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Tsalik EL, Henao R, Montgomery JL, Nawrocki JW, Aydin M, Lydon EC, Ko ER, Petzold E, Nicholson BP, Cairns CB, Glickman SW, Quackenbush E, Kingsmore SF, Jaehne AK, Rivers EP, Langley RJ, Fowler VG, McClain MT, Crisp RJ, Ginsburg GS, Burke TW, Hemmert AC, Woods CW. Discriminating Bacterial and Viral Infection Using a Rapid Host Gene Expression Test. Crit Care Med 2021; 49:1651-1663. [PMID: 33938716 PMCID: PMC8448917 DOI: 10.1097/ccm.0000000000005085] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Host gene expression signatures discriminate bacterial and viral infection but have not been translated to a clinical test platform. This study enrolled an independent cohort of patients to describe and validate a first-in-class host response bacterial/viral test. DESIGN Subjects were recruited from 2006 to 2016. Enrollment blood samples were collected in an RNA preservative and banked for later testing. The reference standard was an expert panel clinical adjudication, which was blinded to gene expression and procalcitonin results. SETTING Four U.S. emergency departments. PATIENTS Six-hundred twenty-three subjects with acute respiratory illness or suspected sepsis. INTERVENTIONS Forty-five-transcript signature measured on the BioFire FilmArray System (BioFire Diagnostics, Salt Lake City, UT) in ~45 minutes. MEASUREMENTS AND MAIN RESULTS Host response bacterial/viral test performance characteristics were evaluated in 623 participants (mean age 46 yr; 45% male) with bacterial infection, viral infection, coinfection, or noninfectious illness. Performance of the host response bacterial/viral test was compared with procalcitonin. The test provided independent probabilities of bacterial and viral infection in ~45 minutes. In the 213-subject training cohort, the host response bacterial/viral test had an area under the curve for bacterial infection of 0.90 (95% CI, 0.84-0.94) and 0.92 (95% CI, 0.87-0.95) for viral infection. Independent validation in 209 subjects revealed similar performance with an area under the curve of 0.85 (95% CI, 0.78-0.90) for bacterial infection and 0.91 (95% CI, 0.85-0.94) for viral infection. The test had 80.1% (95% CI, 73.7-85.4%) average weighted accuracy for bacterial infection and 86.8% (95% CI, 81.8-90.8%) for viral infection in this validation cohort. This was significantly better than 68.7% (95% CI, 62.4-75.4%) observed for procalcitonin (p < 0.001). An additional cohort of 201 subjects with indeterminate phenotypes (coinfection or microbiology-negative infections) revealed similar performance. CONCLUSIONS The host response bacterial/viral measured using the BioFire System rapidly and accurately discriminated bacterial and viral infection better than procalcitonin, which can help support more appropriate antibiotic use.
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Affiliation(s)
- Ephraim L. Tsalik
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ricardo Henao
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Biostatistics and Informatics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Mert Aydin
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Emily C. Lydon
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Emily R. Ko
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Regional Hospital, Durham, NC, USA
| | - Elizabeth Petzold
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Charles B. Cairns
- University of North Carolina Medical Center, Chapel Hill, NC, USA
- Drexel University, Philadelphia, PA, USA
| | - Seth W. Glickman
- University of North Carolina Medical Center, Chapel Hill, NC, USA
| | | | | | | | | | | | - Vance G. Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Micah T. McClain
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Geoffrey S. Ginsburg
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Thomas W. Burke
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Christopher W. Woods
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Duan S, Gu X, Fan G, Zhou F, Zhu G, Cao B. C-reactive protein or procalcitonin combined with rhinorrhea for discrimination of viral from bacterial infections in hospitalized adults in non-intensive care units with lower respiratory tract infections. BMC Pulm Med 2021; 21:308. [PMID: 34583675 PMCID: PMC8478003 DOI: 10.1186/s12890-021-01672-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Whether procalcitonin (PCT) or C-reactive protein (CRP) combined with certain clinical characteristics can better distinguish viral from bacterial infections remains unclear. The aim of the study was to assess the ability of PCT or CRP combined with clinical characteristics to distinguish between viral and bacterial infections in hospitalized non-intensive care unit (ICU) adults with lower respiratory tract infection (LRTI). METHODS This was a post-hoc analysis of a randomized clinical trial previously conducted among LRTI patients. The ability of PCT, CRP and PCT or CRP combined with clinical symptoms to discriminate between viral and bacterial infection were assessed by portraying receiver operating characteristic (ROC) curves among patients with only a viral or a typical bacterial infection. RESULTS In total, 209 infected patients (viral 69%, bacterial 31%) were included in the study. When using CRP or PCT to discriminate between viral and bacterial LRTI, the optimal cut-off points were 22 mg/L and 0.18 ng/mL, respectively. When the optimal cut-off for CRP (≤ 22 mg/L) or PCT (≤ 0.18 ng/mL) combined with rhinorrhea was used to discriminate viral from bacterial LRTI, the AUCs were 0.81 (95% CI: 0.75-0.87) and 0.80 (95% CI: 0.74-0.86), which was statistically significantly better than when CRP or PCT used alone (p < 0.001). When CRP ≤ 22 mg/L, PCT ≤ 0.18 ng/mL and rhinorrhea were combined, the AUC was 0.86 (95% CI: 0.80-0.91), which was statistically significantly higher than when CRP (≤ 22 mg/L) or PCT (≤ 0.18 ng/mL) was combined with rhinorrhea (p = 0.011 and p = 0.021). CONCLUSIONS Either CRP ≤ 22 mg/L or PCT ≤ 0.18 ng/mL combined with rhinorrhea could help distinguish viral from bacterial infections in hospitalized non-ICU adults with LRTI. When rhinorrhea was combined together, discrimination ability was further improved.
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Affiliation(s)
- Shengchen Duan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoying Gu
- Department of Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
- National Clinical Research Center of Respiratory Diseases, Beijing, China
| | - Guohui Fan
- Department of Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
- National Clinical Research Center of Respiratory Diseases, Beijing, China
| | - Fei Zhou
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Guangfa Zhu
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bin Cao
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China.
- National Clinical Research Center of Respiratory Diseases, Beijing, China.
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China.
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Beijing, China.
- Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.
- Tsinghua University-Peking University Joint Center for Life Sciences, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
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103
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Lhopitallier L, Kronenberg A, Meuwly JY, Locatelli I, Mueller Y, Senn N, D'Acremont V, Boillat-Blanco N. Procalcitonin and lung ultrasonography point-of-care testing to determine antibiotic prescription in patients with lower respiratory tract infection in primary care: pragmatic cluster randomised trial. BMJ 2021; 374:n2132. [PMID: 34548312 PMCID: PMC9083102 DOI: 10.1136/bmj.n2132] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess whether point-of care procalcitonin and lung ultrasonography can safely reduce unnecessary antibiotic treatment in patients with lower respiratory tract infections in primary care. DESIGN Three group, pragmatic cluster randomised controlled trial from September 2018 to March 2020. SETTING 60 Swiss general practices. PARTICIPANTS One general practitioner per practice was included. General practitioners screen all patients with acute cough; patients with clinical pneumonia were included. INTERVENTIONS Randomisation in a 1:1:1 of general practitioners to either antibiotics guided by sequential procalcitonin and lung ultrasonography point-of-care tests (UltraPro; n=152), procalcitonin guided antibiotics (n=195), or usual care (n=122). MAIN OUTCOMES Primary outcome was proportion of patients in each group prescribed an antibiotic by day 28. Secondary outcomes included duration of restricted activities due to lower respiratory tract infection within 14 days. RESULTS 60 general practitioners included 469 patients (median age 53 years (interquartile range 38-66); 278 (59%) were female). Probability of antibiotic prescription at day 28 was lower in the procalcitonin group than in the usual care group (0.40 v 0.70, cluster corrected difference -0.26 (95% confidence interval -0.41 to -0.10)). No significant difference was seen between UltraPro and procalcitonin groups (0.41 v 0.40, -0.03 (-0.17 to 0.12)). The median number of days with restricted activities by day 14 was 4 days in the procalcitonin group and 3 days in the usual care group (difference 1 day (95% confidence interval -0.23 to 2.32); hazard ratio 0.75 (95% confidence interval 0.58 to 0.97)), which did not prove non-inferiority. CONCLUSIONS Compared with usual care, point-of-care procalcitonin led to a 26% absolute reduction in the probability of 28 day antibiotic prescription without affecting patients' safety. Point-of-care lung ultrasonography did not further reduce antibiotic prescription, although a potential added value cannot be excluded, owing to the wide confidence intervals. TRIAL REGISTRATION ClinicalTrials.gov NCT03191071.
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Affiliation(s)
- Loïc Lhopitallier
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Medix General Practice, Bern, Switzerland
| | - Jean-Yves Meuwly
- Department of Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Isabella Locatelli
- Department of Education, Research, and Innovation, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Yolanda Mueller
- Department of Family Medicine, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Nicolas Senn
- Department of Family Medicine, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Valérie D'Acremont
- Department of Education, Research, and Innovation, Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- Digital Global Health Department, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
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104
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Affiliation(s)
- Alastair D Hay
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, Bristol, UK
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105
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Boere TM, van Buul LW, Hopstaken RM, van Tulder MW, Twisk JWMR, Verheij TJM, Hertogh CMPM. Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: cluster randomised controlled trial. BMJ 2021; 374:n2198. [PMID: 34548288 PMCID: PMC8453309 DOI: 10.1136/bmj.n2198] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate whether C reactive protein point-of-care testing (CRP POCT) safely reduces antibiotic prescribing for lower respiratory tract infections in nursing home residents. DESIGN Pragmatic, cluster randomised controlled trial. SETTING The UPCARE study included 11 nursing home organisations in the Netherlands. PARTICIPANTS 84 physicians from 11 nursing home organisations included 241 participants with suspected lower respiratory tract infections from September 2018 to the end of March 2020. INTERVENTIONS Nursing homes allocated to the intervention group had access to CRP POCT. The control group provided usual care without CRP POCT for patients with suspected lower respiratory tract infections. MAIN OUTCOME MEASURES The primary outcome measure was antibiotic prescribing at initial consultation. Secondary outcome measures were full recovery at three weeks, changes in antibiotic management and additional diagnostics during follow-up at one week and three weeks, and hospital admission and all cause mortality at any point (initial consultation, one week, or three weeks). RESULTS Antibiotics were prescribed at initial consultation for 84 (53.5%) patients in the intervention group and 65 (82.3%) in the control group. Patients in the intervention group had 4.93 higher odds (95% confidence interval 1.91 to 12.73) of not being prescribed antibiotics at initial consultation compared with the control group, irrespective of treating physician and baseline characteristics. The between group difference in antibiotic prescribing at any point from initial consultation to follow-up was 23.6%. Differences in secondary outcomes between the intervention and control groups were 4.4% in full recovery rates at three weeks (86.4% v 90.8%), 2.2% in all cause mortality rates (3.5% v 1.3%), and 0.7% in hospital admission rates (7.2% v 6.5%). The odds of full recovery at three weeks, and the odds of mortality and hospital admission at any point did not significantly differ between groups. CONCLUSIONS CRP POCT for suspected lower respiratory tract infection safely reduced antibiotic prescribing compared with usual care in nursing home residents. The findings suggest that implementing CRP POCT in nursing homes might contribute to reduced antibiotic use in this setting and help to combat antibiotic resistance. TRIAL REGISTRATION Netherlands Trial Register NL5054.
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Affiliation(s)
- Tjarda M Boere
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Rogier M Hopstaken
- Primary Health Care Center, Hapert en Hoogeloon, Hapert, Netherlands
- Star-shl Diagnostic Centers, Etten-Leur, Netherlands
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Maurits W van Tulder
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jos W M R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
| | - Theo J M Verheij
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
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Wolfisberg S, Gregoriano C, Schuetz P. Procalcitonin for individualizing antibiotic treatment: an update with a focus on COVID-19. Crit Rev Clin Lab Sci 2021; 59:54-65. [PMID: 34517744 PMCID: PMC8442987 DOI: 10.1080/10408363.2021.1975637] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Procalcitonin (PCT) is useful for differentiating between viral and bacterial infections and for reducing the unnecessary use of antibiotics. As the rise of antimicrobial resistance reaches “alarming” levels according to the World Health Organization, the importance of using biomarkers, such as PCT to limit unnecessary antibiotic exposure has further increased. Randomized trials in patients with respiratory tract infections have shown that PCT has prognostic implications and its use, embedded in stewardship protocols, leads to reductions in the use of antibiotics in different clinical settings without compromising clinical outcomes. However, available data are heterogeneous and recent trials found no significant benefit. Still, from these trials, we have learned several key considerations for the optimal use of PCT, which depend on the clinical setting, severity of presentation, and pretest probability for bacterial infection. For patients with respiratory infections and sepsis, PCT can be used to determine whether to initiate antimicrobial therapy in low-risk settings and, together with clinical data, whether to discontinue antimicrobial therapy in certain high-risk settings. There is also increasing evidence regarding PCT-guided therapy in patients with coronavirus disease 2019 (COVID-19). This review provides an up-to-date overview of the use of PCT in different clinical settings and diseases, including a discussion about its potential to improve the care of patients with COVID-19.
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Affiliation(s)
| | | | - Philipp Schuetz
- Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
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Abstract
PURPOSE OF REVIEW Biomarkers, mainly procalcitonin, are commonly used in sepsis diagnosis, prognosis and treatment follow-up. This review summarizes the potential benefit of their use for the critically ill. RECENT FINDINGS Increased clinical evidence from randomized clinical trials of biomarker-guided treatment suggests a trend for appropriate but short antimicrobial treatment for the critically ill. Procalcitonin (PCT) is the most studied biomarker; in the majority of randomized clinical trials, the use of a stopping rule of antibiotics on the day when PCT is below 80% from baseline or less than 0.5 ng/ml was proven effective to reduce length of antimicrobial treatment, antibiotic-associated adverse events and infectious complications like infections by multidrug-resistant organisms and Clostridium difficile. Survival benefit was also noted. SUMMARY Biomarkers, mainly PCT, may help improve sepsis outcome by restriction of injudicious antimicrobial use.
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Damy T, Chouihed T, Delarche N, Berrut G, Cacoub P, Henry P, Lamblin N, Andrès E, Hanon O. Diagnosis and Management of Heart Failure in Elderly Patients from Hospital Admission to Discharge: Position Paper. J Clin Med 2021; 10:jcm10163519. [PMID: 34441815 PMCID: PMC8396904 DOI: 10.3390/jcm10163519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 02/07/2023] Open
Abstract
Multidisciplinary management of worsening heart failure (HF) in the elderly improves survival. To ensure patients have access to adequate care, the current HF and French health authority guidelines advise establishing a clearly defined HF patient pathway. This pathway involves coordinating multiple disciplines to manage decompensating HF. Yet, recent registry data indicate that insufficient numbers of patients receive specialised cardiology care, which increases the risk of rehospitalisation and mortality. The patient pathway in France involves three key stages: presentation with decompensated HF, stabilisation within a hospital setting and transitional care back out into the community. In each of these three phases, HF diagnosis, severity and precipitating factors need to be promptly identified and managed. This is particularly pertinent in older, frail patients who may present with atypical symptoms or coexisting comorbidities and for whom geriatric evaluation may be needed or specific geriatric syndrome management implemented. In the transition phase, multi-professional post-discharge management must be coordinated with community health care professionals. When the patient is discharged, HF medication must be optimised, and patients educated about self-care and monitoring symptoms. This review provides practical guidance to clinicians managing worsening HF in the elderly.
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Affiliation(s)
- Thibaud Damy
- Service de Cardiologie, CHU H. Mondor, 94000 Créteil, France
- Correspondence:
| | - Tahar Chouihed
- Service des SAMU-SMUR-Urgences, Centre d’Investigations Cliniques-1433, INSERM UMR_S 1116, Université de Lorraine, CHRU Nancy, F-CRIN INI-CRCT, 541000 Nancy, France;
| | | | - Gilles Berrut
- CHU Nantes, Pôle Hospitalo-Universitiare de Gérontologie Clinique, 44000 Nantes, France;
| | - Patrice Cacoub
- Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, AP-HP, 75000 Paris, France;
| | - Patrick Henry
- Service de Cardiologie, APHP, Hôpital Lariboisière, 75000 Paris, France;
| | - Nicholas Lamblin
- Service de Cardiologie, Institut Pasteur de Lille, CHU de Lille, Université de Lille, U1167, 59000 Lille, France;
| | - Emmanuel Andrès
- Service Méd. Interne, Diabète, Maladies Métaboliques, Clinique Médicale B, CHU Strasbourg, 67000 Strasbourg, France;
| | - Olivier Hanon
- Service de Gériatrie, APHP, Hôpital Broca, Université de Paris, 54 Rue Pascal, 75013 Paris, France;
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Levsky JM, Haramati LB. "Rule Out" vs "Do Without". Chest 2021; 160:21-22. [PMID: 34246366 PMCID: PMC10162856 DOI: 10.1016/j.chest.2021.02.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jeffrey M Levsky
- Departments of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - Linda B Haramati
- Departments of Radiology and Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY.
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Prognostic Role of Serum Procalcitonin Measurement in Adult Patients Admitted to the Emergency Department with Fever. ANTIBIOTICS (BASEL, SWITZERLAND) 2021; 10:antibiotics10070788. [PMID: 34209605 PMCID: PMC8300691 DOI: 10.3390/antibiotics10070788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 01/08/2023]
Abstract
Background and Objectives. Fever is one of the most common presenting complaints in the Emergency Department (ED). This study aimed at evaluating the prognostic role of serum Procalcitonin (PCT) measurement among adult patients admitted to the ED with fever. Materials and Methods. This is a retrospective cross-sectional study including all consecutive patients admitted to ED with fever and subsequently hospitalized in a period of six-year (January 2014 to December 2019). Inclusion criteria were age > 18 years, fever (T ≥ 38 °C) or chills within 24 h from presentation to the ED as the main symptom, and availability of a PCT determination obtained <24 h since ED access. The primary endpoint was overall in-hospital mortality. Results. Overall, 6595 patients were included in the study cohort (3734 males, 55.6%), with a median age of 71 [58-81] years. Among these, based on clinical findings and quick sequential organ failure assessment (qSOFA), 422 were considered septic (36.2% deceased), and 6173 patients non-septic (16.2% deceased). After correction for baseline covariates, a PCT > 0.5 ng/mL was an independent risk factor for all-cause in-hospital death in both groups (HR 1.77 [1.27-2.48], and 1.80 [1.59-2.59], respectively). Conclusions. Among adult patients admitted with fever, the PCT assessment in ED could have reduced prognostic power for patients with a high suspicion of sepsis. On the other hand, it could be useful for sepsis rule-out for patients at low risk. In these latter patients, the prognostic role of PCT is higher for those with a final diagnosis of bloodstream infection.
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Nuzzo A, Salem S, Malissin I, Diallo A, Deye N, Goury A, Gourlain H, Péron N, Vicaut E, Voicu S, Mégarbane B. Plasma procalcitonin may be an early predictor of liver injury in acetaminophen poisoning: A prospective cohort study. United European Gastroenterol J 2021; 9:571-580. [PMID: 34181312 PMCID: PMC8259278 DOI: 10.1002/ueg2.12093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/26/2021] [Indexed: 01/16/2023] Open
Abstract
Background and Aims Acetaminophen is a common cause of poisoning and liver injury worldwide; however, patient stratification is suboptimal. We aimed to assess the contribution of admission plasma procalcitonin concentration (PCT) to better identify acetaminophen‐poisoned patients likely to develop liver injury. Methods We conducted a prospective observational cohort study including all acetaminophen‐poisoned patients requiring N‐acetylcysteine admitted in a toxicological intensive care unit between 2012 and 2017. Multivariate analysis was performed using a Cox regression model to investigate factors associated with liver injury, defined as an increase in alanine aminotransferase (ALT) >100 IU/L. Results One hundred seventeen patients (age, 32 years (21–53), median [25th–75th percentiles]) were included after self‐ingesting 16 g (9–30) acetaminophen and received N‐acetylcysteine infusion administered within a median 6 h‐delay (4–12) from exposure. Co‐ingestions were reported in 77% of patients. Rumack–Matthew nomogram was non‐interpretable in 47% cases. Liver injury occurred in 38 patients (32%) with a median peak ALT of 2020 IU/L (577–4248). In liver injury patients, admission PCT was significantly increased in comparison to patients without liver injury (21.5 ng/ml (3.2–44.9) versus 0.1 ng/ml (0–0.4), respectively, p < 0.01). The increase in PCT preceded the increase in ALT by 33 h (10–74). In a multivariate analysis, PCT > 1 ng/ml was significantly associated with liver injury (hazard ratio, 7.2 [95% confidence interval, 2.3–22.6; p < 0.001]). PCT (area under the receiver‐operating characteristics curve, 0.91 [95%CI: 0.84–0.97]) predicted liver injury with sensitivity, specificity, negative, and positive predictive values of 0.92, 0.84, 0.96, and 0.73, respectively. Conclusion PCT on admission is associated with liver injury in acetaminophen poisoning. PCT might be used as a predictive tool of liver injury to improve clinical decision‐making.
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Affiliation(s)
- Alexandre Nuzzo
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France.,Department of Gastroenterology, APHP, Beaujon Hospital, Paris University, INSERM UMRS-1148, Clichy, France
| | - Shireen Salem
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Abdourahmane Diallo
- Department of Epidemiology, APHP, Biostatistics and Clinical Research, Fernand-Widal Hospital, Paris University, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Antoine Goury
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Hervé Gourlain
- APHP, Laboratory of Toxicology, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Nicolas Péron
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Eric Vicaut
- Department of Epidemiology, APHP, Biostatistics and Clinical Research, Fernand-Widal Hospital, Paris University, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
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Safarika A, Wacker JW, Katsaros K, Solomonidi N, Giannikopoulos G, Kotsaki A, Koutelidakis IM, Coyle SM, Cheng HK, Liesenfeld O, Sweeney TE, Giamarellos-Bourboulis EJ. A 29-mRNA host response test from blood accurately distinguishes bacterial and viral infections among emergency department patients. Intensive Care Med Exp 2021; 9:31. [PMID: 34142256 PMCID: PMC8211458 DOI: 10.1186/s40635-021-00394-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/12/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Whether or not to administer antibiotics is a common and challenging clinical decision in patients with suspected infections presenting to the emergency department (ED). We prospectively validate InSep, a 29-mRNA blood-based host response test for the prediction of bacterial and viral infections. METHODS The PROMPT trial is a prospective, non-interventional, multi-center clinical study that enrolled 397 adult patients presenting to the ED with signs of acute infection and at least one vital sign change. The infection status was adjudicated using chart review (including a syndromic molecular respiratory panel, procalcitonin and C-reactive protein) by three infectious disease physicians blinded to InSep results. InSep (version BVN-2) was performed using PAXgene Blood RNA processed and quantified on NanoString nCounter SPRINT. InSep results (likelihood of bacterial and viral infection) were compared to the adjudicated infection status. RESULTS Subject mean age was 64 years, comorbidities were significant for diabetes (17.1%), chronic obstructive pulmonary disease (13.6%), and severe neurological disease (6.8%); 16.9% of subjects were immunocompromised. Infections were adjudicated as bacterial (14.1%), viral (11.3%) and noninfected (0.25%): 74.1% of subjects were adjudicated as indeterminate. InSep distinguished bacterial vs. viral/noninfected patients and viral vs. bacterial/noninfected patients using consensus adjudication with AUROCs of 0.94 (95% CI 0.90-0.99) and 0.90 (95% CI 0.83-0.96), respectively. AUROCs for bacterial vs. viral/noninfected patients were 0.88 (95% CI 0.79-0.96) for PCT, 0.80 (95% CI 0.72-89) for CRP and 0.78 (95% CI 0.69-0.87) for white blood cell counts (of note, the latter biomarkers were provided as part of clinical adjudication). To enable clinical actionability, InSep incorporates score cutoffs to allocate patients into interpretation bands. The Very Likely (rule in) InSep bacterial band showed a specificity of 98% compared to 94% for the corresponding PCT band (> 0.5 µg/L); the Very Unlikely (rule-out) band showed a sensitivity of 95% for InSep compared to 86% for PCT. For the detection of viral infections, InSep demonstrated a specificity of 93% for the Very Likely band (rule in) and a sensitivity of 96% for the Very Unlikely band (rule out). CONCLUSIONS InSep demonstrated high accuracy for predicting the presence of both bacterial and viral infections in ED patients with suspected acute infections or suspected sepsis. When translated into a rapid, point-of-care test, InSep will provide ED physicians with actionable results supporting early informed treatment decisions to improve patient outcomes while upholding antimicrobial stewardship. Registration number at Clinicaltrials.gov NCT03295825.
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Affiliation(s)
- Asimina Safarika
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, ATTIKON University Hospital, 1 Rimini Str, 12462, Athens, Greece
| | | | | | - Nicky Solomonidi
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, ATTIKON University Hospital, 1 Rimini Str, 12462, Athens, Greece
| | | | - Antigone Kotsaki
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, ATTIKON University Hospital, 1 Rimini Str, 12462, Athens, Greece
| | | | | | - Henry K Cheng
- Inflammatix Inc, Clinical Affairs, Burlingame, CA, USA
| | | | | | - Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, ATTIKON University Hospital, 1 Rimini Str, 12462, Athens, Greece.
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Huang L, Zhang Y, Liao T, Xu K, Jiang C, Zhuo D, Wang Y, Wen HM, Wang J, Ao L, Hu J. Compact Magneto-Fluorescent Colloids by Hierarchical Assembly of Dual-Components in Radial Channels for Sensitive Point-of-Care Immunoassay. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2021; 17:e2100862. [PMID: 34032374 DOI: 10.1002/smll.202100862] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/15/2021] [Indexed: 06/12/2023]
Abstract
Exploring signal amplification strategies to enhance the sensitivity of lateral flow immunoassay (LFIA) is of great significance for point-of-care (POC) testing of low-concentrated targets in the field of in vitro diagnostics. Here, a highly-sensitive LFIA platform using compact and hierarchical magneto-fluorescent assemblies as both target-enrichment substrates and optical sensing labels is demonstrated. The large-pored dendritic templates are utilized for high-density incorporation of both superparamagnetic iron oxide nanoparticles (IOs) and quantum dots (QDs) within the vertical channels. The hierarchical structure is built via affinity-driven assembly of IOs and QDs from organic phase with silica surface and mercapto-organosilica intermediate layer, respectively. The sequential assembly with central-radial channels enables 3D loading of dual components and separately controlling of discrete functionalities. After the alkyl-organosilica encapsulation and silica sealing, the composite spheres exhibit high stabilities and compatibility with LFIA for procalcitonin (PCT) detection. With the assistance of liquid-phase antigen-capturing, magnetic enrichment, and fluorescence-signal amplification, a limit of detection of 0.031 ng mL-1 for PCT is achieved with a linear range from 0.012 to 10 ng mL-1 . The current LFIA is robust and validated for PCT detection in real serum, which holds great diagnostic significance for precise guidance of antibiotic therapy with POC manner.
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Affiliation(s)
- Liang Huang
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Yuxing Zhang
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Tao Liao
- Shenzhen WWHS Biotech. Inc., Shenzhen, 518100, P. R. China
| | - Kui Xu
- Institute of Biomedical Engineering, The Second Clinical Medical College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, P. R. China
| | - Chenxing Jiang
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Dinglv Zhuo
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Yang Wang
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Hui-Min Wen
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Jing Wang
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Lijiao Ao
- Institute of Biomedical Engineering, The Second Clinical Medical College (Shenzhen People's Hospital) of Jinan University, Shenzhen, 518020, P. R. China
| | - Jun Hu
- College of Chemical Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
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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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Gómez de Oña C, Alvarez-Argüelles ME, Rojo-Alba S, Casares H, Arroyo M, Rodríguez J, de Oña M, Melón S. Alterations in biochemical markers in adenovirus infection. Transl Pediatr 2021; 10:1248-1258. [PMID: 34189083 PMCID: PMC8193001 DOI: 10.21037/tp-20-333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Analyze possible relationships between HAdV and markers for inflammation, specifically the C-reactive protein (CRP) and procalcitonin (PCT) tests, along with other haematological markers. METHODS Retrospective study of 487 children presenting with fever and/or acute respiratory symptoms in the Paediatric Emergency Department. Analyses included viral presence/absence (both HAdV and other respiratory viruses) in respiratory exudates, CRP and PCT alterations in plasma, and haematological markers in whole blood. RESULTS Viral load was >500 copies/103 cells of HAdV in 127 cases (26.1%), of which 66 (52%, P<0.0001) had alterations in PCT, and 112 (88.1%, P<0.0001) in CRP. Haematological markers were similar either HAdV was present or not, although many HAdV positive patients demonstrated leukocytosis (66%). Bacterial cultures from 141 samples showed altered PCT in 27 (60%) with HAdV infection, in 3 (18.7%) with bacterial infection, and 13 (26.5%) without either viral or bacterial infection (P<0.05). CRP was altered in 88.9% of HAdV infected children and in 87% infected with bacteria, although the percentage was greater than in cases where other respiratory viruses were present (61.3% P<0.05). CONCLUSIONS Results demonstrate a clear relationship between HAdV infection and alterations in PCT and CRP which should be taken into account in paediatric patient management.
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Affiliation(s)
| | | | - Susana Rojo-Alba
- Microbiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Helena Casares
- Pediatric Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Mireia Arroyo
- Pediatric Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Julián Rodríguez
- Pediatric Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - María de Oña
- Microbiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Santiago Melón
- Microbiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
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Harikrishna J, Mohan A, Kalyana Chakravarthi DP, Chaudhury A, Kumar BS, Sarma KVS. Serum procalcitonin as a biomarker of bloodstream infection & focal bacterial infection in febrile patients. Indian J Med Res 2021; 151:342-349. [PMID: 32461398 PMCID: PMC7371069 DOI: 10.4103/ijmr.ijmr_324_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background & objectives: Bacteraemia is a serious form of infection in patients presenting with fever, thus, there is a necessity for a biomarker for rapid diagnosis of bacteraemia in such patients to make better therapeutic decisions. This study was conducted to measure the serum procalcitonin (PCT) levels at the time of initial presentation as a biomarker for identifying bacteraemia and as a predictor of mortality in patients admitted with acute fever. Methods: Four hundred and eighty patients, who presented with acute fever requiring admission to a tertiary care teaching hospital in south India, were prospectively studied. All patients were evaluated with a detailed history, physical examination, laboratory and imaging studies. Baseline serum PCT was measured for each patient within six hours of admission. Results: Among patients with single infectious cause (n=275), significantly higher median serum PCT levels were evident in bacteraemia compared to leptospirosis (P=0.002), dengue (P<0.001), scrub typhus (P<0.001) and evident focus of infection without bacteraemia (P=0.036). By receiver-operator characteristic curve analysis, at a cut-off value of >3.2 ng/ml, the sensitivity and specificity of serum PCT levels in predicting bacteraemia were 81.1 and 63.3 per cent, respectively. As per the worst-case scenario analysis, 91 (18.9%) patients had a poor outcome and these had significantly higher median serum PCT levels compared to survivors (n=389) [9.46 (2.03-44.4) vs. 1.23 (0.34-7.645); P<0.001]. At a cut-off value of >3.74 ng/ml, serum PCT levels at initial presentation predicted in-hospital mortality with a sensitivity and specificity of 67 and 67.5 per cent, respectively. Interpretation & conclusions: Our observations suggest that serum PCT level may be a useful biomarker for identifying bacteraemia as well as predicting mortality in patients with acute fever requiring admission to hospital.
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Affiliation(s)
- Janjam Harikrishna
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Alladi Mohan
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - D P Kalyana Chakravarthi
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Abhijit Chaudhury
- Department of Microbiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - B Siddhartha Kumar
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - K V S Sarma
- Department of Community Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
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Moradi T, Bennett N, Shemanski S, Kennedy K, Schlachter A, Boyd S. Use of Procalcitonin and a Respiratory Polymerase Chain Reaction Panel to Reduce Antibiotic Use via an Electronic Medical Record Alert. Clin Infect Dis 2021; 71:1684-1689. [PMID: 31637442 PMCID: PMC7108168 DOI: 10.1093/cid/ciz1042] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/17/2019] [Indexed: 12/23/2022] Open
Abstract
Background Respiratory tract infections are often viral and but are frequently treated with antibiotics, providing a significant opportunity for antibiotic de-escalation in patients. We sought to determine whether an automated electronic medical record best practice alert (BPA) based on procalcitonin and respiratory polymerase chain reaction (PCR) results could help reduce inappropriate antibiotic use in patients with likely viral respiratory illness. Methods This multisite, pre–post, quasi-experimental study included patients 18 years and older with a procalcitonin level <0.25 ng/mL and a virus identified on respiratory PCR within 48 hours of each other, and 1 or more systemic antibiotics ordered. In the study group, a BPA alerted providers of the diagnostic results suggesting viral infection and prompted them to reassess the need for antibiotics. The primary outcome measured was total antibiotic-days of therapy. Results The BPA reduced inpatient antibiotic-days of therapy by a mean of 2.2 days compared with patients who met criteria but did not have the alert fire (8.0 vs 5.8 days, respectively, P < .001). The BPA also reduced the percentage of patients prescribed antibiotics on discharge (20% vs 47.8%, P < .001), whereas there was no difference in need for antibiotic escalation after initial discontinuation (7.6% vs 4.3%, P = .198). Conclusions The automated antimicrobial stewardship BPA effectively reduced antibiotic use and discharge prescribing rates when diagnostics suggested viral respiratory tract infection, without a higher rate for reinitiation of antibiotics after discontinuation.
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Affiliation(s)
- Tony Moradi
- Department of Pharmacy, University of Kansas Health System, Kansas City, Missouri, USA
| | - Nicholas Bennett
- Antimicrobial Stewardship Program, Saint Luke's Health System, Kansas City, Missouri, USA
| | - Shelby Shemanski
- Department of Pharmacy, Saint Luke's Hospital, Kansas City, Missouri, USA
| | - Kevin Kennedy
- Department of Biostatistics, Saint Luke's Hospital, Kansas City, Missouri, USA
| | - Andrew Schlachter
- Department of Pulmonary and Critical Care Medicine, Saint Luke's Hospital, Kansas City, Missouri, USA
| | - Sarah Boyd
- Department of Infectious Disease, Saint Luke's Health System, Kansas City, Missouri, USA
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Gene Expression-Based Diagnosis of Infections in Critically Ill Patients-Prospective Validation of the SepsisMetaScore in a Longitudinal Severe Trauma Cohort. Crit Care Med 2021; 49:e751-e760. [PMID: 33883455 DOI: 10.1097/ccm.0000000000005027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Early diagnosis of infections is pivotal in critically ill patients. Innovative gene expression-based approaches promise to deliver precise, fast, and clinically practicable diagnostic tools to bedside. This study aimed to validate the SepsisMetaScore, an 11-gene signature previously reported by our study group, in a representative longitudinal cohort of trauma patients. DESIGN Prospective observational cohort study. SETTING Surgical ICUs of the University Medical Center Goettingen, Germany. PATIENTS Critically ill patients with severe traumatic injuries. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Paired box gene (PAXgene) RNA blood tubes were drawn at predefined time points over the course of disease. The performance of the SepsisMetaScore was tested using targeted polymerase chain reaction and compared with Procalcitonin using area under the receiver operating characteristics analyses. The SepsisMetaScore showed significant differences between infected and noninfected patients (n = 52). It was able to accurately discriminate infectious from noninfectious acute inflammation with an area under the receiver operating characteristics of 0.92 (95% CI, 0.85-0.99) and significantly outperformed Procalcitonin (area under the receiver operating characteristics curve = 0.53; 95% CI, 0.42-0.64) early in the course of infection (p = 0.014). CONCLUSIONS We demonstrated the clinical utility for diagnosis of infections with higher accuracy using the SepsisMetaScore compared with Procalcitonin in a prospective cohort of severe trauma patients. Future studies should assess whether the SepsisMetaScore may substantially improve clinical practice by accurate differentiation of infections from sterile inflammation and identification of patients at risk for sepsis. Our results support further investigation of the SepsisMetaScore for the development of tailored precision treatment of critically ill patients.
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Abstract
OBJECTIVE To evaluate the role of procalcitonin (PCT) in antibiotic decisions for COVID-19 patients at hospital presentation. DESIGN, SETTING AND PARTICIPANTS Multicenter retrospective observational study of patients 18 years hospitalized due to COVID-19 at the Johns Hopkins Health system. Patients who were transferred from another facility with >24 hours stay and patients who died within 48 hours of hospitalization were excluded. METHODS Elevated PCT values were determined based on each hospitals definition. Antibiotic therapy and PCT results were evaluated for patients with no evidence of bacterial community-acquired pneumonia (bCAP) and patients with confirmed, probable, or possible bCAP. The added value of PCT to clinical criteria in detecting bCAP were evaluated with receiving operating curve characteristics (ROC). RESULTS 64% (611/962) of patients received a PCT. ROC curves for clinical criteria and clinical criteria plus PCT were similar (at 0.5ng/ml and 0.25ng/ml). By bCAP group, median initial PCT values were 0.58 ng/mL (IQR 0.24, 1.14), 0.23 ng/mL (IQR 0.1, 0.63) and 0.15 ng/mL (IQR 0.09, 0.35) for proven/probable, possible, and no bCAP groups. Among patients without bCAP, an elevatedPCT was associated with 1.8 additional days of CAP therapy (95% CI 1.01 2.75, P<0.01) compared to patients with a negative PCT after adjusting for potential confounders. Duration of CAP therapy was similar between patients without a PCT ordered and a low PCT for no bCAP and possible bCAP groups. CONCLUSIONS PCT may be abnormal in COVID-19 patients without bCAP and may result in receipt of unnecessary antibiotics.
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Katz SE, Crook J, Gillon J, Stanford JE, Wang L, Colby JM, Banerjee R. Use of a Procalcitonin-guided Antibiotic Treatment Algorithm in the Pediatric Intensive Care Unit. Pediatr Infect Dis J 2021; 40:333-337. [PMID: 33181782 PMCID: PMC7954892 DOI: 10.1097/inf.0000000000002986] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The utility of procalcitonin testing in the pediatric intensive care unit (PICU) is not known. We sought to determine the impact of a procalcitonin-guided antibiotic treatment algorithm implemented with antibiotic stewardship (AS) guidance vs. usual care on antibiotic use in critically ill children. METHODS Single center, pragmatic, randomized prospective clinical trial of critically ill children admitted to an ICU setting and started on intravenous antibiotics from February 15, 2018, to April 11, 2019. Patients were assigned on a monthly basis to either the procalcitonin or usual care arm. The procalcitonin arm had procalcitonin testing on hospital days 0, 1, 2, and 4 and stewardship assistance with algorithm result interpretation. Both arms had routine AS audit and feedback. The primary outcome was median antibiotic days of therapy per patient in the first 14-days after enrollment. RESULTS Among 270 patients, 137 were in the procalcitonin arm and 133 in the usual care arm. Antibiotic days of therapy (DOT) were not significantly different between the procalcitonin arm (6.6, IQR: 3.1-10.9) and the usual care arm (7.6, IQR: 3-11.8; P = 0.37). More AS recommendations were made in the procalcitonin vs. control arm (54 vs. 37; P = 0.03). Adherence with algorithm-based antibiotic recommendations was high in the procalcitonin arm (70%). CONCLUSIONS We found no difference in antibiotic DOT between study arms. This trial was underpowered but demonstrates feasibility of using a procalcitonin-guided antibiotic treatment algorithm with AS audit and feedback in the PICU.
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Affiliation(s)
- Sophie E. Katz
- Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, TN
| | - Jennifer Crook
- Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, TN
- The University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Jessica Gillon
- Vanderbilt University Medical Center, Department of Pharmacy, Nashville, TN
| | - J. Eric Stanford
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology, Nashville, TN
| | - Li Wang
- Vanderbilt University, Department of Biostatistics, Nashville, TN
| | - Jennifer M. Colby
- Vanderbilt University Medical Center, Department of Pathology, Microbiology and Immunology, Nashville, TN
| | - Ritu Banerjee
- Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, TN
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Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM. Ann Am Thorac Soc 2021; 17:531-540. [PMID: 32356696 PMCID: PMC7193806 DOI: 10.1513/annalsats.202003-188st] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital’s use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is “the right drug at the right time and the right dose for the right bug for the right duration.” A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.
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Williams P, McWilliams C, Soomro K, Harding I, Gurney S, Thomas M, Albur M, Martin Williams O. The dynamics of procalcitonin in COVID-19 patients admitted to Intensive care unit - a multi-centre cohort study in the South West of England, UK. J Infect 2021; 82:e24-e26. [PMID: 33745917 PMCID: PMC7970419 DOI: 10.1016/j.jinf.2021.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/13/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Philip Williams
- University of Bristol UK; PHE National Infection Service UK.
| | - Chris McWilliams
- University of Bristol UK; University Hospitals Bristol and Weston NHS Trust UK
| | - Kamran Soomro
- University Hospitals Bristol and Weston NHS Trust UK; University of the West of England UK
| | | | - Stefan Gurney
- University Hospitals Bristol and Weston NHS Trust UK
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Clinical Significance of Procalcitonin, C-Reactive Protein, and Interleukin-6 in Helping Guide the Antibiotic Use for Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease. DISEASE MARKERS 2021; 2021:8879401. [PMID: 33791046 PMCID: PMC7984918 DOI: 10.1155/2021/8879401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 12/23/2022]
Abstract
Background Currently, standards of antibiotic use in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients are controversial. Objective The aim of the present study was to analyze the value of procalcitonin (PCT), C-reactive protein (CRP), and interleukin-6 (IL-6) levels to guide the antibiotic treatment of AECOPD patients. Methods A total of 371 patients with COPD or AECOPD were included in the study. Clinical and laboratory data were obtained at admission, 325 AECOPD patients and 46 sCOPD patients treated with antibiotics. The receiver operating curve (ROC) was used to evaluate the relationship between CRP, PCT, and IL-6. Results This study included medical record/case control 1, the COPD group (n = 46) and the AECOPD group (n = 325), and medical record control 2, the nonchanged antibiotic group (n = 203) and the changed antibiotic group (n = 61). In case 1, CRP, PCT, and IL-6 levels in the AECOPD group were higher than that in the control group (P < 0.05), while the result of ROC showed that IL-6 had higher AUC values (0.773) and higher sensitivity (71.7%) than other indicators. The specificity of PCT (93.5%) is higher than other indicators. In case 2, ROC curve results showed that the AUC value of IL-6 (0.771) was slightly higher than PCT and CRP. The sensitivity (85.2%) and specificity (65.5%) of CRP were higher than other indicators. Conclusions IL-6 and PCT were elevated in AECOPD patients, resulting in a higher diagnostic value for AECOPD. CRP had a higher diagnostic value for antibiotic use in AECOPD patients.
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Ayala-Lopez N, Peaper DR, Harb R. Procalcitonin Correlates With but Is Not Superior to Other Diagnostic Markers of Bacterial Pneumonia. Am J Clin Pathol 2021; 155:537-546. [PMID: 33210111 DOI: 10.1093/ajcp/aqaa148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Despite extensive research on procalcitonin (PCT)-guided therapy in lower respiratory tract infections, the association between PCT and bacterial pneumonia remains unclear. METHODS We evaluated retrospectively the performance of PCT in patients presenting with lower respiratory tract infection symptoms and grouped by seven diagnoses. All patients had microbial testing, chest imaging, and CBC counts within 1 day of PCT testing. RESULTS Median PCT level in patients diagnosed with bacterial pneumonia was significantly higher than in patients diagnosed with other sources of infections or those not diagnosed with infections. Median PCT levels were not different among patients grouped by type or quantity of pathogen detected. They were significantly higher in patients with higher pathogenicity scores for isolated bacteria, those with abnormal WBC count, and those with chest imaging consistent with bacterial pneumonia. A diagnostic workup that included imaging, WBC count, and Gram stain had an area under the receiver operating characteristic curve of 0.748, and the addition of PCT increased it to 0.778. CONCLUSIONS PCT was higher in patients diagnosed with bacterial pneumonia. Less clear is its diagnostic ability to detect bacterial pneumonia over and above imaging and laboratory data routinely available to clinicians.
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Affiliation(s)
| | - David R Peaper
- Department of Laboratory Medicine, Yale University, New Haven, CT
| | - Roa Harb
- Department of Laboratory Medicine, Yale University, New Haven, CT
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126
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Gilbert DN. Neglected Variables in the Interpretation of Serum Procalcitonin Levels in Patients With Septic Shock. J Infect Dis 2021; 222:S96-S102. [PMID: 32691829 DOI: 10.1093/infdis/jiaa204] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The interpretation of serum procalcitonin (PCT) levels in septic patients is facilitated by reviewing the known stimuli that activate the PCT family of genes. Herein we describe 7 pathways that, alone or in combination, can increase serum PCT levels. As a marker of activation of innate immunity, high PCT levels affect clinical diagnosis, can be trended as a measure of "source" control, and can guide duration of antibacterial therapy in septic patients. Low PCT levels reflect little to no activation of an innate immune response, influence the differential diagnosis, and support the discontinuation of empiric antibiotic therapy. Understanding the pathways that result in elevated serum PCT levels is necessary for interpretation and subsequent clinical management.
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Affiliation(s)
- David N Gilbert
- Department of Medical Education, Providence Portland Medical Center and Oregon Health & Sciences University, Portland, Oregon
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127
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Gauzit R, Castan B, Bonnet E, Bru JP, Cohen R, Diamantis S, Faye A, Hitoto H, Issa N, Lebeaux D, Lesprit P, Maulin L, Poitrenaud D, Raymond J, Strady C, Varon E, Verdon R, Vuotto F, Welker Y, Stahl JP. Anti-infectious treatment duration: The SPILF and GPIP French guidelines and recommendations. Infect Dis Now 2021; 51:114-139. [PMID: 34158156 DOI: 10.1016/j.idnow.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023]
Affiliation(s)
- R Gauzit
- Infectiologie transversale, CHU Cochin, AP-HP, 75014 Paris, France.
| | - B Castan
- Maladies infectieuses et tropicales, CHG, 24000 Périgueux, France
| | - E Bonnet
- Équipe Mobile d'Infectiologie, Hôpital Joseph-Ducuing, Clinique Pasteur, 31300 Toulouse, France
| | - J P Bru
- Maladies Infectieuses, CH Annecy-Genevois, 74374 Pringy, France
| | - R Cohen
- Unité petits nourrissons, CHI, 94000 Créteil, France
| | - S Diamantis
- Maladies Infectieuses et Tropicales, groupe hospitalier Sud Île-de-France, 77000 Melun, France
| | - A Faye
- Pédiatrie Générale et maladies infectieuses, Hôpital Robert-Debré, Université de Paris, AP-HP, 75019 Paris, France
| | - H Hitoto
- Maladies Infectieuses et Tropicales, CH, 72037 Le Mans, France
| | - N Issa
- Réanimation médicale et maladies infectieuses, Hôpital Saint-André, CHU, 33000 Bordeaux, France
| | - D Lebeaux
- Université de Paris, 75006 Paris, France; Microbiologie, Unité Mobile d'Infectiologie, HEGP, AP-HP, 75015 Paris, France
| | - P Lesprit
- Unité transversale d'hygiène et d'infectiologie, Service de Biologie Clinique, Hôpital Foch, 92150 Suresnes, France
| | - L Maulin
- Maladies Infectieuses et tropicales, CHIAP, 13616 Aix-en-Provence, France
| | - D Poitrenaud
- Unité fonctionnelle d'Infectiologie Régionale, CH Ajaccio, 20303 Ajaccio, France
| | - J Raymond
- Bactériologie, Centre Hospitalier Bicêtre, 94270 Kremlin-Bicêtre, France
| | - C Strady
- Cabinet d'infectiologie, Groupe Courlancy, 51100 Reims, France
| | - E Varon
- Laboratoire de Biologie Médicale et Centre National de Référence des Pneumocoques, CHIC, 94000 Créteil, France
| | - R Verdon
- Maladies Infectieuses et Tropicales, CHU, 14033 Caen, France; Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie Univ, UNICAEN, UNIROUEN, GRAM 2.0, 14000 Caen, France
| | - F Vuotto
- Maladies Infectieuses, CHU, Hôpital Huriez, 59000 Lille, France
| | - Y Welker
- Maladies Infectieuses, CHI, 78100 Saint-Germain-en-Laye, France
| | - J P Stahl
- Infectiologie, CHU Grenoble Alpes, 38043 Grenoble, France
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128
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Covino M, Gallo A, Montalto M, De Matteis G, Burzo ML, Simeoni B, Murri R, Candelli M, Ojetti V, Franceschi F. The Role of Early Procalcitonin Determination in the Emergency Departiment in Adults Hospitalized with Fever. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020179. [PMID: 33669753 PMCID: PMC7922631 DOI: 10.3390/medicina57020179] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Abstract
Background and Objectives: Fever is one of the most common presenting complaints in the Emergency Department (ED). The role of serum procalcitonin (PCT) determination in the ED evaluation of adults presenting with fever is still debated. The aim of this study was to evaluate if, in adults presenting to the ED with fever and then hospitalized, the early PCT determination could improve prognosis. Materials and Methods. This is a retrospective, mono-centric study, conducted over a 10-year period (2009-2018). We analyzed consecutive patients ≥18 years admitted to ED with fever and then hospitalized. According to quick sequential organ failure assessment (qSOFA) at admission, we compared patients that had a PCT determination vs. controls. Primary endpoint was overall in-hospital mortality; secondary endpoints were in-hospital length of stay, and mortality in patients with bloodstream infection and acute respiratory infections. Results. The sample included 12,062 patients, median age was 71 years and 55.1% were men. In patients with qSOFA ≥ 2 overall mortality was significantly lower if they had a PCT-guided management in ED, (20.5% vs. 26.5%; p = 0.046). In the qSOFA < 2 group the mortality was not significantly different in PCT patients, except for those with a final diagnosis of bloodstream infection. Conclusions. Among adults hospitalized with fever, the PCT evaluation at ED admission was not associated with better outcomes, with the possible exception of patients affected by bloodstream infections. However, in febrile patients presenting to the ED with qSOFA ≥ 2, the early PCT evaluation could improve the overall in-hospital survival.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
- Correspondence:
| | - Antonella Gallo
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (A.G.); (G.D.M.)
| | - Massimo Montalto
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (A.G.); (G.D.M.)
| | - Giuseppe De Matteis
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (A.G.); (G.D.M.)
| | - Maria Livia Burzo
- Emergency Department, Ospedale Generale M.G. Vannini, Istituto Figlie di San Camillo, 00177 Rome, Italy;
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
| | - Rita Murri
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
- Department of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Marcello Candelli
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
| | - Veronica Ojetti
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCSS, 00168 Rome, Italy; (B.S.); (M.C.); (V.O.); (F.F.)
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.M.); (R.M.)
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129
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Kyriazopoulou E, Liaskou-Antoniou L, Adamis G, Panagaki A, Melachroinopoulos N, Drakou E, Marousis K, Chrysos G, Spyrou A, Alexiou N, Symbardi S, Alexiou Z, Lagou S, Kolonia V, Gkavogianni T, Kyprianou M, Anagnostopoulos I, Poulakou G, Lada M, Makina A, Roulia E, Koupetori M, Apostolopoulos V, Petrou D, Nitsotolis T, Antoniadou A, Giamarellos-Bourboulis EJ. Procalcitonin to Reduce Long-Term Infection-associated Adverse Events in Sepsis. A Randomized Trial. Am J Respir Crit Care Med 2021; 203:202-210. [PMID: 32757963 PMCID: PMC7874409 DOI: 10.1164/rccm.202004-1201oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rationale: Although early antimicrobial discontinuation guided by procalcitonin (PCT) has shown decreased antibiotic consumption in lower respiratory tract infections, the outcomes in long-term sepsis sequelae remain unclear. Objectives: To investigate if PCT guidance may reduce the incidence of long-term infection-associated adverse events in sepsis. Methods: In this multicenter trial, 266 patients with sepsis (by Sepsis-3 definitions) with lower respiratory tract infections, acute pyelonephritis, or primary bloodstream infection were randomized (1:1) to receive either PCT-guided discontinuation of antimicrobials or standard of care. The discontinuation criterion was ≥80% reduction in PCT levels or any PCT ≤0.5 μg/L at Day 5 or later. The primary outcome was the rate of infection-associated adverse events at Day 180, a composite of the incidence of any new infection by Clostridioides difficile or multidrug-resistant organisms, or any death attributed to baseline C. difficile or multidrug-resistant organism infection. Secondary outcomes included 28-day mortality, length of antibiotic therapy, and cost of hospitalization. Measurements and Main Results: The rate of infection-associated adverse events was 7.2% (95% confidence interval [CI], 3.8–13.1%; 9/125) versus 15.3% (95% CI, 10.1–22.4%; 20/131) (hazard ratio, 0.45; 95% CI, 0.20–0.98; P = 0.045); 28-day mortality 15.2% (95% CI, 10–22.5%; 19/125) versus 28.2% (95% CI, 21.2–36.5%; 37/131) (hazard ratio, 0.51; 95% CI, 0.29–0.89; P = 0.02); and median length of antibiotic therapy 5 (range, 5–7) versus 10 (range, 7–15) days (P < 0.001) in the PCT and standard-of-care arms, respectively. The cost of hospitalization was also reduced in the PCT arm. Conclusions: In sepsis, PCT guidance was effective in reducing infection-associated adverse events, 28-day mortality, and cost of hospitalization. Clinical trial registered with www.clinicaltrials.gov (NCT03333304).
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Affiliation(s)
| | | | - George Adamis
- Third Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | | | - Elina Drakou
- Third Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Konstantinos Marousis
- Third Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Georgios Chrysos
- First Department of Internal Medicine, G. Gennimatas General Hospital of Athens, Athens, Greece
| | - Andronikos Spyrou
- Third Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Nikolaos Alexiou
- Second Department of Internal Medicine, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Styliani Symbardi
- Second Department of Internal Medicine, Tzaneio General Hospital of Piraeus, Athens, Greece
| | | | - Styliani Lagou
- Second Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece; and
| | - Virginia Kolonia
- Second Department of Internal Medicine, Sismanogleio General Hospital of Athens, Athens, Greece
| | | | | | - Ioannis Anagnostopoulos
- Second Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece; and
| | - Garyfallia Poulakou
- Second Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece; and
| | - Malvina Lada
- Second Department of Internal Medicine, Sismanogleio General Hospital of Athens, Athens, Greece
| | | | | | - Marina Koupetori
- Second Department of Internal Medicine, Tzaneio General Hospital of Piraeus, Athens, Greece
| | | | - Dimitra Petrou
- Second Department of Internal Medicine, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Thomas Nitsotolis
- First Department of Internal Medicine, G. Gennimatas General Hospital of Athens, Athens, Greece
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130
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Covino M, Fransvea P, Rosa F, Cozza V, Quero G, Simeoni B, Gasbarrini A, Alfieri S, Franceschi F, Sganga G. Early Procalcitonin Assessment in the Emergency Department in Patients with Intra-Abdominal Infection: An Excess or a Need? Surg Infect (Larchmt) 2021; 22:787-796. [PMID: 33533675 DOI: 10.1089/sur.2020.373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Intra-abdominal infection (IAI) is a wide range of intra-abdominal disease. Management involves empirical therapy and source control. Procalcitonin (PCT) has been suggested to assist in defining individual infection status and delivering individualized therapy. The aim of this study was to investigate the effects on patient outcomes of an early procalcitonin (PCT) assessment (in the emergency department [ED]) in patients with IAI. Methods: This was a retrospective, mono-centric study evaluating consecutive patients admitted to the ED from 2015 to 2019 with diagnosis of IAI. According to whether there had been PCT determination in the ED, patients were divided into no ePCT determination (no-ePCT) and early PCT determination in the ED (ePCT). The primary endpoint was the intra-hospital mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay (LOS). The propensity score match (PSM) was generated using a logistic regression model on the baseline covariates considered to be potentially influencing the decision to determine PCT in the ED and confounding factors identified as significant at a preliminary statistical analysis with respect to in-hospital death. Results: A series of 3,429 patients were included. The ePCT group consisted to 768 (22.4%), whereas the no-ePCT group contained 2,661 patients (77.6%). When the PSM was matched to the two groups, no significant difference was observed. Considering patients with uncomplicated infections, the PCT determination was associated with a higher mortality rate. We found no significant differences regarding outcomes with the exception of LOS, which was slightly longer in the ePCT group. However, we observed a tendency toward a minor difference in the number of complications in the ePCT group, in particular a reduced rate of progression to sepsis. Conclusion: Early PCT determination could be irrelevant in IAIs. The PCT value may be cost-effective and possibly improve the prognosis in cIAIs. Further research is needed to understand the optimal use of PCT, including in combination with other emerging diagnostic tests.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Fausto Rosa
- Digestive Surgery, and Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Valerio Cozza
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery, and Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery, and Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A, Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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131
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Smith MD, Fee C, Mace SE, Maughan B, Perkins JC, Kaji A, Wolf SJ. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Ann Emerg Med 2021; 77:e1-e57. [PMID: 33349374 DOI: 10.1016/j.annemergmed.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.
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132
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Kamat IS, Ramachandran V, Eswaran H, Guffey D, Musher DM. Procalcitonin to Distinguish Viral From Bacterial Pneumonia: A Systematic Review and Meta-analysis. Clin Infect Dis 2021; 70:538-542. [PMID: 31241140 DOI: 10.1093/cid/ciz545] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/23/2019] [Indexed: 12/21/2022] Open
Abstract
Because of the diverse etiologies of community-acquired pneumonia (CAP) and the limitations of current diagnostic modalities, serum procalcitonin levels have been proposed as a novel tool to guide antibiotic therapy. Outcome data from procalcitonin-guided therapy trials have shown similar mortality, but the essential question is whether the sensitivity and specificity of procalcitonin levels enable the practitioner to distinguish bacterial pneumonia, which requires antibiotic therapy, from viral pneumonia, which does not. In this meta-analysis of 12 studies in 2408 patients with CAP that included etiologic diagnoses and sufficient data to enable analysis, the sensitivity and specificity of serum procalcitonin were 0.55 (95% confidence interval [CI], .37-.71; I2 = 95.5%) and 0.76 (95% CI, .62-.86; I2 = 94.1%), respectively. Thus, a procalcitonin level is unlikely to provide reliable evidence either to mandate administration of antibiotics or to enable withholding such treatment in patients with CAP.
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Affiliation(s)
- Ishan S Kamat
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Harish Eswaran
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Danielle Guffey
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
| | - Daniel M Musher
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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133
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Rombauts A, Abelenda-Alonso G, Cuervo G, Gudiol C, Carratalà J. Role of the inflammatory response in community-acquired pneumonia: clinical implications. Expert Rev Anti Infect Ther 2021; 20:1261-1274. [PMID: 33034228 DOI: 10.1080/14787210.2021.1834848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Despite adequate antibiotic coverage, community-acquired pneumonia (CAP) remains a leading cause of hospitalization and mortality worldwide. It induces both a local pulmonary and a systemic inflammatory response, particularly significant in severe cases. The intensity of the dysregulated host response varies from patient to patient and has a negative impact on survival and other outcomes. AREAS COVERED This comprehensive review summarizes the pathophysiological aspects of the inflammatory response in CAP, briefly discusses the usefulness of biomarkers, and assesses the clinical evidence for modulating the inflammatory pathways. We searched PubMed for the most relevant studies, reviews, and meta-analysis until August 2020. EXPERT OPINION Notable efforts have been made to identify biomarkers that can accurately differentiate between viral and bacterial etiology, and indeed, to enhance risk stratification in CAP. However, none has proven ideal and no recommended biomarker-guided algorithms exist. Biomarker signatures from proteomic and metabolomic studies could be more useful for such assessments. To date, most studies have produced contradictory results concerning the role of immunomodulatory agents (e.g. corticosteroids, macrolides, and statins) in CAP. Adequately identifying the population who may benefit most from effective modulation of the inflammatory response remains a challenge.
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Affiliation(s)
- Alexander Rombauts
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain
| | - Guillermo Cuervo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain.,Institut Català d'Oncologia (ICO), Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Spain.,Spanish Network for Research in Infectious Disease (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,University of Barcelona, Barcelona, Spain
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134
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Nimesh M, Nandan D, Kumar S, Manik L, Sudarshan J, Duggal N. Serum procalcitonin as an early inflammatory marker in pediatric ventilator-associated pneumonia: A prospective observational study. JOURNAL OF PEDIATRIC CRITICAL CARE 2021. [DOI: 10.4103/jpcc.jpcc_55_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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135
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Magalhães C, Lima M, Trieu-Cuot P, Ferreira P. To give or not to give antibiotics is not the only question. THE LANCET. INFECTIOUS DISEASES 2020; 21:e191-e201. [PMID: 33347816 DOI: 10.1016/s1473-3099(20)30602-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 06/05/2020] [Accepted: 06/25/2020] [Indexed: 02/08/2023]
Abstract
In a 1945 Nobel Lecture, Sir Alexander Fleming warned against the overuse of antibiotics, particularly in response to public pressure. In the subsequent decades, evidence has shown that bacteria can become resistant to almost any available molecule. One key question is how the emergence and dissemination of resistant bacteria or resistance genes can be delayed. Although some clinicians remain sceptical, in this Personal View, we argue that the prescription of fewer antibiotics and shorter treatment duration is just as effective as longer regimens that remain the current guideline. Additionally, we discuss the fact that shorter antibiotic treatments exert less selective pressure on microorganisms, preventing the development of resistance. By contrast, longer treatments associated with a strong selective pressure favour the emergence of resistant clones within commensal organisms. We also emphasise that more studies are needed to identify the optimal duration of antibiotic therapy for common infections, which is important for making changes to the current guidelines, and to identify clinical biomarkers to guide antibiotic treatment in both hospital and ambulatory settings.
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Affiliation(s)
- Catarina Magalhães
- Department of Immuno-Physiology and Pharmacology, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Margarida Lima
- Unidade de Investigação Biomédica do Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal; Department of Hematology, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Patrick Trieu-Cuot
- Institut Pasteur, Unité de Biologie des Bactéries Pathogènes à Gram-positif, Centre National de la Recherche Scientifique (CNRS UMR 2001), Paris, France
| | - Paula Ferreira
- Department of Immuno-Physiology and Pharmacology, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal; Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal; Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal.
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136
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Li F, Kong S, Xie K, Zhang Y, Yan P, Zhao W. High ratio of C-reactive protein/procalcitonin predicts Mycoplasma pneumoniae infection among adults hospitalized with community acquired pneumonia. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 81:65-71. [PMID: 33345630 DOI: 10.1080/00365513.2020.1858491] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There is limited data on serum biomarkers in distinguishing Mycoplasma pneumoniae (MP) from Streptococcus pneumoniae (SP) and viral pneumoniae (VP) etiologies of community-acquired pneumonia (CAP). A retrospective study of inpatients diagnosed with CAP at the First Affiliated Hospital of Dali University (Dali, Yunnan, China) between January 2018 and June 2020 was conducted. The demographic, clinical and laboratory data of the patients with CAP were analyzed. Univariate analyses identified predictors for MP infections. The discriminative power of C-reactive protein (CRP), procalcitonin (PCT), CRP/PCT and CRP/PCT >350 μg/ng was assessed by area under the curve (AUC) of the receiver operating characteristic (ROC) curves. A total of 552 CAP patients, including 247 (44.7%) with MP, 152 (27.6%) with SP and 153 (27.7%) with influenza A and B viruses, were enrolled. When comparing MP with SP, cough and CRP/PCT >350 μg/ng (odds ratio [OR]) 2.88, p < .001) were predictors for MP. CRP/PCT >350 μg/ng had 76% sensitivity and 100% specificity (AUC = 0.89, p < .001, 95% confidence interval [CI]:0.81-0.94) to predict MP infections. Furthermore, similar results were again obtained when comparing MP with VP. CRP/PCT >350 μg/ng present better information (OR: 4.70; AUC = 0.92, p < .001, 87% sensitivity and 100% specificity). In addition, comparing MP and non-MP (SP and VP combined), CRP/PCT >350 μg/ng exhibited excellent performance (AUC = 0.90, 95%CI 0.83-0.95, p < .001, 76% sensitivity and 100% specificity). CRP/PCT ratio may be a potential index to distinguish MP-CAP from non-MP-CAP.
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Affiliation(s)
- Fuxing Li
- Department of Clinical Laboratory, School of Clinical Medicine, Dali University, Dali, China
| | - Shan Kong
- Department of Clinical Laboratory, School of Clinical Medicine, Dali University, Dali, China
| | - Kexin Xie
- Department of Clinical Laboratory, School of Clinical Medicine, Dali University, Dali, China
| | - Yulin Zhang
- Department of Clinical Laboratory, School of Clinical Medicine, Dali University, Dali, China
| | - Ping Yan
- Department of Gastroenterology, The First Affiliated Hospital of Dali University, Dali, China
| | - Weidong Zhao
- Department of Clinical Laboratory, School of Clinical Medicine, Dali University, Dali, China.,Institute of Translational Medicine for Metabolic Diseases, Dali University, Dali, China
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Foti G, Giannini A, Bottino N, Castelli GP, Cecconi M, Grasselli G, Guatteri L, Latronico N, Langer T, Monti G, Muttini S, Pesenti A, Radrizzani D, Ranucci M, Russotto V, Fumagalli R. Management of critically ill patients with COVID-19: suggestions and instructions from the coordination of intensive care units of Lombardy. Minerva Anestesiol 2020; 86:1234-1245. [PMID: 33228329 DOI: 10.23736/s0375-9393.20.14762-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
With 63,098 confirmed cases on 17 April 2020 and 11,384 deaths, Lombardy has been the most affected region in Italy by coronavirus disease 2019 (COVID-19). To cope with this emergency, the COVID-19 Lombardy intensive care units (ICU) network was created. The network identified the need of defining a list of clinical recommendations to standardize treatment of patients with COVID-19 admitted to Intensive Care Unit (ICU). Three core topics were identified: 1) rational use of intensive care resources; 2) ventilation strategies; 3) non-ventilatory interventions. Identification of patients who may benefit from ICU treatment is challenging. Clinicians should consider baseline performance and frailty status and they should adopt disease-specific staging tools. Continuous positive airway pressure, mainly delivered through a helmet as elective method, should be considered as initial treatment for all patients with respiratory failure associated with COVID-19. In case of persisting dyspnea and/or desaturation despite 4-6 hours of noninvasive ventilation, endotracheal intubation and invasive mechanical ventilation should be considered. In the early phase, muscle relaxant use and volume-controlled ventilation is recommended. Prone position should be performed in patients with PaO<inf>2</inf>/FiO<inf>2</inf>≤100 mmHg. For patients admitted to ICU with COVID-19 interstitial pneumonia, we do not recommend empiric antibiotic therapy for community-acquired pneumonia. Consultation of an infectious disease specialist is suggested before start of any antiviral therapy. In conclusion, the COVID-19 Lombardy ICU Network identified a list of best practice statements supported by the available evidence and clinical experience or identified as panel members expert opinions for the management of critically ill patients with COVID-19.
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Affiliation(s)
- Giuseppe Foti
- Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy.,School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesiology and Intensive Care, Children's Hospital, ASST Spedali Civili Hospital, Brescia, Italy
| | - Nicola Bottino
- Department of Anesthesiology, Reanimation and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gian Paolo Castelli
- Department of Anesthesiology and Intensive Care, ASST Mantua, Carlo Poma Hospital, Mantua, Italy
| | - Maurizio Cecconi
- Department of Anesthesiology and Intensive Care Medicine, IRCCS Humanitas Clinic, Rozzano, Milan, Italy.,Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Reanimation and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luca Guatteri
- Department of Anesthesiology and Intensive Care, Sacra Famiglia Fatebenefratelli Hospital, Erba, Como, Italy
| | - Nicola Latronico
- Unit of Pediatric Anesthesiology and Intensive Care, Children's Hospital, ASST Spedali Civili Hospital, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesiology, Critical Care and Emergency, ASST Spedali Civili, Brescia, Italy
| | - Thomas Langer
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anesthesiology and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giacomo Monti
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Hospital, Milan, Italy
| | - Stefano Muttini
- Department of Anesthesiology and Intensive Care, ASST Santi Paolo e Carlo, San Carlo Hospital, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesiology, Reanimation and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Danilo Radrizzani
- Department of Anesthesiology and Intensive Care, ASST Ovest Milanese, Hospital of Legnano, Legnano, Milan, Italy
| | - Marco Ranucci
- Department of Anesthesiology and Intensive Care, IRCCS San Donato Hospital, Milan, Italy
| | - Vincenzo Russotto
- Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy - .,School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anesthesiology and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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138
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Impact of restricting procalcitonin measurements in a Swiss tertiary-care hospital on antibiotic use, clinical outcomes, and costs: An interrupted time-series analysis. Infect Control Hosp Epidemiol 2020; 42:890-892. [PMID: 33261687 DOI: 10.1017/ice.2020.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We evaluated the impact of a restriction of procalcitonin measurements on antibiotic use, length of stay, mortality, and cost in a Swiss tertiary-care hospital using interrupted time-series analysis. There was no significant change in level or slope for rates of antibiotic consumption, and costs decreased considerably, by ~54,488 CHF (US$55,714) per month.
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139
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Respiratory viral testing and antibacterial treatment in patients hospitalized with community-acquired pneumonia. Infect Control Hosp Epidemiol 2020; 42:817-825. [PMID: 33256870 DOI: 10.1017/ice.2020.1312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Viruses are more common than bacteria in patients hospitalized with community-acquired pneumonia. Little is known, however, about the frequency of respiratory viral testing and its associations with antimicrobial utilization. DESIGN Retrospective cohort study. SETTING The study included 179 US hospitals. PATIENTS Adults admitted with pneumonia between July 2010 and June 2015. METHODS We assessed the frequency of respiratory virus testing and compared antimicrobial utilization, mortality, length of stay, and costs between tested versus untested patients, and between virus-positive versus virus-negative patients. RESULTS Among 166,273 patients with pneumonia on admission, 40,787 patients (24.5%) were tested for respiratory viruses, 94.8% were tested for influenza, and 20.7% were tested for other viruses. Viral assays were positive in 5,133 of 40,787 tested patients (12.6%), typically for influenza and rhinovirus. Tested patients were younger and had fewer comorbidities than untested patients, but patients with positive viral assays were older and had more comorbidities than those with negative assays. Blood cultures were positive for bacterial pathogens in 2.7% of patients with positive viral assays versus 5.3% of patients with negative viral tests (P < .001). Antibacterial courses were shorter for virus-positive versus -negative patients overall (mean 5.5 vs 6.4 days; P < .001) but varied by bacterial testing: 8.1 versus 8.0 days (P = .60) if bacterial tests were positive; 5.3 versus 6.1 days (P < .001) if bacterial tests were negative; and 3.3 versus 5.2 days (P < .001) if bacterial tests were not obtained (interaction P < .001). CONCLUSIONS A minority of patients hospitalized with pneumonia were tested for respiratory viruses; only a fraction of potential viral pathogens were assayed; and patients with positive viral tests often received long antibacterial courses.
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140
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Chen K, Pleasants KA, Pleasants RA, Beiko T, Washburn RG, Yu Z, Zhai S, Drummond MB. Procalcitonin for Antibiotic Prescription in Chronic Obstructive Pulmonary Disease Exacerbations: Systematic Review, Meta-Analysis, and Clinical Perspective. Pulm Ther 2020; 6:201-214. [PMID: 32676981 PMCID: PMC7672148 DOI: 10.1007/s41030-020-00123-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Indexed: 10/26/2022] Open
Abstract
The 2020 Global Initiative for Obstructive Lung Disease report indicates that the blood biomarker procalcitonin (PCT) may assist in decision-making regarding the initiation of antibiotics for chronic obstructive pulmonary disease (COPD) exacerbations. PCT is an acute-phase reactant that increases in response to inflammation and infection, and has been studied in various bacterial infections for initiation and de-escalation of antibacterials. The purpose of this systematic review and meta-analysis was to evaluate the strength of the data on the use of PCT to guide antibiotic prescription in COPD exacerbations. Among the randomized clinical trials included in our meta-analysis, almost all of which were conducted exclusively in the hospital setting. PCT was found to decrease overall antibiotic exposure in COPD exacerbations by 2.01 days (p = 0.04), while no apparent effects were found on clinical outcomes (length of hospital stay, p = 0.88; treatment failure p = 0.51; all-cause mortality p = 0.28). However, the majority of blood PCT levels in COPD exacerbations were below the manufacturer-recommended cutoff for antibiotics, and the use of this marker was associated with worse outcomes in the intensive care setting. Further, based on additional sensitivity analysis excluding studies with high risk of bias or with converted outcome value, the effect of PCT on antibiotic duration in RCTs was no longer significant (MD = -1.88 days, 95% CI [-3.95, 0.19] days, p = 0.08, and MD = -1.72 days, 95% CI [-4.28, 0.83] days, p = 0.19, respectively). Our review and analysis does not support the use of PCT to guide antibiotic prescription in COPD exacerbations.
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Affiliation(s)
- Ken Chen
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Tatsiana Beiko
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ronald G Washburn
- Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | - Zhiheng Yu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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141
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Abstract
Given the large number of patients seen in the emergency department (ED) and concerns with antibiotic overprescribing, the ED is an important setting to target for antimicrobial stewardship (AS) initiatives. The ED is positioned between ambulatory and inpatient settings, making AS collaboration with clinicians and other health care providers in the hospital, long-term care facilities, and ambulatory settings critical to success. This article details ED-focused AS strategies on empiric antimicrobial selection, prompt administration, preventing ED return and readmissions, suggested collaborations between ED AS leadership and other key partners, and potential future strategies for expansion.
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142
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Yuan S, Zheng N, Zheng W, Jiang Q, Qiao B, Jing H, Li Y, Qi X, Cao W, Song S. Analytical evaluation of Reebio procalcitonin latex-enhanced immunoturbidimetric assay on the HITACHI Labospect 008AS. Clin Chem Lab Med 2020; 59:e23-e26. [PMID: 33554508 DOI: 10.1515/cclm-2020-0796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/14/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Shunzong Yuan
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Naxin Zheng
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Wenwen Zheng
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Qian Jiang
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Bing Qiao
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Huarong Jing
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Ying Li
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Xiaoyu Qi
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Wenjing Cao
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
| | - Shiping Song
- Department of Laboratory Medicine, The Fifth Medical Center, Chinese PLA General Hospital (Former 307th hospital of the PLA), Beijing, P.R. China
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143
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Antibiotic prescribing patterns for coronavirus disease 2019 (COVID-19) in two emergency departments with rapid procalcitonin. Infect Control Hosp Epidemiol 2020; 42:359-361. [PMID: 33208206 PMCID: PMC7737132 DOI: 10.1017/ice.2020.1329] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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144
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Milne S, Sin DD. Biomarkers in Chronic Obstructive Pulmonary Disease: The Gateway to Precision Medicine. Clin Chest Med 2020; 41:383-394. [PMID: 32800193 DOI: 10.1016/j.ccm.2020.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a highly heterogeneous disease with limited adequate treatments. Biomarkers-which may relate to disease susceptibility, diagnosis, prognosis, or treatment response-are ideally suited to dissecting such a complex disease and form a critical component of the precision medicine paradigm. Not all potential candidates, however, make good biomarkers. To date, only plasma fibrinogen has been approved by regulatory bodies as a biomarker of exacerbation risk for clinical trial enrichment. This review outlines some of the challenges of biomarker research in COPD and highlights novel and promising biomarker candidates.
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Affiliation(s)
- Stephen Milne
- Centre for Heart Lung Innovation and Division of Respiratory Medicine, University of British Columbia, Room 166, St Paul's Hospital, 1081 Burrard St, Vancouver, British Columbia V6Z 1Y6, Canada; Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2006, Australia.
| | - Don D Sin
- Centre for Heart Lung Innovation and Division of Respiratory Medicine, University of British Columbia, Room 166, St Paul's Hospital, 1081 Burrard St, Vancouver, British Columbia V6Z 1Y6, Canada
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145
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Stutsrim AE, Griffin CM, Palavecino EL, Hildreth AN, Avery MD, Chang MC, Miller PR, Nunn AM. Screening for Bacteremia in Trauma Patients: Traditional Markers Fall Short. Am Surg 2020; 87:765-770. [PMID: 33170029 DOI: 10.1177/0003134820954786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Deranged physiology in trauma complicates the clinical identification of sepsis, resulting in overscreening for bacteremia. No clinical signs or biomarkers accurately diagnose sepsis in this population. Our objective was to evaluate the accuracy of the current criteria used to prompt screening for bacteremia in trauma patients and determine independent predictors of bacteremia. MATERIALS AND METHODS Adult trauma patients admitted to our level I academic trauma center who had blood cultures (BCs) drawn were identified. Those with positive BCs were compared to those with negative or false positive BCs. False positive was defined as a BC deemed contaminated and not treated at the discretion of the attending physician. RESULTS Over a 2-year period, 366 trauma patients had BCs drawn. After excluding surveillance cultures (those drawn to demonstrate bacteremia clearance), 492 unique BC sets were evaluated; 104 (21.1%) BC sets were positive; 30 (28.8%) of these were falsely positive, resulting in a true-positive rate of 15% in the screened population. Univariate analysis suggested temperature and heart rate were associated with positive BC, while multivariable analysis found only the presence of a central line and lactic acid to be predictive. Procalcitonin (PCT) was poorly predictive, with a positive predictive value of 18% and a negative predictive value of 91%. CONCLUSION Current tools for identifying bacteremia in trauma patients result in overscreening. PCT may have a limited role as a negative predictor for bacteremia. Given that false-positive BCs have negative patient and economic consequences, future study should focus on development of alternative screening modalities.
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Affiliation(s)
- Ashlee E Stutsrim
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Caitlin M Griffin
- Department of General Surgery, University of Louisville, Louisville, KY, USA
| | | | - Amy N Hildreth
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Martin D Avery
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael C Chang
- Department of General Surgery, University of South Alabama, Mobile, AL, USA
| | - Preston R Miller
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andrew M Nunn
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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146
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May L, Martín Quirós A, Ten Oever J, Hoogerwerf J, Schoffelen T, Schouten J. Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions. Clin Microbiol Infect 2020; 27:204-209. [PMID: 33144202 DOI: 10.1016/j.cmi.2020.10.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Emergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions. OBJECTIVES We aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting. SOURCES (a) a PubMed search for 'antimicrobial stewardship' and 'emergency department', and (b) published reviews on effectiveness combined with publications from the first source. CONTENT (a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review. IMPLICATIONS Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA, USA
| | | | - Jaap Ten Oever
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jacobien Hoogerwerf
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Teske Schoffelen
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
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147
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Heilmann E, Gregoriano C, Wirz Y, Luyt CE, Wolff M, Chastre J, Tubach F, Christ-Crain M, Bouadma L, Annane D, Damas P, Kristoffersen KB, Oliveira CF, Stolz D, Tamm M, de Jong E, Reinhart K, Shehabi Y, Verduri A, Nobre V, Nijsten M, deLange DW, van Oers JAH, Beishuizen A, Girbes ARJ, Mueller B, Schuetz P. Association of kidney function with effectiveness of procalcitonin-guided antibiotic treatment: a patient-level meta-analysis from randomized controlled trials. Clin Chem Lab Med 2020; 59:441-453. [PMID: 32986609 DOI: 10.1515/cclm-2020-0931] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/31/2020] [Indexed: 12/25/2022]
Abstract
Objectives Patients with impaired kidney function have a significantly slower decrease of procalcitonin (PCT) levels during infection. Our aim was to study PCT-guided antibiotic stewardship and clinical outcomes in patients with impairments of kidney function as assessed by creatinine levels measured upon hospital admission. Methods We pooled and analyzed individual data from 15 randomized controlled trials who were randomly assigned to receive antibiotic therapy based on a PCT-algorithms or based on standard of care. We stratified patients on the initial glomerular filtration rate (GFR, ml/min/1.73 m2) in three groups (GFR >90 [chronic kidney disease; CKD 1], GFR 15-89 [CKD 2-4] and GFR<15 [CKD 5]). The main efficacy and safety endpoints were duration of antibiotic treatment and 30-day mortality. Results Mean duration of antibiotic treatment was significantly shorter in PCT-guided (n=2,492) compared to control patients (n=2,510) (9.5-7.6 days; adjusted difference in days -2.01 [95% CI, -2.45 to -1.58]). CKD 5 patients had overall longer treatment durations, but a 2.5-day reduction in treatment duration was still found in patients receiving in PCT-guided care (11.3 vs. 8.6 days [95% CI -3.59 to -1.40]). There were 397 deaths in 2,492 PCT-group patients (15.9%) compared to 460 deaths in 2,510 control patients (18.3%) (adjusted odds ratio, 0.88 [95% CI 0.78 to 0.98)]. Effects of PCT-guidance on antibiotic treatment duration and mortality were similar in subgroups stratified by infection type and clinical setting (p interaction >0.05). Conclusions This individual patient data meta-analysis confirms that the use of PCT in patients with impaired kidney function, as assessed by admission creatinine levels, is associated with shorter antibiotic courses and lower mortality rates.
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Affiliation(s)
- Eva Heilmann
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Yannick Wirz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean Chastre
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Florence Tubach
- Département d'Epidémiologie Biostatistique et Recherche Clinique, AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Basel, Basel, Switzerland
| | - Lila Bouadma
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Djillali Annane
- Department of Critical Care, Hyperbaric Medicine and Home Respiratory Unit, Center for Neuromuscular Diseases, Raymond Poincaré Hospital (AP-HP), Garches, France
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Domaine universitaire de Liège, Liege, Belgium
| | | | - Carolina F Oliveira
- Department of Internal Medicine, School of Medcine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Daiana Stolz
- Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Michael Tamm
- Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Evelien de Jong
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Yahya Shehabi
- Critical Care and Peri-operative Medicine, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Alessia Verduri
- Department of Medical and Surgical Sciences,Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Vandack Nobre
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Maarten Nijsten
- University Medical Centre, University of Groningen, Groningen, The Netherlands
| | | | | | | | - Armand R J Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Beat Mueller
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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148
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O'Riordan F, Shiely F, Byrne S, O'Brien D, Palmer B, Dahly D, O'Connor TM, Curran D, Fleming A. An investigation of the effects of procalcitonin testing on antimicrobial prescribing in respiratory tract infections in an Irish university hospital setting: a feasibility study. J Antimicrob Chemother 2020; 74:3352-3361. [PMID: 31325313 DOI: 10.1093/jac/dkz313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/03/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Diagnostic uncertainty and a high prevalence of viral infections present unique challenges for antimicrobial prescribing for respiratory tract infections (RTIs). Procalcitonin (PCT) has been shown to support prescribing decisions and reduce antimicrobial use safely in patients with RTIs, but recent study results have been variable. METHODS We conducted a feasibility study of the introduction of PCT testing in patients admitted to hospital with a lower RTI to determine if PCT testing is an effective and worthwhile intervention to introduce to support the existing antimicrobial stewardship (AMS) programme and safely decrease antimicrobial prescribing in patients admitted with RTIs. RESULTS A total of 79 patients were randomized to the intervention PCT-guided treatment group and 40 patients to the standard care respiratory control group. The addition of PCT testing led to a significant decrease in duration of antimicrobial prescriptions (mean 6.8 versus 8.9 days, P = 0.012) and decreased length of hospital stay (median 7 versus 8 days, P = 0.009) between the PCT and respiratory control group. PCT did not demonstrate a significant reduction in antimicrobial consumption when measured as DDDs and days of therapy. CONCLUSIONS PCT testing had a positive effect on antimicrobial prescribing during this feasibility study. The successful implementation of PCT testing in a randomized controlled trial requires an ongoing comprehensive education programme, greater integration into the AMS programme and delivery of PCT results in a timely manner. This feasibility study has shown that a larger randomized controlled trial would be beneficial to further explore the positive aspects of these findings.
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Affiliation(s)
- F O'Riordan
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland.,Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - F Shiely
- HRB Clinical Research Facility Cork, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - S Byrne
- Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - D O'Brien
- Department of Microbiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - B Palmer
- HRB Clinical Research Facility Cork, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - D Dahly
- HRB Clinical Research Facility Cork, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - T M O'Connor
- Department of Respiratory Medicine, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - D Curran
- Department of Respiratory Medicine, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - A Fleming
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland.,Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland
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149
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Keitel K, Samaka J, Masimba J, Temba H, Said Z, Kagoro F, Mlaganile T, Sangu W, Genton B, D'Acremont V. Safety and Efficacy of C-reactive Protein-guided Antibiotic Use to Treat Acute Respiratory Infections in Tanzanian Children: A Planned Subgroup Analysis of a Randomized Controlled Noninferiority Trial Evaluating a Novel Electronic Clinical Decision Algorithm (ePOCT). Clin Infect Dis 2020; 69:1926-1934. [PMID: 30715250 DOI: 10.1093/cid/ciz080] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/30/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The safety and efficacy of using C-reactive protein (CRP) to decide on antibiotic prescription among febrile children at risk of pneumonia has not been tested. METHODS This was a randomized (1:1) controlled noninferiority trial in 9 primary care centers in Tanzania (substudy of the ePOCT trial evaluating a novel electronic decision algorithm). Children aged 2-59 months with fever and cough and without life-threatening conditions received an antibiotic based on a CRP-informed strategy (combination of CRP ≥80 mg/L plus age/temperature-corrected tachypnea and/or chest indrawing) or current World Health Organization standard (respiratory rate ≥50 breaths/minute). The primary outcome was clinical failure by day (D) 7; the secondary outcomes were antibiotic prescription at D0, secondary hospitalization, or death by D30. RESULTS A total of 1726 children were included (intervention: 868, control: 858; 0.7% lost to follow-up). The proportion of clinical failure by D7 was 2.9% (25/865) in the intervention arm vs 4.8% (41/854) in the control arm (risk difference, -1.9% [95% confidence interval {CI}, -3.7% to -.1%]; risk ratio [RR], 0.60 [95% CI, .37-.98]). Twenty of 865 (2.3%) children in the intervention arm vs 345 of 854 (40.4%) in the control arm received antibiotics at D0 (RR, 0.06 [95% CI, .04-.09]). There were fewer secondary hospitalizations and deaths in the CRP arm: 0.5% (4/865) vs 1.5% (13/854) (RR, 0.30 [95% CI, .10-.93]). CONCLUSIONS CRP testing using a cutoff of ≥80 mg/L, integrated into an electronic decision algorithm, was able to improve clinical outcome in children with respiratory infections while substantially reducing antibiotic prescription. CLINICAL TRIALS REGISTRATION NCT02225769.
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Affiliation(s)
- Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel.,Department of Pediatric Emergency Medicine, University Hospital Bern, Switzerland
| | - Josephine Samaka
- Ifakara Health Institute, Dar es Salaam, Tanzania.,Amana Hospital, Dar es Salaam, Tanzania
| | - John Masimba
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Zamzam Said
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Frank Kagoro
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | | | - Blaise Genton
- Swiss Tropical and Public Health Institute, Basel.,Infectious Diseases Service, University Hospital Lausanne, Switzerland
| | - Valerie D'Acremont
- Swiss Tropical and Public Health Institute, Basel.,Department of Ambulatory Care and Community Medicine, University Hospital Lausanne, Switzerland
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150
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Clark LT, Beuschel TS, Buss PM, Jameson AP, Dumkow LE. Comparison of procalcitonin testing to a targeted audit-and-feedback strategy on prescribed durations of therapy for community-acquired pneumonia. Diagn Microbiol Infect Dis 2020; 99:115202. [PMID: 33007583 DOI: 10.1016/j.diagmicrobio.2020.115202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 11/30/2022]
Abstract
The procalcitonin (PCT) assay is FDA-approved to help guide antimicrobial treatment, however, conflicting data exist regarding its impact on durations of therapy. The purpose of this study was to compare the impact of PCT to a targeted audit-and-feedback (TAF) strategy on antibiotic durations of therapy for community-acquired pneumonia (CAP). A retrospective cohort study was conducted at two community teaching hospitals, one implementing PCT with routine audit-and-feedback and one implementing TAF recommending 5 days of therapy for uncomplicated CAP. Three hundred eleven patients with antibiotics ordered having an indication of pneumonia were included (Pre-TAF n = 80, Pre-PCT n = 80, Post-TAF n = 80, Post-PCT n = 71). Average duration of therapy was similar at baseline (Pre-TAF = 7.0 days vs Pre-PCT = 7.8 days, p = 0.1) and post-intervention (Post-TAF = 5.5 days vs Post-PCT = 5.4 days, p = 0.8) between groups. PCT and TAF were equally effective antimicrobial stewardship strategies in reducing total days of antibiotic therapy prescribed for CAP with no differences observed in patient outcomes.
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Affiliation(s)
- Lauren T Clark
- Mercy Health Saint Mary's Pharmaceutical Services Department, Grand Rapids, MI, USA.
| | - Thomas S Beuschel
- Mercy Health Saint Mary's Pharmaceutical Services Department, Grand Rapids, MI, USA
| | - Paige M Buss
- Mercy Health Saint Mary's Pharmaceutical Services Department, Grand Rapids, MI, USA
| | - Andrew P Jameson
- Division of Infectious Disease, Mercy Health Saint Mary's, Grand Rapids, MI, USA
| | - Lisa E Dumkow
- Mercy Health Saint Mary's Pharmaceutical Services Department, Grand Rapids, MI, USA
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