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Brito V, Niederman MS. How Does One Diagnose and Manage Severe Community-Acquired Pneumonia? EVIDENCE-BASED PRACTICE OF CRITICAL CARE 2011. [PMCID: PMC7152406 DOI: 10.1016/b978-1-4160-5476-4.00038-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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52
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Blasi F, Stolz D, Piffer F. Biomarkers in lower respiratory tract infections. Pulm Pharmacol Ther 2010; 23:501-7. [DOI: 10.1016/j.pupt.2010.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 04/20/2010] [Accepted: 04/25/2010] [Indexed: 02/06/2023]
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Hur M, Moon HW, Yun YM, Kim KH, Kim HS, Lee KM. [Comparison of diagnostic utility between procalcitonin and C-reactive protein for the patients with blood culture-positive sepsis]. Korean J Lab Med 2010; 29:529-35. [PMID: 20046084 DOI: 10.3343/kjlm.2009.29.6.529] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Procalcitonin (PCT) is a relatively new marker for bacterial infections, and its diagnostic utility has been variable across the studies. We investigated the diagnostic utility of PCT for the patients with blood culture-positive sepsis, and compared it with that of C-reactive protein (CRP). METHODS In 1,270 consecutive blood samples, PCT and CRP were simultaneously measured and results were compared according to the five categories of PCT concentrations (<0.05 ng/mL; 0.05-0.49 ng/mL; 0.5-1.99 ng/mL; 2-9.99 ng/mL; > or = 10 ng/mL). In 506 samples, they were further analyzed according to the result of blood culture. PCT and CRP were measured using enzyme-linked fluorescent assay (bioMerieux Co., France) and rate nephelometry (Beckman Coulter Co., USA), respectively. Their diagnostic utilities were compared using ROC curves. RESULTS The mean concentrations of CRP in five categories of PCT were 15.4 mg/L, 42.1 mg/L, 101.2 mg/L, 125.0 mg/L, 167.1 mg/L, respectively (P<0.0001). Both PCT and CRP showed significant differences between the two positive and negative groups of blood culture (PCT, 8.47 vs 2.44 ng/mL, P=0.0133; CRP, 110.48 vs 59.78 mg/L, P<0.0001). The areas under the ROC curves (95% confidence interval) for PCT and CRP were 0.720 (0.644-0.788) and 0.558 (0.478-0.636), respectively, and showed a significant difference (P=0.005). CONCLUSIONS The diagnostic utility of PCT is superior to that of CRP for the patients with blood culture-positive sepsis. PCT seems to be reliable for sepsis diagnosis, and may provide useful information for the critically ill patients.
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Affiliation(s)
- Mina Hur
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea.
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Procalcitonin and C-reactive protein in severe 2009 H1N1 influenza infection. Intensive Care Med 2010; 36:528-32. [PMID: 20069274 PMCID: PMC7080172 DOI: 10.1007/s00134-009-1746-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 12/23/2009] [Indexed: 10/26/2022]
Abstract
PURPOSE To examine whether, in an adult intensive care unit (ICU), procalcitonin or C-reactive protein (CRP) levels discriminated between 2009 H1N1 influenza infection and community-acquired pneumonia of bacterial origin. METHODS A retrospective observational study performed at an Australian hospital over a 4-month winter period during the 2009 H1N1 influenza pandemic. Levels on admission of procalcitonin and CRP were compared between patients admitted to the ICU with community-acquired pneumonia of bacterial and 2009 H1N1 origin. RESULTS Compared to those with bacterial or mixed infection (n = 9), patients with 2009 H1N1 infection (n = 16) were significantly more likely to have bilateral chest X-ray infiltrates, lower APACHE scores, more prolonged lengths of stay in ICU and lower white cell count, procalcitonin and CRP levels. Using a cutoff of >0.8 ng/ml, the sensitivity and specificity of procalcitonin for detection of patients with bacterial/mixed infection were 100 and 62%, respectively. A CRP cutoff of >200 mg/l best identified patients with bacterial/mixed infection (sensitivity 100%, specificity 87.5%). In combination, procalcitonin levels >0.8 ng/ml and CRP >200 mg/l had optimal sensitivity (100%), specificity (94%), negative predictive value (100%) and positive predictive value (90%). Receiver-operating characteristic curve analysis suggested the diagnostic accuracy of procalcitonin may be inferior to CRP in this setting. CONCLUSIONS Procalcitonin measurement potentially assists in the discrimination between severe lower respiratory tract infections of bacterial and 2009 H1N1 origin, although less effectively than CRP. Low values, particularly when combined with low CRP levels, suggested bacterial infection, alone or in combination with influenza, was unlikely.
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Accuracy of C-reactive protein, procalcitonin, and mid-regional pro-atrial natriuretic peptide to guide site of care of community-acquired pneumonia. Intensive Care Med 2010; 36:799-809. [DOI: 10.1007/s00134-010-1818-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 11/02/2009] [Indexed: 01/31/2023]
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de Jager C, de Wit N, Weers-Pothoff G, van der Poll T, Wever P. Procalcitonin kinetics in Legionella pneumophila pneumonia. Clin Microbiol Infect 2009; 15:1020-5. [DOI: 10.1111/j.1469-0691.2009.02773.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rammaert B, Verdier N, Cavestri B, Nseir S. Procalcitonin as a prognostic factor in severe acute exacerbation of chronic obstructive pulmonary disease. Respirology 2009; 14:969-74. [PMID: 19659517 DOI: 10.1111/j.1440-1843.2009.01597.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Little is known about the value of procalcitonin in predicting mortality in patients with an exacerbation of COPD. This study evaluated the clinical and biological predictors of intensive care unit (ICU) mortality in patients with a severe acute exacerbation of COPD. METHODS A prospective observational cohort study was conducted of consecutive patients with severe acute exacerbation of COPD requiring intubation and mechanical ventilation. At ICU admission, data were collected on the patients' clinical condition, blood leukocyte count, C-reactive protein and procalcitonin. Cox proportional hazards model was used to determine the risk factors for ICU mortality. RESULTS One hundred and sixteen patients were included in this study. Mean age was 67 years. The mean simplified acute physiology score was 43. Sixty-five per cent of study patients had chronic respiratory insufficiency. Bacteria were cultured at levels considered significant in 36% of study patients. Logistic organ dysfunction score (hazard ratio (95% CI) = 1.19 (1.03-1.37), P = 0.013), rapidly fatal underlying disease (3.33 (1.40-7.87), P = 0.003) and procalcitonin level (1.01 (1-1.03), P = 0.018) were independently associated with increased risk for ICU mortality. Non-invasive mechanical ventilation use before intubation was independently associated with reduced risk for ICU mortality (0.34 (0.14-0.84), P = 0.020). CONCLUSIONS In patients with severe acute exacerbation of COPD requiring intubation and mechanical ventilation, logistic organ dysfunction score, rapidly fatal underlying disease and procalcitonin are independently associated with increased risk for ICU mortality. Non-invasive mechanical ventilation use before intubation was independently associated with reduced risk for ICU mortality.
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Affiliation(s)
- Blandine Rammaert
- Intensive Care Unit, Calmette Hospital, Lille University, Lille cedex, France
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Krüger S, Ewig S, Papassotiriou J, Kunde J, Marre R, von Baum H, Suttor N, Welte T. Inflammatory parameters predict etiologic patterns but do not allow for individual prediction of etiology in patients with CAP: results from the German competence network CAPNETZ. Respir Res 2009; 10:65. [PMID: 19594893 PMCID: PMC2714042 DOI: 10.1186/1465-9921-10-65] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 07/12/2009] [Indexed: 01/29/2023] Open
Abstract
Background Aim of this study was to evaluate the correlation of inflammatory markers procalcitonin (PCT), C-reactive protein (CRP) and leukocyte count (WBC) with microbiological etiology of CAP. Methods We enrolled 1337 patients (62 ± 18 y, 45% f) with proven CAP. Extensive microbiological workup was performed. In all patients PCT, CRP, WBC and CRB-65 score were determined. Patients were classified according to microbial diagnosis and CRB-65 score. Results In patients with typical bacterial CAP, levels of PCT, CRP and WBC were significantly higher compared to CAP of atypical or viral etiology. There were no significant differences in PCT, CRP and WBC in patients with atypical or viral etiology of CAP. In contrast to CRP and WBC, PCT markedly increased with severity of CAP as measured by CRB-65 score (p < 0.0001). In ROC analysis for discrimination of patients with CRB-65 scores > 1, AUC for PCT was 0.69 (95% CI 0.66 to 0.71), which was higher compared to CRP and WBC (p < 0.0001). CRB-65, PCT, CRP and WBC were higher (p < 0.0001) in hospitalised patients in comparison to outpatients. Conclusion PCT, CRP and WBC are highest in typical bacterial etiology in CAP but do not allow individual prediction of etiology. In contrast to CRP and WBC, PCT is useful in severity assessment of CAP.
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Affiliation(s)
- Stefan Krüger
- Medical Clinic I, University Clinic RWTH Aachen, Germany.
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Don M, Valent F, Korppi M, Falleti E, De Candia A, Fasoli L, Tenore A, Canciani M. Efficacy of serum procalcitonin in evaluating severity of community-acquired pneumonia in childhood. ACTA ACUST UNITED AC 2009; 39:129-37. [PMID: 17366029 DOI: 10.1080/00365540600951283] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Microbe-specific diagnosis of community-acquired pneumonia (CAP) in childhood is difficult in clinical practice. Chest radiographs and non-specific inflammatory markers have been used to separate presumably bacterial from viral infection but the results have been inconsistent. The aim of the present study was to evaluate the usefulness of procalcitonin (PCT) in assessing the severity as well as the bacterial or viral aetiology of CAP. Serum PCT was measured by an immunoluminometric assay in 100 patients with CAP; 26 were treated as inpatients and 74 as outpatients. The pulmonary infiltrate was considered to be alveolar in 62 and interstitial in 38 cases, according to the radiological diagnosis. The bacterial and viral aetiology of pneumonia was studied by an extensive serological test panel. No differences were found in PCT concentrations between the 4 aetiological (pneumococcal, atypical bacterial, viral, unknown) and the 3 age (< 2, 2-4 and > or = 5 y) groups. Serum PCT was >0.5 ng/ml in 69%, >1.0 ng/ml in 54% and >2.0 ng/ml in 47% of all patients. PCT was higher in patients that were admitted than as outpatients (medians 17.81 vs 0.72 ng/ml, respectively, p<0.01) and higher in alveolar than in interstitial pneumonia (medians 9.43 vs 0.53 ng/ml, respectively, p<0.01). In conclusion, serum PCT values were found to be related to the severity of CAP in children even though they were not capable, at any level of serum concentration, to differentiate between bacterial and viral aetiology.
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Affiliation(s)
- Massimiliano Don
- Department of Paediatrics, School of Medicine, DPMSC, University of Udine, Udine, Italy.
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Gorišek B, Miksić NG, Krajnc P, Pakiž M, Turk Z. The Role of Procalcitonin in Gynaecological Surgery. J Int Med Res 2009; 37:918-26. [DOI: 10.1177/147323000903700338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
We evaluated postoperative concentrations of inflammatory indicators, including procalcitonin, after gynaecological operations for benign and malignant tumours in patients with a normal postoperative course and assessed the utility of procalcitonin in differentiating between non-bacterial inflammation and bacteraemic complications in the postoperative period. This prospective study included 99 patients: 47 after a standard gynaecological operation (Piver I) and no postoperative infectious complications (group 1), 35 after a major procedure (Piver II or III) and no postoperative infectious complications (group 2), and five with postoperative sepsis after Piver II or III procedures (group 3). We also studied serum procalcitonin concentrations in a group of 12 patients (group 4) with terminal forms of gynaecological cancer who were hospitalized for palliative treatment but did not undergo surgery. Postoperative C-reactive protein (CRP) concentration corresponded with extent of tissue trauma in groups 1 and 2 and was significantly lower in group 1 than group 2. Inflammatory indicators were highest in groups 1 and 2 on postoperative day 2. In group 3, in which sepsis developed, values were highest on postoperative day 4. In particular, procalcitonin was > 2 ng/ml in all patients with postoperative sepsis by postoperative day 2 but was always ≤ 2 ng/ml in patients without sepsis. In contrast, high procalcitonin levels were noted in the patients in group 4 compared with group 3, with two-thirds of group 4 patients having levels > 2 ng/ml, with no signs of infection or raised CRP. It is concluded that, for early detection of postoperative infectious complications after gynaecological surgery, procalcitonin levels > 2 ng/ml are more specific than CRP.
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Affiliation(s)
- B Gorišek
- Clinical Department of Gynaecological Oncology, University Clinical Centre Maribor, Maribor, Slovenia
| | - NG Miksić
- Clinical Department of Infectious Diseases, University Clinical Centre Maribor, Maribor, Slovenia
| | - P Krajnc
- Clinical Department of Gynaecological Oncology, University Clinical Centre Maribor, Maribor, Slovenia
| | - M Pakiž
- Clinical Department of Gynaecological Oncology, University Clinical Centre Maribor, Maribor, Slovenia
| | - Z Turk
- Clinical Department of Medical Rehabilitation, University Clinical Centre Maribor, Maribor, Slovenia
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Lee SH, Kim CH, Kim JY, Park SW, Kim YW, Hyun IG, Woo H, Kim HS. Usefulness of Semi-quantitative Procalcitonin Assay in Critically Ill Patients with Bacterial Pneumonia. Infect Chemother 2009. [DOI: 10.3947/ic.2009.41.6.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Seung Hwa Lee
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Cheol-Hong Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Ji Youn Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Seon Wook Park
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Young Wook Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - In Gyu Hyun
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Heungjeong Woo
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Hyun Soo Kim
- Department of Laboratory Medicine, Hallym University College of Medicine, Seoul, Korea
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Niederman M. Biological Markers to Determine Eligibility in Trials for Community‐Acquired Pneumonia: A Focus on Procalcitonin. Clin Infect Dis 2008; 47:S127-S132. [DOI: 10.1086/591393] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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CRP: a new prognosis marker in community-acquired pneumonia? Am J Med 2008; 121:e21; author reply e23. [PMID: 18691466 DOI: 10.1016/j.amjmed.2008.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Accepted: 03/14/2008] [Indexed: 11/22/2022]
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65
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Linssen CFM, Bekers O, Drent M, Jacobs JA. C-reactive protein and procalcitonin concentrations in bronchoalveolar lavage fluid as a predictor of ventilator-associated pneumonia. Ann Clin Biochem 2008; 45:293-8. [PMID: 18482918 DOI: 10.1258/acb.2007.007133] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Diagnosis of ventilator-associated pneumonia (VAP) is difficult. The usefulness of high-sensitivity procalcitonin (ProCa-S) and high-sensitivity C-reactive protein (CRPH) in bronchoalveolar lavage (BAL) fluid and serum in the prediction of VAP was determined. METHODS The study was conducted over a 28-month period (November 1999-June 2002) at the University Hospital Maastricht. BAL fluid samples were collected from patients admitted to the intensive care unit. Differential cell count and quantitative culture of BAL fluid were performed. C-reactive protein (CRP) and procalcitonin (PCT) on BAL fluid were determined by means of two high-sensitivity kits (CRPH and ProCa-S, respectively). Since both kits were designed for use on serum, validation for use on BAL fluid was performed. RESULTS A total of 117 patients were included. 43.6% (51/117) had microbiologically confirmed VAP. Both CRPH and ProCa-S showed good matrix effect, linearity and intra- and inter-assay variation. No significant differences in PCT and CRP concentrations in serum and BAL fluid were found between the VAP and the non-VAP group. CONCLUSIONS Both the ProCa-S and the CRPH kits can be used for assessing the concentration of PCT and CRP in BAL fluid, respectively. PCT and CRP concentrations in BAL fluid appeared to be of no additional value in the diagnosis of VAP.
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Affiliation(s)
- Catharina F M Linssen
- Department of Medical Microbiology, University Hospital Maastricht, P Debyelaan 25, Maastricht, The Netherlands.
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66
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Uys A, Rapoport BL, Fickl H, Meyer PWA, Anderson R. Prediction of outcome in cancer patients with febrile neutropenia: comparison of the Multinational Association of Supportive Care in Cancer risk-index score with procalcitonin, C-reactive protein, serum amyloid A, and interleukins-1beta, -6, -8 and -10. Eur J Cancer Care (Engl) 2008; 16:475-83. [PMID: 17944761 DOI: 10.1111/j.1365-2354.2007.00780.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The primary objective of the study was to compare the predictive potential of procalcitonin (PCT), C-reactive protein (CRP), serum amyloid A (SAA), and interleukin (IL)-1beta, IL-6, IL-8, and IL-10, with that of the Multinational Association of Supportive Care in Cancer (MASCC) risk-index score in cancer patients on presentation with chemotherapy-induced febrile neutropenia (FN). Seventy-eight consecutive FN episodes in 63 patients were included, and MASCC scores, as well as concentrations of CRP, SAA, PCT, and IL-1beta, IL-6, IL-8 and IL-10, and haematological parameters were determined on presentation, 72 h later and at outcome. Multivariate analysis of data revealed the MASCC score, but none of the laboratory parameters, to be an accurate, independent variable (P < 0.0001) for prediction of resolution with or without complications and death. Of the various laboratory parameters, PCT had the strongest association with the MASCC score (r = -0.51; P < 0.0001). In cancer patients who present with FN, the MASCC risk-index score is a useful predictor of outcome, while measurement of PCT, CRP, SAA, or IL-1beta, IL-6, IL-8 and IL-10, is of limited value.
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Affiliation(s)
- A Uys
- The Medical Oncology Centre of Rosebank, Johannesburg, South Africa.
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67
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Hirakata Y, Yanagihara K, Kurihara S, Izumikawa K, Seki M, Miyazaki Y, Kohno S. Comparison of usefulness of plasma procalcitonin and C-reactive protein measurements for estimation of severity in adults with community-acquired pneumonia. Diagn Microbiol Infect Dis 2008; 61:170-4. [DOI: 10.1016/j.diagmicrobio.2008.01.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Revised: 12/28/2007] [Accepted: 01/16/2008] [Indexed: 10/22/2022]
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TSENG JS, CHAN MC, HSU JY, KUO BIT, WU CL. Procalcitonin is a valuable prognostic marker in ARDS caused by community-acquired pneumonia. Respirology 2008; 13:505-9. [DOI: 10.1111/j.1440-1843.2008.01293.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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69
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Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations. Crit Care Med 2008; 36:941-52. [PMID: 18431284 DOI: 10.1097/ccm.0b013e318165babb] [Citation(s) in RCA: 368] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The use of procalcitonin (ProCT) as a marker of several clinical conditions, in particular, systemic inflammation, infection, and sepsis, will be clarified, and its current limitations will be delineated. In particular, the need for a more sensitive assay will be emphasized. For these purposes, the medical literature comprising clinical studies pertaining to the measurement of serum ProCT in various clinical settings was examined. DATA SOURCE AND SELECTION A PubMed search (1965 through November 2007) was conducted, including manual cross-referencing. Pertinent complete publications were obtained using the MeSH terms procalcitonin, C-reactive protein, sepsis, and biological markers. Textbook chapters were also read and extracted. DATA EXTRACTION AND SYNTHESIS Available clinical and other patient data from these sources were reviewed, including any data relating to precipitating factors, clinical findings, associated illnesses, and patient outcome. Published data concerning sensitivity, specificity, and reproducibility of ProCT assays were reviewed. CONCLUSIONS Based on available data, the measurement of serum ProCT has definite utility as a marker of severe systemic inflammation, infection, and sepsis. However, publications concerning its diagnostic and prognostic utility are contradictory. In addition, patient characteristics and clinical settings vary markedly, and the data have been difficult to interpret and often extrapolated inappropriately to clinical usage. Furthermore, attempts at meta-analyses are greatly compromised by the divergent circumstances of reported studies and by the sparsity and different timing of the ProCT assays. Although a high ProCT commonly occurs in infection, it is also elevated in some noninfectious conditions. Thus, the test is not a specific indicator of either infection or sepsis. Moreover, in any individual patient, the precipitating cause of an illness, the clinical milieu, and complicating conditions may render tenuous any reliable estimations of severity or prognosis. It also is apparent that even a febrile septic patient with documented bacteremia may not necessarily have a serum ProCT that is elevated above the limit of functional sensitivity of the assay. In this regard, the most commonly applied assay (i.e., LUMItest) is insufficiently sensitive to detect potentially important mild elevations or trends. Clinical studies with a more sensitive ProCT assay that is capable of rapid and practicable day-to-day monitoring are needed and shortly may be available. In addition, investigations showing that ProCT and its related peptides may have mediator relevance point to the need for evaluating therapeutic countermeasures and studying the pathophysiologic effect of hyperprocalcitonemia in serious infection and sepsis.
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Delerme S, Chenevier-Gobeaux C, Doumenc B, Ray P. Useulness of B Natriuretic Peptides and Procalcitonin in Emergency Medicine. Biomark Insights 2008; 3:203-217. [PMID: 19578505 PMCID: PMC2688345 DOI: 10.4137/bmi.s499] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presented to an emergency department (ED), and it is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. For diagnosing CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in elderly population, and in patients with renal dysfunction. They might have also a prognostic value. Studies demonstrated that the use of BNP or NT-proBNP in dyspneic patients early in the ED reduced the time to discharge, total treatment cost. BNP and NT-proBNP should be available in every ED 24 hours a day, because literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. Etiologic diagnosis of febrile patients who present to an ED is complex and sometimes difficult. However, new evidence showed that there are interventions (including early appropriate antibiotics), which could reduce mortality rate in patients with sepsis. For diagnosing sepsis, procalcitonin (PCT) is more accurate than C-reactive protein. Thus, because of its excellent specificity and positive predictive value, an elevated PCT concentration (higher than 0.5 ng/mL) indicates ongoing and potentially severe systemic infection, which needs early antibiotics (e.g. meningitis). In lower respiratory tract infections, CAP or COPD exacerbation, PCT guidance reduced total antibiotic exposure and/or antibiotic treatment duration.
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Affiliation(s)
- S Delerme
- Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance-Publique Hôpitaux de Paris (AP-HP), 47-83 boulevard de l'hôpital, 75013 Paris, Université Pierre et Marie Curie Paris 6, France
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Charles PE, Ladoire S, Aho S, Quenot JP, Doise JM, Prin S, Olsson NO, Blettery B. Serum procalcitonin elevation in critically ill patients at the onset of bacteremia caused by either Gram negative or Gram positive bacteria. BMC Infect Dis 2008; 8:38. [PMID: 18366777 PMCID: PMC2289831 DOI: 10.1186/1471-2334-8-38] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 03/26/2008] [Indexed: 02/05/2023] Open
Abstract
Background In the ICU, bacteremia is a life-threatening infection whose prognosis is highly dependent on early recognition and treatment with appropriate antibiotics. Procalcitonin levels have been shown to distinguish between bacteremia and noninfectious inflammatory states accurately and quickly in critically ill patients. However, we still do not know to what extent the magnitude of PCT elevation at the onset of bacteremia varies according to the Gram stain result. Methods Review of the medical records of every patient treated between May, 2004 and December, 2006 who had bacteremia caused by either Gram positive (GP) or Gram negative (GN) bacteria, and whose PCT dosage at the onset of infection was available. Results 97 episodes of either GN bacteremia (n = 52) or GP bacteremia (n = 45) were included. Procalcitonin levels were found to be markedly higher in patients with GN bacteremia than in those with GP bacteremia, whereas the SOFA score value in the two groups was similar. Moreover, in the study population, a high PCT value was found to be independently associated with GN bacteremia. A PCT level of 16.0 ng/mL yielded an 83.0% positive predictive value and a 74.0% negative predictive value for GN-related bacteremia in the study cohort (AUROCC = 0.79; 95% CI, 0.71–0.88). Conclusion In a critically ill patient with clinical sepsis, GN bacteremia could be associated with higher PCT values than those found in GP bacteremia, regardless of the severity of the disease.
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Coelho L, Póvoa P, Almeida E, Fernandes A, Mealha R, Moreira P, Sabino H. Usefulness of C-reactive protein in monitoring the severe community-acquired pneumonia clinical course. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R92. [PMID: 17723153 PMCID: PMC2206486 DOI: 10.1186/cc6105] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 08/10/2007] [Accepted: 08/28/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of the present study was to evaluate the C-reactive protein level, the body temperature and the white cell count in patients after prescription of antibiotics in order to describe the clinical resolution of severe community-acquired pneumonia. METHODS A cohort of 53 consecutive patients with severe community-acquired pneumonia was studied. The C-reactive protein levels, body temperature and white cell count were monitored daily. RESULTS By day 3 a C-reactive protein level 0.5 times the initial level was a marker of poor outcome (sensitivity, 0.91; specificity, 0.59). Patients were divided according to their C-reactive protein patterns of response to antibiotics, into fast response, slow response, nonresponse, and biphasic response. About 96% of patients with a C-reactive protein pattern of fast response and 74% of patients with a slow response pattern survived, whereas those patients with the patterns of nonresponse and of biphasic response had a mortality rate of 100% and 33%, respectively (P < 0.001). On day 3 of antibiotic therapy, a decrease in C-reactive protein levels by 0.31 or more from the previous day's level was a marker of good prognosis (sensitivity, 0.75; specificity, 0.85). CONCLUSION Daily C-reactive protein measurement after antibiotic prescription is useful in identification, as early as day 3, of severe community-acquired pneumonia patients with poor outcome. The identification of the C-reactive protein pattern of response to antibiotic therapy was useful in the recognition of the individual clinical course, either improving or worsening, as well as the rate of improvement, in patients with severe community-acquired pneumonia.
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Affiliation(s)
- Luís Coelho
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal
| | - Pedro Póvoa
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal
| | - Eduardo Almeida
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal
| | - Antero Fernandes
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal
| | - Rui Mealha
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal
| | - Pedro Moreira
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal
| | - Henrique Sabino
- Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal
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73
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Fransson BA, Bergström A, Wardrop KJ, Hagman R. Assessment of three automated assays for C-reactive protein determination in dogs. Am J Vet Res 2007; 68:1281-6. [DOI: 10.2460/ajvr.68.12.1281] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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74
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Wada H, Okazaki M, Yokoyama T, Kurai D, Goto H. [Antimicrobials and infection control]. Nihon Yakurigaku Zasshi 2007; 130:380-385. [PMID: 18000352 DOI: 10.1254/fpj.130.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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75
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Prat C, Lacoma A, Dominguez J, Papassotiriou J, Morgenthaler NG, Andreo F, Tudela P, Ruiz-Manzano J, Ausina V. Midregional pro-atrial natriuretic peptide as a prognostic marker in pneumonia. J Infect 2007; 55:400-7. [PMID: 17825918 DOI: 10.1016/j.jinf.2007.07.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 07/17/2007] [Accepted: 07/19/2007] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the usefulness of midregional pro-atrial natriuretic peptide (MR-proANP) measurement in the stratification of severity in community-acquired pneumonia. METHODS The population studied was three hundred patients admitted to Emergency Department of a tertiary university hospital presenting clinical signs of lower respiratory tract infection, a new infiltrate on the chest radiograph and a confirmed pneumonia by clinical evolution. Patients were stratified by the Pneumonia Severity Index (PSI), by CURB-65 score and by the development of complications. Serum samples were obtained at the moment of admission and prior to antibiotic therapy, and stored until analysis. MR-proANP was measured by B.R.A.H.M.S MR-proANP KRYPTOR. RESULTS Serum levels of MR-proANP increased with the severity of pneumonia, according to PSI score and CURB-65 score. Median MR-proANP levels were significantly higher (p<0.0001) in patients with high PSI risk class (IV-V) than in those with low PSI risk class (I-III). MR-proANP levels were also significantly higher (p=0.029) in those patients that developed complications or died. There was no association between MR-proANP and etiology of pneumonia and the radiographic extent. CONCLUSION We can conclude that MR-proANP measurement was helpful for individual risk assessment in patients with pneumonia admitted to the emergency department.
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Affiliation(s)
- Cristina Prat
- Servei de Microbiologia, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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76
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Abstract
Procalcitonin measurement has been claimed as a helpful marker in bacterial infection and sepsis. It has obtained FDA approval and is now widely marketed in the United States and Europe. This review summarises the current assays available, the evidence for its use and possible future applications of the assay.
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Affiliation(s)
- Hans-Gerhard Schneider
- Clinical Biochemistry Unit, Alfred Pathology Service, The Alfred Hospital, Monash University, Melbourne, Australia.
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77
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases in North America. The purpose of this review is to highlight recent advances in epidemiology, risk factors, severity criteria and antibiotic therapeutic regimens used for community-acquired pneumonia management. RECENT FINDINGS All guidelines recommend early and appropriate empiric therapy directed against common typical organisms, such as Streptococcus pneumoniae, and other atypical organisms, but clinicians should be aware of newer emerging pathogens such as community-acquired methicillin-resistant Staphylococcus aureus and Gram-negative pathogens. SUMMARY The optimum outcome in community-acquired pneumonia can be achieved by careful risk stratification using prediction rules together with appropriate antibiotic regimens. The mainstay of community-acquired pneumonia prevention is influenza and pneumococcal immunization. Promotion of smoking cessation will also help curtail the incidence of pneumococcal disease.
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Affiliation(s)
- Arunabh Talwar
- Department of Medicine, North Shore University Hospital, Manhasset, New York 11030, USA.
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78
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C-Reactive Protein and Procalcitonin as Markers of Infection, Inflammatory Response, and Sepsis. ACTA ACUST UNITED AC 2007. [DOI: 10.1097/cpm.0b013e3180555bbe] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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79
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Niederman MS. Recent advances in community-acquired pneumonia: inpatient and outpatient. Chest 2007; 131:1205-15. [PMID: 17426229 PMCID: PMC7125778 DOI: 10.1378/chest.06-1994] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Accepted: 10/05/2005] [Indexed: 11/21/2022] Open
Abstract
Community-acquired pneumonia (CAP) is a common illness, with the majority of patients treated out of the hospital, yet the greatest burden of the cost of care comes from inpatient management. In the past several years, the management of these patients has advanced, with new information about the natural history and prognosis of illness, the utility of serum markers to guide management, the use of appropriate clinical tools to guide the site-of-care decision, and the finding that guidelines can be developed in a way that improves patient outcome. The challenges to patient management include the emergence of new pathogens and the progression of antibiotic resistance in some of the common pathogens such as Streptococcus pneumoniae. Few new antimicrobial treatment options are available, and the utility of some new therapies has been limited by drug-related toxicity. Ancillary care for severe pneumonia with activated protein C and corticosteroids is being studied, but recently, inpatient care has been most affected by the development of evidence-based "core measures" for management that have been promoted by the Centers for Medicare and Medicaid Services, which form the basis for the public reporting of hospital performance in CAP care.
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Key Words
- community-acquired pneumonia
- drug resistance
- methicilllin-resistant pneumonia
- severe pneumonia
- severity index
- staphylococcus aureus
- streptococcus pneumoniae
- apache, acute physiology and chronic health evaluation
- cap, community-acquired pneumonia
- cms, centers for medicare and medicaid services
- crp, c-reactive protein
- curb-65, confusion, elevated bun level, elevated respiratory rate, low systolic or diastolic bp, and age > 65 years of age
- drsp, drug-resistant streptococcus pneumoniae
- hcap, health-care-associated pneumonia
- mrsa, methicillin-resistant staphylococcus aureus
- or, odds ratio
- pct, procalcitonin
- psi, pneumonia severity index
- sars, severe acute respiratory syndrome
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Affiliation(s)
- Michael S Niederman
- Department of Medicine, Winthrop-University Hospital, 222 Station Plaza N, Suite 509, Mineola, NY 11501, USA.
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80
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Benhamou D, Goupil F. Les infections respiratoires basses communautaires de l’adulte non immunodéprimé. Rev Mal Respir 2007; 24:381-6. [PMID: 17417181 DOI: 10.1016/s0761-8425(07)91075-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- D Benhamou
- Service de Pneumologie, CHU Rouen, France.
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81
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Community-Acquired Respiratory Complications in the Intensive Care Unit: Pneumonia and Acute Exacerbations of COPD. INFECTIOUS DISEASES IN CRITICAL CARE 2007. [PMCID: PMC7121741 DOI: 10.1007/978-3-540-34406-3_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This chapter will review the two most common lower respiratory tract infections in the intensive care unit (ICU), community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In addition we will provide an overview of the topics including recommendations for the diagnosis and treatment.
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Abstract
PURPOSE OF REVIEW Community-acquired pneumonia (CAP) is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases. CAP patients requiring intensive care unit (ICU) admission carry the highest mortality rates. This paper aims to review the current literature regarding epidemiology, risk factors, severity criteria and reasons for admitting the hospitalized patient to the ICU, and the empiric and specific antibiotic therapeutic regimens employed. RECENT FINDINGS Multiple sets of clinical practice guidelines have been published in the past few years addressing the treatment of CAP. The guidelines all agree that CAP patients admitted to the hospital represent a major concern, and appropriate empiric therapy should be instituted to improve clinical outcomes. SUMMARY The cost, morbidity and mortality of CAP patients requiring ICU admission remain unacceptably high. These are heterogeneous groups of patients, so it is important to use risk-stratification based on clinical parameters and prediction tools. Appropriate antibiotic therapy is an important component in the management of both groups of patients. In particular, it is essential to administer an appropriate antimicrobial agent from the initiation of therapy, so that the risks of treatment failure and the morbidity of CAP may be minimized.
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Affiliation(s)
- Marcos I Restrepo
- Division of Pulmonary and Crit Care Med, South Texas Veterans Healthcare System, Audie L. Murphy Division, University of Texas Health Science Center at San Antonio 78229, USA
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83
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Faure K. Comment évaluer, orienter et suivre un patient ayant une pneumonie aiguë communautaire ? Une exacerbation de bronchopneumopathie chronique obstructive ? Med Mal Infect 2006; 36:734-83. [PMID: 17092675 PMCID: PMC7133787 DOI: 10.1016/j.medmal.2006.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
L'objectif de cette revue est de présenter une analyse bibliographique de la littérature de ces cinq dernières années concernant les pneumonies aiguës communautaires (PAC) et les exacerbations aiguës de bronchopneumopathies chroniques obstructives (EABPCO). La PAC et l'EABPCO sont des pathologies fréquentes grevées d'une mortalité et/ou morbidité encore élevée de nos jours. La connaissance des facteurs de risque d'évolution compliquée et l'identification des signes de gravité souvent liés au risque de mortalité permettent d'orienter le patient pour un traitement ambulatoire, en hospitalisation conventionnelle ou en secteur de réanimation ; des règles prédictives ont été établies dans ce sens. La littérature concernant les critères de sortie d'hospitalisation et le suivi des patients est plus pauvre.
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Affiliation(s)
- K Faure
- Service de réanimation médicale et maladies infectieuses, centre hospitalier de Tourcoing, 135, rue du Président-Coty, 59208 Tourcoing, France.
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Boussekey N, Leroy O, Alfandari S, Devos P, Georges H, Guery B. Procalcitonin kinetics in the prognosis of severe community-acquired pneumonia. Intensive Care Med 2006; 32:469-72. [PMID: 16477418 DOI: 10.1007/s00134-005-0047-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2005] [Accepted: 12/16/2005] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Procalcitonin (PCT) kinetics is a good prognosis marker in infectious diseases, but few studies of community-acquired pneumonia (CAP) have been performed in intensive care units (ICU). We analyzed the relationship between PCT kinetics and outcome in ICU patients with severe CAP. DESIGN AND SETTING Prospective observational study in a 16-bed university hospital ICU. PATIENTS 100 critically ill patients with community-acquired pneumonia. MEASUREMENTS AND RESULTS Median PCT was 5.2 ng/ml on day 1 and 2.9 ng/ml on day 3. It increased from day 1 to day 3 in nonsurvivors but decreased in survivors. In multivariate analysis four variables were associated with death: invasive ventilation (odds ratio 10-), multilobar involvement (5.6-), LOD score (6.9-), and PCT increase from day 1 to day 3 (4.5-). In intubated patients with a PCT level below 0.95 ng/ml on day 3 the survival rate was 95%. CONCLUSION Increased PCT from day 1 to day 3 in severe CAP is a poor prognosis factor. A PCT level less than 0.95 ng/ml on day 3 in intubated patients is associated with a favorable outcome.
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Affiliation(s)
- Nicolas Boussekey
- Tourcoing Hospital, Intensive Care and Infectious Disease Unit, 135 rue du Président Coty BP 619, 59208, Tourcoing cedex, France.
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85
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Müller B, Prat C. Markers of acute inflammation in assessing and managing lower respiratory tract infections: focus on procalcitonin. Clin Microbiol Infect 2006. [DOI: 10.1111/j.1469-0691.2006.01654.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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