R, Ruiz Rodríguez JC, Morais R, Póvoa P. Antibiotic treatment in patients with sepsis: a narrative review. Hosp Pract (1995) 2020; 50:203-213. [PMID: 32627615 DOI: 10.1080/21548331.2020.1791541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, with unacceptably high morbidity and mortality. Similar to acute myocardial infarction or cerebral vascular accident, sepsis is a severe and continuous time-dependent condition. Thus, in the case of sepsis, early and adequate administration of antimicrobials must be a priority, ideally within the first hour of diagnosis, simultaneously with organ support.As a consequence of the emergence of multidrug-resistant pathogens, the choice of antimicrobials should be performed according to the local pathogen patterns of resistance. Individual antimicrobial optimization is essential to achieve adequate concentrations of antimicrobials, to reduce adverse effects, and to ensure successful outcomes, as well as preventing the emergence of multidrug-resistant pathogens. The loading dose is the administration of an initial higher dose of antimicrobials, regardless of the presence of organ dysfunction. Further doses should be implemented according to pharmacokinetics/pharmacodynamics of antimicrobials and should be adjusted according to the presence of renal or liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring can help to achieve therapeutic levels of antimicrobials. Duration and adequacy of treatment must be reviewed at regular intervals to allow effective de-escalation and administration of short courses of antimicrobials for most patients. Antimicrobial stewardship frameworks, leadership, focus on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients the process of care and overall quality of care.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Juan Carlos Ruiz Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rui Morais
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal
| | - Pedro Póvoa
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
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17
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Christensen I, Haug JB, Berild D, Bjørnholt JV, Jelsness-Jørgensen LP. Hospital physicians' experiences with procalcitonin - implications for antimicrobial stewardship; a qualitative study. BMC Infect Dis 2020; 20:515. [PMID: 32677903 PMCID: PMC7364625 DOI: 10.1186/s12879-020-05246-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/10/2020] [Indexed: 12/03/2022] Open
Abstract
Background Procalcitonin is an inflammatory biomarker that is sensitive for bacterial infections and a promising clinical decision aid in antimicrobial stewardship programs. However, there are few studies of physicians’ experiences concerning the use of PCT. The objective of this study was to investigate whether hospital physicians’ experience with procalcitonin after 18 months of use can inform the PCT implementation in antimicrobial stewardship programs. Materials/methods We deployed a qualitative approach using semi-structured interviews with 14 hospital physicians who had experience with procalcitonin in clinical practice. Interviews were audio-taped, transcribed verbatim and analysed using thematic analysis. Results Physicians reported a knowledge gap, which made them uncertain about the appropriate procalcitonin use, interpretation, and trustworthiness. Simultaneously, the physicians experienced procalcitonin as a useful clinical decision aid but emphasised that their clinical evaluation of the patient was the most important factor when deciding on antibiotic treatment. Conclusions Procalcitonin was regarded a helpful clinical tool, but the physicians called for more knowledge about its appropriate uses. Active implementation of unambiguous procalcitonin algorithms and physician education may enhance the utility of the test as an antimicrobial stewardship adjunct.
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Affiliation(s)
- Ingrid Christensen
- Department of INFECTION Control, Østfold Hospital Trust, Kalnes, Norway. .,Faculty of Medicine, University of Oslo, PhD Program Medicine and Health Sciences, Oslo, Norway.
| | - Jon Birger Haug
- Department of INFECTION Control, Østfold Hospital Trust, Kalnes, Norway
| | - Dag Berild
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Oslo University, Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway
| | - Jørgen Vildershøj Bjørnholt
- Oslo University, Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway.,Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Lars-Petter Jelsness-Jørgensen
- Faculty of Health and Social Studies, Østfold University College, Fredrikstad, Norway.,Department of Science, Østfold Hospital Trust, Kalnes, Norway
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18
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Schneider JE, Romanowsky J, Schuetz P, Stojanovic I, Cheng HK, Liesenfeld O, Buturovic L, Sweeney TE. Cost Impact Model of a Novel Multi-mRNA Host Response Assay for Diagnosis and Risk Assessment of Acute Respiratory Tract Infections and Sepsis in the Emergency Department. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2020; 7:24-34. [PMID: 32685595 PMCID: PMC7299497 DOI: 10.36469/jheor.2020.12637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/20/2020] [Accepted: 03/27/2020] [Indexed: 06/02/2023]
Abstract
BACKGROUND Early identification of acute infections and sepsis remains an unmet medical need. While early detection and initiation of treatment reduces mortality, inappropriate treatment leads to adverse events and the development of antimicrobial resistance. Current diagnostic and prognostic solutions, including procalcitonin, lack required accuracy. A novel blood-based host response test, HostDx™ Sepsis by Inflammatix, Inc., assesses the likelihood of a bacterial infection, the likelihood of a viral infection, and the severity of the condition. OBJECTIVES We estimated the economic impact of adopting HostDx Sepsis testing among patients with suspected acute respiratory tract infection (ARTI) in the emergency department (ED). METHODS Our cost impact model estimated costs for adult ED patients with suspected ARTI under the standard of care versus with the adoption of HostDx Sepsis from the perspective of US payers. Included costs were those assumed to be associated with an episode of sepsis diagnosis, management, and treatment. Projected accuracies for test predictions, disease prevalence, and clinical parameters was derived from patient-level meta-analysis data of randomized trials, supplemented with published performance data for HostDx Sepsis. One-way sensitivity analysis was performed on key input parameters. RESULTS Compared to standard of care including procalcitonin, the superior test characteristics of HostDx Sepsis resulted in an average cost savings of approximately US$1974 per patient (-31.3%) exclusive of the cost of HostDx Sepsis. Reductions in hospital days (-0.80 days, -36.7%), antibiotic days (-1.49 days, -29.5%), and percent 30-day mortality (-1.67%, -13.64%) were driven by HostDx Sepsis providing fewer "noninformative" moderate risk predictions and more "certain" low- or high-risk predictions compared to standard of care, especially for patients who were not severely ill. These results were robust to changes in key parameters, including disease prevalence. CONCLUSIONS Our model shows substantial savings associated with introduction of HostDx Sepsis among patients with ARTIs in EDs. These results need confirmation in interventional trials.
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Affiliation(s)
| | | | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Aarau,
Switzerland
- Department of Endocrinology/Metabolism/Clinical Nutrition, Department of Internal Medicine, Kantonsspital Aarau, Aarau,
Switzerland
- Medical Faculty, University of Basel, Basel,
Switzerland
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19
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Lippi G, Salvagno GL, Gelati M, Pucci M, Demonte D, Faggian D, Plebani M. Analytical Evaluation of the New Beckman Coulter Access Procalcitonin (PCT) Chemiluminescent Immunoassay. Diagnostics (Basel) 2020; 10:diagnostics10030128. [PMID: 32111028 PMCID: PMC7151122 DOI: 10.3390/diagnostics10030128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/01/2020] [Accepted: 02/25/2020] [Indexed: 12/21/2022] Open
Abstract
This study was designed to evaluate the analytical performance of the recently commercialized Beckman Coulter Access procalcitonin (PCT) chemiluminescent test on the Access immunoassay system. The analytical assessment encompassed the estimation of limit of blank (LoB), limit of detection (LoD), functional sensitivity (i.e., PCT value with ≤10% imprecision), linearity, imprecision and comparability of values with BRAHMS PCT-sensitive Kryptor. LoB, LoD and functional sensitivity were 0.002 μg/L, 0.003 μg/L and 0.003 μg/L, respectively. Intra-assay, inter-assay and total imprecision for plasma pools with low, medium and high PCT values were 1.8–2.1%, 2.4–3.7% and 3.1–4.3%, respectively. The assay exhibited excellent linearity between 0.02 and 84.0 μg/L. Excellent correlation (r = 0.999; p < 0.001) and negligible bias (3.2%) were found by comparing values obtained in paired plasma samples with BRAHMS PCT-sensitive Kryptor. Diagnostic agreement at 0.5, 2.0 and 10 μg/L PCT values ranged between 98%-100%. The results of this study confirm that Access PCT displays excellent analytical performance and high comparability with BRAHMS PCT-sensitive Kryptor.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, 37134 Verona, Italy; (G.L.); (M.G.); (M.P.); (D.D.)
| | - Gian Luca Salvagno
- Section of Clinical Biochemistry, University of Verona, 37134 Verona, Italy; (G.L.); (M.G.); (M.P.); (D.D.)
- Correspondence:
| | - Matteo Gelati
- Section of Clinical Biochemistry, University of Verona, 37134 Verona, Italy; (G.L.); (M.G.); (M.P.); (D.D.)
| | - Mairi Pucci
- Section of Clinical Biochemistry, University of Verona, 37134 Verona, Italy; (G.L.); (M.G.); (M.P.); (D.D.)
| | - Davide Demonte
- Section of Clinical Biochemistry, University of Verona, 37134 Verona, Italy; (G.L.); (M.G.); (M.P.); (D.D.)
| | - Diego Faggian
- Department of Laboratory Medicine, University Hospital of Padova, 35128 Padova, Italy; (D.F.); (M.P.)
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, 35128 Padova, Italy; (D.F.); (M.P.)
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20
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Abstract
Procalcitonin is a biomarker that is generally elevated in bacterial infections. This review describes a conceptual framework for biomarkers using lessons from the history of troponin, applies this framework to procalcitonin with a review of observational studies and randomized trials in and out of the intensive care unit, and concludes with clinical recommendations and thoughts on how to test a test.
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21
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Newton JA, Robinson S, Ling CLL, Zimmer L, Kuper K, Trivedi KK. Impact of Procalcitonin Levels Combined with Active Intervention on Antimicrobial Stewardship in a Community Hospital. Open Forum Infect Dis 2019; 6:ofz355. [PMID: 31400276 PMCID: PMC6824524 DOI: 10.1093/ofid/ofz355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/30/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Procalcitonin (PCT) guidance alone or in conjunction with antibiotic stewardship programs (ASP) has been shown to reduce antibiotic utilization and duration of therapy without adversely affecting patient outcomes. METHODS In a community hospital, we investigated the impact of PCT with ASP recommendations on length of stay (LOS), length of antimicrobial therapy (LOT) after ASP recommendation, and total LOT over a one-year period. Adult patients with at least one PCT value and concomitant ASP recommendations were included. Patients were grouped by provider ASP compliance and further stratified by normal versus elevated PCT values. No specific PCT algorithm was utilized. RESULTS A total of 857 patients were retrospectively analyzed. Physicians complied with 73.7% of ASP recommendations. There were no significant differences in LOS based on ASP compliance. Mean LOT after ASP recommendations and mean total LOT were significantly shorter (2.5 vs. 3.9 days, p<0.0001 and 5.1 vs. 6.6 days, p<0.0001, respectively) in the ASP complier group. When stratified by initial PCT levels, ASP compliers for patients with normal PCT levels had the shortest duration of therapy for all groups; among patients with elevated PCT levels, the duration of therapy was significantly shorter in the ASP compliant group (5.79 vs. 7.12 days, p<0.0111). When controlling for baseline differences in initial PCT levels, LOS was found to be marginally shorter in the ASP compliant group (p = 0.076). CONCLUSIONS PCT-guided ASP physician recommendations, when accepted by providers, led to reduction in antimicrobial LOT in a community hospital. This benefit was extended across patient groups irrespective of initial PCT levels.
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Affiliation(s)
- James A Newton
- Washington Regional Medical Center, Fayetteville, Arkansas
| | - Samantha Robinson
- Department of Mathematical Sciences, University of Arkansas, Fayetteville
| | | | | | - Kristi Kuper
- Center for Pharmacy Practice Excellence, Vizient, Inc., Irving, Texas
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Stenner E, Barbati G, West N, Del Ben F, Martin F, Ruscio M. Agreement between procalcitonin measurements using the new point-of-care testing ichroma™ reader and the automated Kryptor instrument. J LAB MED 2019. [DOI: 10.1515/labmed-2018-0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
To evaluate if procalcitonin (PCT) measurements made using the new point-of-care testing (POCT) ichroma™ are interchangeable with those made using Kryptor.
Methods
Serum samples (n = 117) were processed sequentially on Kryptor and ichroma™. Statistical analysis was performed using Passing-Bablok (PB) regression and the Bland-Altman (BA) test. Cohen’s kappa statistic was used to calculate the concordance at the clinically relevant cutoffs.
Results
PB regression did not show a significant deviation from linearity; proportional and constant differences were observed between ichroma™ and Kryptor. The 95% confidence interval (CI) of the mean bias percentage was very large, exceeding the maximum allowable total error (TE) (approximately 20%) and the clinical reference change value (about 60%). However, the concordance between methods at the clinically relevant cutoffs was strong, with the exception of the 0.25 ng/mL cutoff, which was moderate.
Conclusions
Our data suggest that ichroma™ is not interchangeable with Kryptor, so cannot be mixed; one must choose one instrument only and be consistent. However, while the strong concordance at the clinically relevant cutoffs allows us to consider ichroma™ a suitable option to Kryptor to support clinicians’ decision-making, nevertheless the moderate agreement at the 0.25 ng/mL cutoff recommends caution in interpreting the data around this cutoff.
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Lippi G, Cervellin G. Procalcitonin for diagnosing and monitoring bacterial infections: for or against? ACTA ACUST UNITED AC 2018; 56:1193-1195. [DOI: 10.1515/cclm-2018-0312] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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