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Becerra-Hervás J, Guitart C, Covas A, Bobillo-Pérez S, Rodríguez-Fanjul J, Carrasco-Jordan JL, Cambra Lasaosa FJ, Jordan I, Balaguer M. The Clinical Pulmonary Infection Score Combined with Procalcitonin and Lung Ultrasound (CPIS-PLUS), a Good Tool for Ventilator Associated Pneumonia Early Diagnosis in Pediatrics. CHILDREN (BASEL, SWITZERLAND) 2024; 11:592. [PMID: 38790587 PMCID: PMC11120099 DOI: 10.3390/children11050592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024]
Abstract
Ventilator-associated pneumonia (VAP) is common in Pediatric Intensive Care Units. Although early detection is crucial, current diagnostic methods are not definitive. This study aimed to identify lung ultrasound (LUS) findings and procalcitonin (PCT) values in pediatric patients with VAP to create a new early diagnosis score combined with the Clinical Pulmonary Infection Score (CPIS), the CPIS-PLUS score. Prospective longitudinal and interventional study. Pediatric patients with suspected VAP were included and classified into VAP or non-VAP groups, based on Centers of Disease Control (CDC) criteria for the final diagnosis. A chest-X-ray (CXR), LUS, and blood test were performed within the first 12 h of admission. CPIS score was calculated. A total of 108 patients with VAP suspicion were included, and VAP was finally diagnosed in 51 (47%) patients. CPIS-PLUS showed high accuracy in VAP diagnosis with a sensitivity (Sn) of 80% (95% CI 65-89%) and specificity (Sp) of 73% (95% CI 54-86%). The area under the curve (AUC) resulted in 0.86 for CPIS-PLUS vs. 0.61 for CPIS. In conclusion, this pilot study showed that CPIS-PLUS could be a potential and reliable tool for VAP early diagnosis in pediatric patients. Internal and external validations are needed to confirm the potential value of this score to facilitate VAP diagnosis in pediatric patients.
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Affiliation(s)
- Judit Becerra-Hervás
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Faculty of Medicine, University of Barcelona, c. Casanova, 143, 08036 Barcelona, Spain;
| | - Carmina Guitart
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
| | - Aina Covas
- Neonatal Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain;
| | - Sara Bobillo-Pérez
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
| | - Javier Rodríguez-Fanjul
- Neonatal Intensive Care Unit, Department of Paediatrics, Hospital Germans Trias i Pujol, Autonomous University of Barcelona, 08916 Badalona, Spain;
| | - Josep L. Carrasco-Jordan
- Faculty of Medicine, University of Barcelona, c. Casanova, 143, 08036 Barcelona, Spain;
- Biostatistics, Department of Basic Clinical Practice, University of Barcelona, 08036 Barcelona, Spain
| | - Francisco José Cambra Lasaosa
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Faculty of Medicine, University of Barcelona, c. Casanova, 143, 08036 Barcelona, Spain;
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
- Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, CIBERESP, 08950 Barcelona, Spain
| | - Mònica Balaguer
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
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Saura O, Luyt CE. Procalcitonin as a biomarker to guide treatments for patients with lower respiratory tract infections. Expert Rev Respir Med 2023; 17:651-661. [PMID: 37639716 DOI: 10.1080/17476348.2023.2251394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Lower respiratory tract infections are amongst the main causes for hospital/intensive care unit admissions and antimicrobial prescriptions. In order to reduce antimicrobial pressure, antibiotic administration could be optimized through procalcitonin-based algorithms. AREAS COVERED In this review, we discuss the performances of procalcitonin for the diagnosis and the management of community-acquired and ventilator-associated pneumonia. We provide up-to-date evidence and deliver clear messages regarding the purpose of procalcitonin to reduce unnecessary antimicrobial exposure. EXPERT OPINION Antimicrobial pressure and resulting antimicrobial resistances are a major public health issue as well as a daily struggle in the management of patients with severe infectious diseases, especially in intensive care units where antibiotic exposure is high. Procalcitonin-guided antibiotic administration has proven its efficacy in reducing unnecessary antibiotic use in lower respiratory tract infections without excess in mortality, hospital length of stay or disease relapse. Procalcitonin-guided algorithms should be implemented in wards taking care of patients with severe infections. However, procalcitonin performances are different regarding the setting of the infection (community versus hospital-acquired infections) the antibiotic management (start or termination of antibiotic) as well as patient's condition (immunosuppressed or in shock) and we encourage the physicians to be aware of these limitations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM, UMRS_1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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3
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Khilnani GC, Tiwari P, Zirpe KG, Chaudhry D, Govil D, Dixit S, Kulkarni AP, Todi SK, Hadda V, Jain N, Govindagoudar MB, Samavedam S, Jha SK, Tyagi N, Jaju MR, Sharma A. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022; 26:S77-S94. [PMID: 36896360 PMCID: PMC9989870 DOI: 10.5005/jp-journals-10071-24326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/21/2022] [Indexed: 11/07/2022] Open
Abstract
How to cite this article: Khilnani GC, Tiwari P, Zirpe KG, Chaudhary D, Govil D, Dixit S, et al. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022;26(S2):S77-S94.
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Affiliation(s)
- Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary Medicine, School of Excellence in Pulmonary Medicine, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | | | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, Pandit Bhagwat Dayal Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta - The Medicty, Gurugram, Haryana, India
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan Surgery Hospital, Pune, Maharashtra, India; Department of Critical Care Medicine, MJM Hospital, Pune, Maharashtra, India
| | - Atul Prabhakar Kulkarni
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neetu Jain
- Department of Pulmonary Medicine, Critical Care and Sleep Disorders, Pushpawati Singhania Hospital & Research Institute, New Delhi, India
| | | | - Srinivas Samavedam
- Department of Critical Care Management, Virinchi Hospital, Hyderabad, Telangana, India
| | | | - Niraj Tyagi
- Department of Institute of Critical Care Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | - Madhusudan R Jaju
- Critical Care Medicine Sunshine Hospital, Gachibowli, Hyderabad, India
| | - Anita Sharma
- Department of Lab Medicine, Fortes Hospital, Mohali, Punjab, India
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Teng G, Wang N, Nie X, Zhang L, Liu H. Analysis of risk factors for early-onset ventilator-associated pneumonia in a neurosurgical intensive care unit. BMC Infect Dis 2022; 22:66. [PMID: 35057762 PMCID: PMC8772091 DOI: 10.1186/s12879-022-07053-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 01/11/2022] [Indexed: 12/21/2022] Open
Abstract
Abstract
Background
Ventilator-associated pneumonia (VAP) is a severe infection among patients in the neurosurgery intensive care unit (NICU).
Methods
We retrospectively evaluated risk factors for early-onset ventilator-associated pneumonia (EOVAP) from January 2019 to December 2019 at a NICU. A total of 89 NICU patients who were intubated within 48 h of onset and whose mechanical ventilation time was at least 7 days were enrolled. We evaluated EOVAP that occurred within the first 7 days after the onset of mechanical ventilation. The enrolled patients had no history of chronic lung disease and no clinical manifestations of infection before intubation. Clinical data of patients were recorded, and the incidence of and risk factors for EOVAP were analyzed. Patients were also grouped by age (≥ 65 vs. < 65 years) and whether they had received hypothermia treatment or not.
Results
Among 89 mechanically ventilated patients (49 men and 40 women; the mean age ± SD was 60.1 ± 14.3 years), 40 patients (44.9%) developed EOVAP within 7 days and 14 patients (15.7%) had a multidrug resistant bacterial infection. Binary logistic regression analysis indicated that older age (≥ 65 years) (odds ratio [OR]:3.53, 95% confidence interval [CI]:1.27–9.79, P = 0.015) and therapeutic hypothermia (OR:3.68, CI:1.10–12.31, p = 0.034) were independent predictors of EOVAP. Levels of peripheral blood leukocytes, neutrophils and platelets were lower in the therapeutic hypothermia group than those who did not receive hypothermia treatment.
Conclusions
This study found that older age (≥ 65 years) and therapeutic hypothermia were independently associated with the risk of EOVAP in NICU patients.
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Póvoa P, Coelho L. Which Biomarkers Can Be Used as Diagnostic Tools for Infection in Suspected Sepsis? Semin Respir Crit Care Med 2021; 42:662-671. [PMID: 34544183 DOI: 10.1055/s-0041-1735148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The diagnosis of infection in patients with suspected sepsis is frequently difficult to achieve with a reasonable degree of certainty. Currently, the diagnosis of infection still relies on a combination of systemic manifestations, manifestations of organ dysfunction, and microbiological documentation. In addition, the microbiologic confirmation of infection is obtained only after 2 to 3 days of empiric antibiotic therapy. These criteria are far from perfect being at least in part responsible for the overuse and misuse of antibiotics, in the community and in hospital, and probably the main drive for antibiotic resistance. Biomarkers have been studied and used in several clinical settings as surrogate markers of infection to improve their diagnostic accuracy as well as in the assessment of response to antibiotics and in antibiotic stewardship programs. The aim of this review is to provide a clear overview of the current evidence of usefulness of biomarkers in several clinical scenarios, namely, to diagnose infection to prescribe antibiotics, to exclude infection to withhold antibiotics, and to identify the causative pathogen to target antimicrobial treatment. In recent years, new evidence with "old" biomarkers, like C-reactive protein and procalcitonin, as well as new biomarkers and molecular tests, as breathomics or bacterial DNA identification by polymerase chain reaction, increased markedly in different areas adding useful information for clinical decision making at the bedside when adequately used. The recent evidence shows that the information given by biomarkers can support the suspicion of infection and pathogen identification but also, and not less important, can exclude its diagnosis. Although the ideal biomarker has not yet been found, there are various promising biomarkers that represent true evolutions in the diagnosis of infection in patients with suspected sepsis.
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Affiliation(s)
- Pedro Póvoa
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.,Nova Medical School, Clinical Medicine, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Luis Coelho
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.,Nova Medical School, Clinical Medicine, CHRC, New University of Lisbon, Lisbon, Portugal
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Al-Omari B, McMeekin P, Allen AJ, Akram AR, Graziadio S, Suklan J, Jones WS, Lendrem BC, Winter A, Cullinan M, Gray J, Dhaliwal K, Walsh TS, Craven TH. Systematic review of studies investigating ventilator associated pneumonia diagnostics in intensive care. BMC Pulm Med 2021; 21:196. [PMID: 34107929 PMCID: PMC8189711 DOI: 10.1186/s12890-021-01560-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is an important diagnosis in critical care. VAP research is complicated by the lack of agreed diagnostic criteria and reference standard test criteria. Our aim was to review which reference standard tests are used to evaluate novel index tests for suspected VAP. Methods We conducted a comprehensive search using electronic databases and hand reference checks. The Cochrane Library, MEDLINE, CINHAL, EMBASE, and web of science were searched from 2008 until November 2018. All terms related to VAP diagnostics in the intensive treatment unit were used to conduct the search. We adopted a checklist from the critical appraisal skills programme checklist for diagnostic studies to assess the quality of the included studies. Results We identified 2441 records, of which 178 were selected for full-text review. Following methodological examination and quality assessment, 44 studies were included in narrative data synthesis. Thirty-two (72.7%) studies utilised a sole microbiological reference standard; the remaining 12 studies utilised a composite reference standard, nine of which included a mandatory microbiological criterion. Histopathological criteria were optional in four studies but mandatory in none. Conclusions Nearly all reference standards for VAP used in diagnostic test research required some microbiological confirmation of infection, with BAL culture being the most common reference standard used. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01560-0.
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Affiliation(s)
- Basem Al-Omari
- College of Medicine and Health Sciences, Khalifa University, PO Box 127788, Abu Dhabi, UAE. .,Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.
| | - Peter McMeekin
- School of Health and Life Science, University of Northumbria, Newcastle upon Tyne, UK
| | - A Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ahsan R Akram
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,York Health Economics Consortium, Enterprise House, Innovation Way, University of York, York, UK
| | - Jana Suklan
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - William S Jones
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - B Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amanda Winter
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Milo Cullinan
- Laboratory Medicine, Newcastle-Upon-Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Joanne Gray
- School of Health and Life Science, University of Northumbria, Newcastle upon Tyne, UK
| | - Kevin Dhaliwal
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Thomas H Craven
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
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7
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Jones TC, Biele G, Mühlemann B, Veith T, Schneider J, Beheim-Schwarzbach J, Bleicker T, Tesch J, Schmidt ML, Sander LE, Kurth F, Menzel P, Schwarzer R, Zuchowski M, Hofmann J, Krumbholz A, Stein A, Edelmann A, Corman VM, Drosten C. Estimating infectiousness throughout SARS-CoV-2 infection course. Science 2021; 373:science.abi5273. [PMID: 34035154 PMCID: PMC9267347 DOI: 10.1126/science.abi5273] [Citation(s) in RCA: 293] [Impact Index Per Article: 97.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/21/2021] [Indexed: 12/20/2022]
Abstract
The role that individuals with asymptomatic or mildly symptomatic severe acute respiratory syndrome coronavirus 2 have in transmission of the virus is not well understood. Jones et al. investigated viral load in patients, comparing those showing few, if any, symptoms with hospitalized cases. Approximately 400,000 individuals, mostly from Berlin, were tested from February 2020 to March 2021 and about 6% tested positive. Of the 25,381 positive subjects, about 8% showed very high viral loads. People became infectious within 2 days of infection, and in hospitalized individuals, about 4 days elapsed from the start of virus shedding to the time of peak viral load, which occurred 1 to 3 days before the onset of symptoms. Overall, viral load was highly variable, but was about 10-fold higher in persons infected with the B.1.1.7 variant. Children had slightly lower viral loads than adults, although this difference may not be clinically significant. Science, abi5273, this issue p. eabi5273 INTRODUCTION Although post facto studies have revealed the importance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission from presymptomatic, asymptomatic, and mildly symptomatic (PAMS) cases, the virological basis of their infectiousness remains largely unquantified. The reasons for the rapid spread of variant lineages of concern, such as B.1.1.7, have yet to be fully determined. RATIONALE Viral load (viral RNA concentration) in patient samples and the rate of isolation success of virus from clinical specimens in cell culture are the clinical parameters most directly relevant to infectiousness and hence to transmission. To increase our understanding of the infectiousness of SARS-CoV-2, especially in PAMS cases and those infected with the B.1.1.7 variant, we analyzed viral load data from 25,381 German cases, including 9519 hospitalized patients, 6110 PAMS cases from walk-in test centers, 1533 B.1.1.7 variant infections, and the viral load time series of 4434 (mainly hospitalized) patients. Viral load results were then combined with estimated cell culture isolation probabilities, producing a clinical proxy estimate of infectiousness. RESULTS PAMS subjects had, at the first positive test, viral loads and estimated infectiousness only slightly less than hospitalized patients. Similarly, children were found to have mean viral loads only slightly lower (0.5 log10 units or less) than those of adults and ~78% of the adult peak cell culture isolation probability. Eight percent of first-positive viral loads were 109 copies per swab or higher, across a wide age range (mean 37.6 years, standard deviation 13.4 years), representing a likely highly infectious minority, one-third of whom were PAMS. Relative to non-B.1.1.7 cases, patients with the B.1.1.7 variant had viral loads that were higher by a factor of 10 and estimated cell culture infectivity that was higher by a factor of 2.6. Similar ranges of viral loads from B.1.1.7 and B.1.177 samples were shown to be capable of causing infection in Caco-2 cell culture. A time-course analysis estimates that a peak viral load of 108.1 copies per swab is reached 4.3 days after onset of shedding and shows that, across the course of infection, hospitalized patients have slightly higher viral loads than nonhospitalized cases, who in turn have viral loads slightly higher than PAMS cases. Higher viral loads are observed in first-positive tests of PAMS subjects, likely as a result of systematic earlier testing. Mean culture isolation probability declines to 0.5 at 5 days after peak viral load and to 0.3 at 10 days after peak viral load. We estimate a rate of viral load decline of 0.17 log10 units per day, which, combined with reported estimates of incubation time and time to loss of successful cell culture isolation, suggests that viral load peaks 1 to 3 days before onset of symptoms (in symptomatic cases). CONCLUSION PAMS subjects who test positive at walk-in test centers can be expected to be approximately as infectious as hospitalized patients. The level of expected infectious viral shedding of PAMS people is of high importance because they are circulating in the community at the time of detection of infection. Although viral load and cell culture infectivity cannot be translated directly to transmission probability, it is likely that the rapid spread of the B.1.1.7 variant is partly attributable to higher viral load in these cases. Easily measured virological parameters can be used, for example, to estimate transmission risk from different groups (by age, gender, clinical status, etc.), to quantify variance, to show differences in virus variants, to highlight and quantify overdispersion, and to inform quarantine, containment, and elimination strategies. Two elementary parameters for quantifying viral infection and shedding are viral load and whether samples yield a replicating virus isolate in cell culture. We examined 25,381 cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Germany, including 6110 from test centers attended by presymptomatic, asymptomatic, and mildly symptomatic (PAMS) subjects, 9519 who were hospitalized, and 1533 B.1.1.7 lineage infections. The viral load of the youngest subjects was lower than that of the older subjects by 0.5 (or fewer) log10 units, and they displayed an estimated ~78% of the peak cell culture replication probability; in part this was due to smaller swab sizes and unlikely to be clinically relevant. Viral loads above 109 copies per swab were found in 8% of subjects, one-third of whom were PAMS, with a mean age of 37.6 years. We estimate 4.3 days from onset of shedding to peak viral load (108.1 RNA copies per swab) and peak cell culture isolation probability (0.75). B.1.1.7 subjects had mean log10 viral load 1.05 higher than that of non-B.1.1.7 subjects, and the estimated cell culture replication probability of B.1.1.7 subjects was higher by a factor of 2.6.
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Affiliation(s)
- Terry C Jones
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.,German Centre for Infection Research (DZIF), partner site Charité, 10117 Berlin, Germany.,Centre for Pathogen Evolution, Department of Zoology, University of Cambridge, Cambridge CB2 3EJ, U.K
| | - Guido Biele
- Norwegian Institute of Public Health, 0473 Oslo, Norway.,University of Oslo, 0315 Oslo, Norway
| | - Barbara Mühlemann
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.,German Centre for Infection Research (DZIF), partner site Charité, 10117 Berlin, Germany
| | - Talitha Veith
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.,German Centre for Infection Research (DZIF), partner site Charité, 10117 Berlin, Germany
| | - Julia Schneider
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.,German Centre for Infection Research (DZIF), partner site Charité, 10117 Berlin, Germany
| | - Jörn Beheim-Schwarzbach
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Tobias Bleicker
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Julia Tesch
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Marie Luisa Schmidt
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Leif Erik Sander
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany
| | - Florian Kurth
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117 Berlin, Germany.,Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, and Department of Medicine I, University Medical Centre Hamburg-Eppendorf, 20359 Hamburg, Germany
| | - Peter Menzel
- Labor Berlin-Charité Vivantes GmbH, Sylter Straße 2, 13353 Berlin, Germany
| | - Rolf Schwarzer
- Labor Berlin-Charité Vivantes GmbH, Sylter Straße 2, 13353 Berlin, Germany
| | - Marta Zuchowski
- Labor Berlin-Charité Vivantes GmbH, Sylter Straße 2, 13353 Berlin, Germany
| | - Jörg Hofmann
- Labor Berlin-Charité Vivantes GmbH, Sylter Straße 2, 13353 Berlin, Germany
| | - Andi Krumbholz
- Institute for Infection Medicine, Christian-Albrechts-Universität zu Kiel and University Medical Center Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany.,Labor Dr. Krause und Kollegen MVZ GmbH, 24106 Kiel, Germany
| | - Angela Stein
- Labor Berlin-Charité Vivantes GmbH, Sylter Straße 2, 13353 Berlin, Germany
| | - Anke Edelmann
- Labor Berlin-Charité Vivantes GmbH, Sylter Straße 2, 13353 Berlin, Germany
| | - Victor Max Corman
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.,German Centre for Infection Research (DZIF), partner site Charité, 10117 Berlin, Germany
| | - Christian Drosten
- Institute of Virology, Charité--Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany. .,German Centre for Infection Research (DZIF), partner site Charité, 10117 Berlin, Germany
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8
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Tusor N, De Cunto A, Basma Y, Klein JL, Meau-Petit V. Ventilator-associated pneumonia in neonates: the role of point of care lung ultrasound. Eur J Pediatr 2021; 180:137-146. [PMID: 32592026 PMCID: PMC7317892 DOI: 10.1007/s00431-020-03710-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/29/2020] [Accepted: 05/29/2020] [Indexed: 12/27/2022]
Abstract
No consensus exists regarding the definition of ventilator-associated pneumonia (VAP) in neonates and reliability of chest X-ray (CXR) is low. Lung ultrasound (LU) is a potential alternative diagnostic tool. The aim was to define characteristics of VAP in our patient population and propose a multiparameter score, incorporating LU, for VAP diagnosis. Between March 25, 2018, and May 25, 2019, infants with VAP were identified. Clinical, laboratory and microbiology data were collected. CXRs and LU scans were reviewed. A multiparameter VAP score, including LU, was calculated on Day 1 and Day 3 for infants with VAP and for a control group and compared with CXR. VAP incidence was 10.47 episodes/1000 ventilator days. LU and CXR were available for 31 episodes in 21 infants with VAP, and for six episodes in five patients without VAP. On Day 1, a VAP score of > 4, and on Day 3 a score of > 5 showed sensitivity of 0.94, and area under the curve of 0.91 and 0.97, respectively. AUC for clinical information only was 0.88 and for clinical and CXR 0.85.Conclusion: The multiparameter VAP score including LU could be useful in diagnosing VAP in neonates with underlying lung pathology. What is Known: • Ventilator associated pneumonia (VAP) is common in infants on the neonatal unit and is associated with increased use of antibiotics, prolonged ventilation and higher incidence of chronic lung disease. • Commonly used definitions of VAP are difficult to apply in neonates and interpretation of chest X-ray is challenging with poor inter-rater agreement in patients with underlying chronic lung disease. What is New: • The multiparameter VAP score combining clinical, microbiology and lung ultrasound (LU) data is predictive for VAP diagnosis in preterm infants with chronic lung disease. • LU findings of VAP in neonates showed high inter-rater agreement and included consolidated lung areas, dynamic bronchograms and pleural effusion.
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Affiliation(s)
- Nora Tusor
- Neonatal Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
| | - Angela De Cunto
- Neonatal Intensive Care Unit, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, North Wing 6th floor, Westminster Bridge Road, London, SE1 0EH UK
| | - Yousef Basma
- Neonatal Transfer Service London, Royal London Hospital, Whitechapel Road, London, E1 1FR UK
| | - John L. Klein
- Department of Infectious Diseases, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, North Wing 2nd floor, Westminster Bridge Road, London, SE1 0EH UK
| | - Virginie Meau-Petit
- Neonatal Intensive Care Unit, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, North Wing 6th floor, Westminster Bridge Road, London, SE1 0EH UK
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9
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Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis. Intensive Care Med 2020; 46:1170-1179. [PMID: 32306086 PMCID: PMC7223448 DOI: 10.1007/s00134-020-06036-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/02/2020] [Indexed: 02/01/2023]
Abstract
The accuracy of the signs and tests that clinicians use to diagnose ventilator-associated pneumonia (VAP) and initiate antibiotic treatment has not been well characterized. We sought to characterize and compare the accuracy of physical examination, chest radiography, endotracheal aspirate (ETA), bronchoscopic sampling cultures (protected specimen brush [PSB] and bronchoalveolar lavage [BAL]), and CPIS > 6 to diagnose VAP. We searched six databases from inception through September 2019 and selected English-language studies investigating accuracy of any of the above tests for VAP diagnosis. Reference standard was histopathological analysis. Two reviewers independently extracted data and assessed study quality. We included 25 studies (1639 patients). The pooled sensitivity and specificity of physical examination findings for VAP were poor: fever (66.4% [95% confidence interval [CI]: 40.7-85.0], 53.9% [95% CI 34.5-72.2]) and purulent secretions (77.0% [95% CI 64.7-85.9], 39.0% [95% CI 25.8-54.0]). Any infiltrate on chest radiography had a sensitivity of 88.9% (95% CI 73.9-95.8) and specificity of 26.1% (95% CI 15.1-41.4). ETA had a sensitivity of 75.7% (95% CI 51.5-90.1) and specificity of 67.9% (95% CI 40.5-86.8). Among bronchoscopic sampling methods, PSB had a sensitivity of 61.4% [95% CI 43.7-76.5] and specificity of 76.5% [95% CI 64.2-85.6]; while BAL had a sensitivity of 71.1% [95% CI 49.9-85.9] and specificity of 79.6% [95% CI 66.2-85.9]. CPIS > 6 had a sensitivity of 73.8% (95% CI 50.6-88.5) and specificity of 66.4% (95% CI 43.9-83.3). Classic clinical indicators had poor accuracy for diagnosis of VAP. Reliance upon these indicators in isolation may result in misdiagnosis and potentially unnecessary antimicrobial use.
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10
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Hellyer TP, McAuley DF, Walsh TS, Anderson N, Conway Morris A, Singh S, Dark P, Roy AI, Perkins GD, McMullan R, Emerson LM, Blackwood B, Wright SE, Kefala K, O'Kane CM, Baudouin SV, Paterson RL, Rostron AJ, Agus A, Bannard-Smith J, Robin NM, Welters ID, Bassford C, Yates B, Spencer C, Laha SK, Hulme J, Bonner S, Linnett V, Sonksen J, Van Den Broeck T, Boschman G, Keenan DJ, Scott J, Allen AJ, Phair G, Parker J, Bowett SA, Simpson AJ. Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation. THE LANCET. RESPIRATORY MEDICINE 2020; 8:182-191. [PMID: 31810865 PMCID: PMC7599318 DOI: 10.1016/s2213-2600(19)30367-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1β and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia. METHODS VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1β and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveolar lavage fluid from all patients and ventilator-associated pneumonia was confirmed by at least 104 colony forming units per mL of bronchoalveolar lavage fluid. The primary outcome was the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage. Data were analysed on an intention-to-treat basis, with an additional per-protocol analysis that excluded patients randomly assigned to the intervention group who defaulted to routine use of antibiotics because of failure to return an adequate biomarker result. An embedded process evaluation assessed factors influencing trial adoption, recruitment, and decision making. This study is registered with ISRCTN, ISRCTN65937227, and ClinicalTrials.gov, NCT01972425. FINDINGS Between Nov 6, 2013, and Sept 13, 2016, 360 patients were screened for inclusion in the study. 146 patients were ineligible, leaving 214 who were recruited to the study. Four patients were excluded before randomisation, meaning that 210 patients were randomly assigned to biomarker-guided recommendation on antibiotics (n=104) or routine use of antibiotics (n=106). One patient in the biomarker-guided recommendation group was withdrawn by the clinical team before bronchoscopy and so was excluded from the intention-to-treat analysis. We found no significant difference in the primary outcome of the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage in the intention-to-treat analysis (p=0·58). Bronchoalveolar lavage was associated with a small and transient increase in oxygen requirements. Established prescribing practices, reluctance for bronchoalveolar lavage, and dependence on a chain of trial-related procedures emerged as factors that impaired trial processes. INTERPRETATION Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect. FUNDING UK Department of Health and the Wellcome Trust.
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Affiliation(s)
- Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Daniel F McAuley
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK; Regional Intensive Care Unit, The Royal Hospitals, Belfast, UK
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK; Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Suveer Singh
- Department of Cancer and Surgery, Imperial College London, London, UK
| | - Paul Dark
- Division of Infection Immunity and Respiratory Medicine, Manchester National Institute for Health Research Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Intensive Care Unit, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ronan McMullan
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lydia M Emerson
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Stephen E Wright
- Integrated Critical Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Kallirroi Kefala
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Cecilia M O'Kane
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Simon V Baudouin
- Intensive Care Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Ross L Paterson
- Intensive Care Unit, Western General Hospital, Edinburgh, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK; Integrated Critical Care Unit, Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Jonathan Bannard-Smith
- Intensive Care Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicole M Robin
- Intensive Care Unit, Countess of Chester NHS Foundation Trust, Chester, UK
| | - Ingeborg D Welters
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Christopher Bassford
- Intensive Care Unit, University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Bryan Yates
- Intensive Care Unit, Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Craig Spencer
- Intensive Care Unit, Preston Royal Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Shondipon K Laha
- Intensive Care Unit, Preston Royal Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Jonathan Hulme
- Intensive Care Unit, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Stephen Bonner
- Intensive Care Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Vanessa Linnett
- Intensive Care Unit, Queen Elizabeth Hospital, Gateshead NHS Foundation Trust, Gateshead, UK
| | - Julian Sonksen
- Intensive Care Unit, Russells Hall Hospital, Dudley Group NHS Foundation Trust, Dudley, UK
| | | | - Gert Boschman
- Becton Dickinson Biosciences Europe, Erembodegem, Belgium
| | | | - Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - A Joy Allen
- National Institute for Health Research Newcastle In Vitro Diagnostics Cooperative, Newcastle University, Newcastle, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Jennie Parker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle, UK
| | - Susan A Bowett
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK; National Institute for Health Research Newcastle In Vitro Diagnostics Cooperative, Newcastle University, Newcastle, UK.
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11
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Burillo A, de Egea V, Onori R, Martín-Rabadán P, Cercenado E, Jiménez-Navarro L, Muñoz P, Bouza E. Gradient diffusion antibiogram used directly on bronchial aspirates for a rapid diagnosis of ventilator-associated pneumonia. Antimicrob Resist Infect Control 2019; 8:176. [PMID: 31807286 PMCID: PMC6857332 DOI: 10.1186/s13756-019-0640-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 11/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background In patients with suspected ventilator-associated pneumonia, a rapid etiological diagnosis is crucial as incorrect or delayed treatment in the first few hours leads to a worse prognosis and a higher mortality rate. This study examines the efficacy of a rapid antibiogram on bronchial aspirates in patients with suspected ventilator-associated pneumonia (VAP). Methods The direct gradient diffusion susceptibility testing method (GDM) on respiratory samples was compared with a standard broth microdilution method (BMD) after quantitative cultures in patients with suspicion of VAP. Samples were preselected by Gram staining (for good quality microbiological samples with a predominant single bacterial morphotype). The antibiotics tested were ceftazidime, ceftobiprole, ceftolozane-tazobactam, meropenem, doripenem, and tedizolid. Results Over a 16-month study period, 445 bronchial aspirate samples were selected from 1376 samples received at our laboratory from 672 adult patients. By direct plating on Mueller-Hinton agar, we recovered 504 (95.5%) of the 528 microorganisms identified by the standard semiquantitative method. Antimicrobial susceptibility testing by GDM was compared with the BMD method in 472 strains (216 Enterobacteriaceae, 138 P. aeruginosa and 118 S. aureus.) and 1652 individual microorganism-antimicrobial agent combinations. There was total agreement between both methods in 98% of combinations. The Kappa index between both techniques was excellent (over 80%). There was only one potential major error for P. aeruginosa susceptibility to ceftazidime. Conclusions The six GDM strips directly placed on plated bronchial aspirates obtained from patients with a suspicion of VAP provided accurate and reliable susceptibility results within 24 h.
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Affiliation(s)
- Almudena Burillo
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,2Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria, 28040 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Viviana de Egea
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Raffaella Onori
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Pablo Martín-Rabadán
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,4CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Servicio Madrileño de Salud, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Emilia Cercenado
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,2Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria, 28040 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,4CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Servicio Madrileño de Salud, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Laura Jiménez-Navarro
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Patricia Muñoz
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,2Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria, 28040 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,4CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Servicio Madrileño de Salud, Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Emilio Bouza
- 1Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,2Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Ciudad Universitaria, 28040 Madrid, Spain.,3Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.,4CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Servicio Madrileño de Salud, Doctor Esquerdo 46, 28007 Madrid, Spain
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12
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Colour Doppler ultrasound after major cardiac surgery improves diagnostic accuracy of the pulmonary infection score in acute respiratory failure. Eur J Anaesthesiol 2019; 36:676-682. [DOI: 10.1097/eja.0000000000001022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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13
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt C, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar J, Bruyère R, Chanques G. Pneumonies associées aux soins de réanimation* RFE commune SFAR–SRLF. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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14
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Bouhemad B, Dransart-Rayé O, Mojoli F, Mongodi S. Lung ultrasound for diagnosis and monitoring of ventilator-associated pneumonia. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:418. [PMID: 30581826 DOI: 10.21037/atm.2018.10.46] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units (ICU) and is associated with increased mortality, use of antimicrobials, longer mechanical ventilation, and higher healthcare costs. Lung ultrasonography (LUS) can be used at the bedside and gained widespread acceptance in ICU. Although the visualization of a single LUS sign cannot be considered specific for a diagnosis, clinically-driven LUS examination in particular setting and clinical conditions allow ruling in or out quickly and accurately several causes of acute respiratory failure. This article reviews LUS signs for VAP diagnosis and summarizes the studies testing LUS for VAP diagnosis and monitoring. Many VAP occurs in already injured regions, thus presence of lobar consolidation is not enough to affirm VAP. However, a linear/arborescent air-bronchogram confirms the diagnosis of VAP with a good specificity, a normal LUS rules out the diagnosis of VAP (in experimented hands). LUS, thanks to its bedside ready availability, has the potential to become a key tool in early VAP diagnosis. LUS could ideally represent the decision-making tool for antimicrobial therapy administration in the timeframe of the technical time required for bronchoalveolar lavage analysis. A systematic approach for diagnosis and monitoring of VAP with LUS is also proposed in this review. But specific data on LUS specificity and sensitivity for the diagnosis of VAP are still lacking and should be investigated.
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Affiliation(s)
- Bélaïd Bouhemad
- Department of Anesthesiology and Intensive Care, C.H.U. Dijon, France.,Dijon and Université Bourgogne Franche-Comté, LNC UMR866, Dijon, France
| | - Ophélie Dransart-Rayé
- Department of Anesthesiology and Intensive Care, C.H.U. Dijon, France.,Dijon and Université Bourgogne Franche-Comté, LNC UMR866, Dijon, France
| | - Francesco Mojoli
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy.,Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Silvia Mongodi
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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15
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Diagnostic value of procalcitonin in ventilator-associated pneumonia. Med Clin (Barc) 2018; 152:216-221. [PMID: 30154009 DOI: 10.1016/j.medcli.2018.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Procalcitonin (PCT) can help the early diagnosis of bacterial infections and estimate the response obtained. The objective is to study the value of PCT for the diagnosis of ventilator-associated pneumonia (VAP). PATIENTS AND METHOD Prospective and observational study, carried out for 18 months, in a polyvalent Intensive Care Unit (ICU). Those included were over 18 years of age, with suspected pneumonia after 48h of mechanical ventilation (MV). Collected were demographic characteristics; admission pathology; reason for beginning MV; gravity scores (APACHE II, SAPS II and SOFA); C-reactive protein (CRP) and PCT. At the time of suspicion of VAP: early or late, radiological severity, presence of septic shock, SOFA, CRP, PCT and microbiology. RESULTS Ninety-one patients with suspected VAP were included. The mean age was 42 (17.76) and that of hospitalisation in the ICU was 18.59 (11.69) days. VAP was confirmed in 74 patients, of which 19 (25.7%) presented septic shock. The mortality was 28.4%. There were no significant differences of the PCT in the patients who presented VAP versus those who did not present VAP (P=.449). When patients without VAP, with VAP and VAP with shock, were compared, the PCT median was 0.38 (CI95%: 0.22-1.90), 0.56 (CI95%: 0.19-1.77) and 1.93 (CI95%: 0.38-10.07), respectively (P=.169). CONCLUSIONS In our study, PCT did not prove useful for the diagnosis of VAP.
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16
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Abstract
PURPOSE OF REVIEW Nosocomial pneumonia is a frequent and severe nosocomial infection divided in two distinct groups: hospital-acquired pneumonia and ventilator-associated pneumonia (VAP). In this context, the VAP is notoriously difficult to diagnose clinically, resulting from the lack of a 'gold standard' method of diagnosis. RECENT FINDINGS The use of biomarkers may potentially improve the early diagnosis of infections allowing earlier and better identification and treatment. An exhausting list of biomarkers has been studied and although far from perfect, procalcitonin (PCT) and C-reactive protein (CRP) are the most studied biomarkers used in clinical practice. Data coming from literature suggests the use of PCT for VAP prognosis and as a based algorithm tool for the reduction of duration of pneumonia therapy, as well as, the use of the CRP dynamics to the early prediction of VAP and the response to the antibiotics. SUMMARY The evidence for the use of biomarkers to diagnose nosocomial pneumonia as a stand-alone tool is low to moderate. Improved performance for both PCT and CRP can be obtained by using them in association with clinical features or scoring systems but prospective studies are still needed to validate this hypothesis.
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17
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt CE, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar JR, Bruyère R, Chanques G. Hospital-acquired pneumonia in ICU. Anaesth Crit Care Pain Med 2018; 37:83-98. [DOI: 10.1016/j.accpm.2017.11.006] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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18
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Póvoa P, Martin-Loeches I, Ramirez P, Bos LD, Esperatti M, Silvestre J, Gili G, Goma G, Berlanga E, Espasa M, Gonçalves E, Torres A, Artigas A. Biomarkers kinetics in the assessment of ventilator-associated pneumonia response to antibiotics - results from the BioVAP study. J Crit Care 2017; 41:91-97. [PMID: 28502892 DOI: 10.1016/j.jcrc.2017.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 01/31/2023]
Abstract
PURPOSE Our aim was to evaluate the role of biomarker kinetics in the assessment of ventilator-associated pneumonia (VAP) response to antibiotics. MATERIALS AND METHODS We performed a prospective, multicenter, observational study to evaluate in 37 microbiologically documented VAP, the kinetics of C-reactive protein (CRP), procalcitonin (PCT), mid-region fragment of pro-adrenomedullin (MR-proADM). The kinetics of each variable, from day 1 to 6 of therapy, was assessed with a time dependent analysis comparing survivors and non-survivors. RESULTS During the study period kinetics of CRP as well as its relative changes, CRP-ratio, was significantly different between survivors and non-survivors (p=0.026 and p=0.005, respectively). On day 4 of antibiotic therapy, CRP of survivors was 47% of the initial value while it was 96% in non-survivors. The kinetics of other studied variables did not distinguish between survivors and non-survivors. In survivors the bacterial load also decreased markedly. Adequate initial antibiotic therapy was associated with lower mortality (p=0.025) and faster CRP decrease (p=0.029). CONCLUSIONS C-reactive protein kinetics can be used to identify VAP patients with poor outcome as soon as four days after the initiation of treatment. (Trial registration - NCT02078999; registered 3 August 2012).
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Affiliation(s)
- Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal.
| | - Ignacio Martin-Loeches
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, Sabadell, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Spain.
| | - Paula Ramirez
- CIBER de Enfermedades Respiratorias (CIBERES), Spain; Intensive Care Unit, University Hospital La Fe, Valencia, Spain.
| | - Lieuwe D Bos
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Mariano Esperatti
- CIBER de Enfermedades Respiratorias (CIBERES), Spain; Intensive Care Unit, Hospital Privado de Comunidad, Mar del Plata, Argentina.
| | - Joana Silvestre
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal.
| | - Gisela Gili
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, Sabadell, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Spain.
| | - Gemma Goma
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, Sabadell, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Spain.
| | - Eugenio Berlanga
- Laboratory Department, UDIAT, Corporación Sanitaria Universitaria Parc Taulí, Sabadell, Spain.
| | - Mateu Espasa
- Laboratory Department, UDIAT, Corporación Sanitaria Universitaria Parc Taulí, Sabadell, Spain.
| | - Elsa Gonçalves
- NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal; Microbiology Department, Egas Moniz Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.
| | - Antoni Torres
- CIBER de Enfermedades Respiratorias (CIBERES), Spain; Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, IDIBAPS, Barcelona, Spain.
| | - Antonio Artigas
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, Sabadell, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Spain.
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Abo-Hagar HH, Abo-Elezz AAE, Mehrez M, Mabrouk MM, Elshora OA. Diagnostic Efficacy of Serum Amyloid A Protein and Soluble Intercellular Adhesion Molecule 1 in Pediatric Ventilator-Associated Pneumonia. J Intensive Care Med 2017; 34:503-510. [DOI: 10.1177/0885066617702598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives: Study of inflammatory biomarkers which may aid in early detection of ventilator-associated pneumonia (VAP) in children and predicting their outcome. Patients: Thirty-five children, aged 2 months to 13 years, needed mechanical ventilation (MV) for more than 48 hours due to causes other than pneumonia. Methods: Measurement of serum amyloid A (SAA) protein, soluble intercellular adhesion molecule 1 (sICAM-1), and C-reactive protein (CRP), modified clinical pulmonary infection score (CPIS) and performing culture of endotracheal aspirate at the start and on the third day of MV. Results: Ventilator-associated pneumonia was diagnosed by CPIS in 6 (17.1%) of 35 patients. On the third day of MV, there was a significant increase in serum mean levels of SAA, sICAM-1, and CRP in comparison to the start of MV ( P = .005, .004, and .01, respectively). Three (50%) of 6 patients with VAP died, while 4 (14.28%) of 28 patients without VAP died. The sensitivity of serum SAA, sICAM-1, and CPIS were 100% for predicting VAP, while specificity was highest for CPIS (96.55%) followed by SAA (93.1%). Combination of CPIS and SAA increased the specificity to 100%. For predicting nonsurvival, serum SAA and sICAM-1 had a sensitivity of 100% and a specificity of 92.86% and 89.29%, respectively. Conclusion: Serum amyloid A and sICAM-1 may be considered as reliable markers for detection of VAP. Combination of serum SAA with CPIS increased the specificity to 100%. Measurement of SAA in patients with VAP also had a good predictive value for nonsurvival in such patients.
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Affiliation(s)
- Hamdy H. Abo-Hagar
- Pediatric Intensive Care Unit, Faculty of Medicine, Pediatric Department, Tanta University, Gharbia Governorate, Tanta, Egypt
| | - Ahmed Abd ElBasset Abo-Elezz
- Pediatric Intensive Care Unit, Faculty of Medicine, Pediatric Department, Tanta University, Gharbia Governorate, Tanta, Egypt
| | - Mostafa Mehrez
- Pediatric Intensive Care Unit, Faculty of Medicine, Pediatric Department, Tanta University, Gharbia Governorate, Tanta, Egypt
| | - Maaly M. Mabrouk
- Clinical Pathology Department, Tanta University, Gharbia Governorate, Tanta, Egypt
| | - Ola A. Elshora
- Clinical Pathology Department, Tanta University, Gharbia Governorate, Tanta, Egypt
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20
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Barton AK, Pelli A, Rieger M, Gehlen H. Procalcitonin as a biomarker in equine chronic pneumopathies. BMC Vet Res 2016; 12:281. [PMID: 27938364 PMCID: PMC5148850 DOI: 10.1186/s12917-016-0912-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 12/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Procalcitonin (PCT), a precursor protein of the hormone calcitonin, is a sensitive inflammatory marker in human medicine, which is primarily used for diagnosis of bacterial sepsis, but is also useful in diagnosis of exacerbation of asthma and COPD. In this study, PCT was evaluated as a potential biomarker for different chronic pneumopathies in the horse using an equine specific ELISA in comparison to established clinical markers and different interleukins. Sixty-four horses were classified as free of respiratory disease, recurrent airway obstruction (RAO), inflammatory airway disease (IAD) or chronic interstitial pneumopathy (CIP) using a scoring system. PCT concentrations were measured in plasma (n = 17) and in the cell-free supernatant of bronchoalveolar lavage (n = 64). PCT concentrations were correlated to interleukins IL-1ß and IL-6 in BALF, clinical findings and BALF cytology. RESULTS The median PCT concentrations in plasma were increased in respiratory disease (174.46 ng/ml, n = 7) compared to controls (13.94 ng/ml, n = 10, P = 0.05) and correlated to PCT in BALF supernatant (rs = 0.48). Compared to controls (5.49 ng/ml, n = 15), median PCT concentrations in BALF supernatant correlated to the overall clinical score (rs = 0.32, P = 0.007) and were significantly increased in RAO (13.40 ng/ml, n = 21) and IAD (16.89 ng/ml, n = 16), while no differences were found for CIP (12.02 ng/ml, n = 12). No significant increases were found for IL-1 and IL-6 between controls and respiratory disease in general as well as different disease groups. CONCLUSIONS Although some correlations were found between PCT in plasma, BALF supernatant and clinical scores, PCT in BALF does not seem to be a superior marker compared to established clinical markers. PCT in plasma seems to be more promising and a greater number of samples should be evaluated in further studies.
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Affiliation(s)
- Ann Kristin Barton
- Equine Clinic, Freie Universitaet Berlin, Oertzenweg 19b, 10163 Berlin, Germany
| | - Anna Pelli
- Equine Clinic, Freie Universitaet Berlin, Oertzenweg 19b, 10163 Berlin, Germany
| | - Martin Rieger
- Research unit microbe-plant interactions, Helmholtz Zentrum Muenchen, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - Heidrun Gehlen
- Equine Clinic, Freie Universitaet Berlin, Oertzenweg 19b, 10163 Berlin, Germany
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21
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Michaud GC, Channick CL, Law AC, McCannon JB, Antkowiak M, Garrison G, Sayah D, Huynh RH, Brady AK, Adamson R, DuBrock H, Akuthota P, Marion C, Dela Cruz C, Town JA, Çoruh B, Thomson CC. ATS Core Curriculum 2016. Part IV. Adult Pulmonary Medicine Core Curriculum. Ann Am Thorac Soc 2016; 13:1160-9. [PMID: 27388404 PMCID: PMC6138058 DOI: 10.1513/annalsats.201601-060cme] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/28/2016] [Indexed: 02/07/2023] Open
Affiliation(s)
- Gaëtane C Michaud
- 1 Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York
| | - Colleen L Channick
- 2 Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anica C Law
- 2 Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jessica B McCannon
- 2 Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - MaryEllen Antkowiak
- 3 Pulmonary and Critical Care Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Garth Garrison
- 3 Pulmonary and Critical Care Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - David Sayah
- 4 Pulmonary and Critical Care Medicine, University of California, Los Angeles, Los Angeles, California
| | - Richard H Huynh
- 4 Pulmonary and Critical Care Medicine, University of California, Los Angeles, Los Angeles, California
| | - Anna K Brady
- 5 Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Rosemary Adamson
- 5 Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Hilary DuBrock
- 6 Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Praveen Akuthota
- 6 Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Chad Marion
- 7 Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut; and
| | - Charles Dela Cruz
- 7 Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut; and
| | - James A Town
- 5 Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Başak Çoruh
- 5 Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Carey C Thomson
- 8 Pulmonary and Critical Care Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Póvoa P, Martin-Loeches I, Ramirez P, Bos LD, Esperatti M, Silvestre J, Gili G, Goma G, Berlanga E, Espasa M, Gonçalves E, Torres A, Artigas A. Biomarker kinetics in the prediction of VAP diagnosis: results from the BioVAP study. Ann Intensive Care 2016; 6:32. [PMID: 27076187 PMCID: PMC4830786 DOI: 10.1186/s13613-016-0134-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 03/28/2016] [Indexed: 01/22/2023] Open
Abstract
Background Prediction of diagnosis of ventilator-associated pneumonia (VAP) remains difficult. Our aim was to assess the value of biomarker kinetics in VAP prediction. Methods We performed a prospective, multicenter, observational study to evaluate predictive accuracy of biomarker kinetics, namely C-reactive protein (CRP), procalcitonin (PCT), mid-region fragment of pro-adrenomedullin (MR-proADM), for VAP management in 211 patients receiving mechanical ventilation for >72 h. For the present analysis, we assessed all (N = 138) mechanically ventilated patients without an infection at admission. The kinetics of each variable, from day 1 to day 6 of mechanical ventilation, was assessed with each variable’s slopes (rate of biomarker change per day), highest level and maximum amplitude of variation (Δmax). Results A total of 35 patients (25.4 %) developed a VAP and were compared with 70 non-infected controls (50.7 %). We excluded 33 patients (23.9 %) who developed a non-VAP nosocomial infection. Among the studied biomarkers, CRP and CRP ratio showed the best performance in VAP prediction. The slope of CRP change over time (adjusted odds ratio [aOR] 1.624, confidence interval [CI]95% [1.206, 2.189], p = 0.001), the highest CRP ratio concentration (aOR 1.202, CI95% [1.061, 1.363], p = 0.004) and Δmax CRP (aOR 1.139, CI95% [1.039, 1.248], p = 0.006), during the first 6 days of mechanical ventilation, were all significantly associated with VAP development. Both PCT and MR-proADM showed a poor predictive performance as well as temperature and white cell count. Conclusions Our results suggest that in patients under mechanical ventilation, daily CRP monitoring was useful in VAP prediction. Trial registration NCT02078999 Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0134-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pedro Póvoa
- Polyvalent Intensive Care Unit, Centro Hospitalar de Lisboa Ocidental, São Francisco Xavier Hospital, Estrada do Forte do Alto do Duque, 1449-005, Lisbon, Portugal. .,NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal.
| | - Ignacio Martin-Loeches
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, Sabadell, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Paula Ramirez
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Intensive Care Unit, University Hospital La Fe, Valencia, Spain
| | - Lieuwe D Bos
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Mariano Esperatti
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, IDIBAPS, Barcelona, Spain
| | - Joana Silvestre
- Polyvalent Intensive Care Unit, Centro Hospitalar de Lisboa Ocidental, São Francisco Xavier Hospital, Estrada do Forte do Alto do Duque, 1449-005, Lisbon, Portugal.,NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal
| | - Gisela Gili
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, Sabadell, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Gema Goma
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, Sabadell, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Eugenio Berlanga
- Laboratory Department, UDIAT, Corporación Sanitaria Universitaria Parc Taulí, Sabadell, Spain
| | - Mateu Espasa
- Laboratory Department, UDIAT, Corporación Sanitaria Universitaria Parc Taulí, Sabadell, Spain
| | - Elsa Gonçalves
- NOVA Medical School, CEDOC, New University of Lisbon, Lisbon, Portugal.,Microbiology Department, Centro Hospitalar de Lisboa Ocidental, Egas Moniz Hospital, Lisbon, Portugal
| | - Antoni Torres
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, IDIBAPS, Barcelona, Spain
| | - Antonio Artigas
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, Sabadell, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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23
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Lung Ultrasound for Early Diagnosis of Ventilator-Associated Pneumonia. Chest 2015; 149:969-80. [PMID: 26836896 DOI: 10.1016/j.chest.2015.12.012] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/03/2015] [Accepted: 12/01/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Lung ultrasound (LUS) has been successfully applied for monitoring aeration in ventilator-associated pneumonia (VAP) and to diagnose and monitor community-acquired pneumonia. However, no scientific evidence is yet available on whether LUS reliably improves the diagnosis of VAP. METHODS In a multicenter prospective study of 99 patients with suspected VAP, we investigated the diagnostic performance of LUS findings of infection, subpleural consolidation, lobar consolidation, and dynamic arborescent/linear air bronchogram. We also evaluated the combination of LUS with direct microbiologic examination of endotracheal aspirates (EA). Scores for LUS findings and EA were analyzed in two ways. First, the clinical-LUS score (ventilator-associated pneumonia lung ultrasound score [VPLUS]) was calculated as follows: ≥ 2 areas with subpleural consolidations, 1 point; ≥ 1 area with dynamic arborescent/linear air bronchogram, 2 points; and purulent EA, 1 point. Second, the VPLUS-direct gram stain examination (EAgram) was scored as follows: ≥ 2 areas with subpleural consolidations, 1 point; ≥ 1 area with dynamic arborescent/linear air bronchogram, 2 points; purulent EA, 1 point; and positive direct gram stain EA examination, 2 points. RESULTS For the diagnosis of VAP, subpleural consolidation and dynamic arborescent/linear air bronchogram had a positive predictive value of 86% with a positive likelihood ratio of 2.8. Two dynamic linear/arborescent air bronchograms produced a positive predictive value of 94% with a positive likelihood ratio of 7.1. The area under the curve for VPLUS-EAgram and VPLUS were 0.832 and 0.743, respectively. VPLUS-EAgram ≥ 3 had 77% (58-90) specificity and 78% (65-88) sensitivity; VPLUS ≥ 2 had 69% (50-84) specificity and 71% (58-81) sensitivity. CONCLUSIONS By detecting ultrasound features of infection, LUS was a reliable tool for early VAP diagnosis at the bedside. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02244723; URL: www.clinicaltrials.gov.
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24
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Bréchot N, Hékimian G, Chastre J, Luyt CE. Procalcitonin to guide antibiotic therapy in the ICU. Int J Antimicrob Agents 2015; 46 Suppl 1:S19-24. [DOI: 10.1016/j.ijantimicag.2015.10.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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26
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Siegler BH, Weiterer S, Lichtenstern C, Stumpp D, Brenner T, Hofer S, Weigand MA, Uhle F. [Use of biomarkers in sepsis. Update and perspectives]. Anaesthesist 2015; 63:678-90. [PMID: 25002138 DOI: 10.1007/s00101-014-2347-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sepsis and related complications are a challenge for intensive care medicine. Despite many advances in antibiotic therapy sepsis remains one of the most common diseases of patients in intensive care units and is designated as the main cause of death in critically ill patients. Persisting sepsis leads to impaired immunity, resulting in immunosuppression. Unspecific predictive signs complicate an early diagnosis; however, an early initiation of adequate therapy is of crucial importance for the prognosis. Scoring systems can be applied for the initial evaluation but are controversially discussed concerning the monitoring of disease progression and therapy as well as outcome prediction. Biomarkers are considered as a complementary approach.
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Affiliation(s)
- B H Siegler
- Klinik für Anaesthesiologie und Operative Intensivmedizin, Universitätsklinikum Gießen und Marburg, Standort Gießen, Rudolf-Buchheim Str. 7, 35392, Gießen, Deutschland
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27
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Kojic D, Siegler BH, Uhle F, Lichtenstern C, Nawroth PP, Weigand MA, Hofer S, Brenner T. Are there new approaches for diagnosis, therapy guidance and outcome prediction of sepsis? World J Exp Med 2015; 5:50-63. [PMID: 25992320 PMCID: PMC4436940 DOI: 10.5493/wjem.v5.i2.50] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 01/09/2015] [Accepted: 04/02/2015] [Indexed: 02/06/2023] Open
Abstract
Beside many efforts to improve outcome, sepsis is still one of the most frequent causes of death in critically ill patients. It is the most common condition with high mortality in intensive care units. The complexity of the septic syndrome comprises immunological aspects - i.e., sepsis induced immunosuppression - but is not restricted to this fact in modern concepts. So far, exact mechanisms and variables determining outcome and mortality stay unclear. Since there is no typical risk profile, early diagnosis and risk stratification remain difficult, which hinders rapid and effective treatment initiation. Due to the heterogeneous nature of sepsis, potential therapy options should be adapted to the individual. Biomarkers like C-reactive protein and procalcitonin are routinely used as complementary tools in clinical decision-making. Beyond the acute phase proteins, a wide bunch of promising substances and non-laboratory tools with potential diagnostic and prognostic value is under intensive investigation. So far, clinical decision just based on biomarker assessment is not yet feasible. However, biomarkers should be considered as a complementary approach.
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28
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Burillo A, Bouza E. Use of rapid diagnostic techniques in ICU patients with infections. BMC Infect Dis 2014; 14:593. [PMID: 25430913 PMCID: PMC4247221 DOI: 10.1186/s12879-014-0593-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 10/28/2014] [Indexed: 12/12/2022] Open
Abstract
Background Infection is a common complication seen in ICU patients. Given the correlation between infection and mortality in these patients, a rapid etiological diagnosis and the determination of antimicrobial resistance markers are of paramount importance, especially in view of today's globally spread of multi drug resistance microorganisms. This paper reviews some of the rapid diagnostic techniques available for ICU patients with infections. Methods A narrative review of recent peer-reviewed literature (published between 1995 and 2014) was performed using as the search terms: Intensive care medicine, Microbiological techniques, Clinical laboratory techniques, Diagnosis, and Rapid diagnosis, with no language restrictions. Results The most developed microbiology fields for a rapid diagnosis of infection in critically ill patients are those related to the diagnosis of bloodstream infection, pneumonia -both ventilator associated and non-ventilator associated-, urinary tract infection, skin and soft tissue infections, viral infections and tuberculosis. Conclusions New developments in the field of microbiology have served to shorten turnaround times and optimize the treatment of many types of infection. Although there are still some unresolved limitations of the use of molecular techniques for a rapid diagnosis of infection in the ICU patient, this approach holds much promise for the future.
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Affiliation(s)
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, Madrid, 28007, Spain.
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29
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Jung B, Molinari N, Nasri M, Hajjej Z, Chanques G, Jean-Pierre H, Panaro F, Jaber S. Procalcitonin biomarker kinetics fails to predict treatment response in perioperative abdominal infection with septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R255. [PMID: 24156734 PMCID: PMC4056026 DOI: 10.1186/cc13082] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 09/11/2013] [Indexed: 02/05/2023]
Abstract
Introduction Procalcitonin (PCT) biomarker is suggested to tailor antibiotic therapy in the medical intensive care unit (ICU) but studies in perioperative medicine are scarce. The aim of this study was to determine whether PCT reported thresholds are associated with the initial treatment response in perioperative septic shock secondary to intra-abdominal infection. Methods This single ICU, observational study included patients with perioperative septic shocks secondary to intra-abdominal infection. Demographics, PCT at days 0, 1, 3, 5, treatment response and outcome were collected. Treatment failure included death related to the initial infection, second source control treatment or a new onset intra-abdominal infection. The primary endpoint was to assess whether PCT thresholds (0.5 ng/ml or a drop from the peak of at least 80%) predict the initial treatment response. Results We included 101 consecutive cases. Initial treatment failed in 36 patients with a subsequent mortality of 75%. Upon admission, PCT was doubled when treatment ultimately failed (21.7 ng/ml ± 38.7 vs. 41.7 ng/ml ± 75.7; P = 0.04). Although 95% of the patients in whom PCT dropped down below 0.5 ng/ml responded to treatment, 50% of the patients in whom PCT remained above 0.5 ng/ml also responded successfully to treatment. Moreover, despite a PCT drop of at least 80%, 40% of patients had treatment failure. Conclusions In perioperative intra-abdominal infections with shock, PCT decrease to 0.5 ng/ml lacked sensitivity to predict treatment response and its decrease of at least 80% from its peak failed to accurately predict treatment response. Studies in perioperative severe infections are needed before using PCT to tailor antibiotic use in this population.
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Sotillo-Díaz JC, Bermejo-López E, García-Olivares P, Peral-Gutiérrez JA, Sancho-González M, Guerrero-Sanz JE. [Role of plasma procalcitonin in the diagnosis of ventilator-associated pneumonia: systematic review and metaanalysis]. Med Intensiva 2013; 38:337-46. [PMID: 24035696 DOI: 10.1016/j.medin.2013.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 07/10/2013] [Accepted: 07/12/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the role of plasma procalcitonin (PCT) levels in diagnosing ventilator-associated pneumonia. DESIGN A systematic review of publications prospectively assessing the diagnostic role of PCT in ventilator-associated pneumonia was carried out. The search was performed using Medline, Embase, the Cochrane Collaboration and MEDION, with reviewing of the references of retrieved articles. We extracted data that allowed the calculation of sensitivity, specificity, likelihood ratios and diagnostic odds ratio. Intervention Metaregression was performed to determine whether exposure to previous antibiotic treatment, the time to occurrence of ventilator-associated pneumonia and the type of patients had an impact upon the diagnostic performance of procalcitonin. RESULTS Seven studies were considered (373 patients, 434 episodes). We found no publication bias or threshold effect. High plasma PCT levels were associated to an increased risk of suffering ventilator-associated pneumonia (OR: 8.39; 95% CI: 5.4-12.6). The pooled data on sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio found were 76% (69-82), 79% (74-84), 4.35 (2.48-7.62), 0.26 (0.15-0.46) and 17.9 (10.1-31.7), respectively. Diagnostic yield was modified by prior exposure to antibiotics (rDOR 0.11, 0.02-0.069), but not by the type of critically ill patient or the time to occurrence of ventilator-associated pneumonia. CONCLUSIONS Our results suggest that PCT provides additional information on the risk of VAP. Inclusion of PCT in diagnostic algorithms could improve their effectiveness.
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Affiliation(s)
- J C Sotillo-Díaz
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - E Bermejo-López
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - P García-Olivares
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J A Peral-Gutiérrez
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - M Sancho-González
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J E Guerrero-Sanz
- Servicio de Medicina Intensiva, Hospital General Universitario Gregorio Marañón, Madrid, España
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31
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Figueiredo A, Germano N, Guedes P, Marcelino P. The evolving concepts of haemodynamic support: from pulmonary artery catheter to echocardiography and theragnostics. Curr Cardiol Rev 2013; 7:136-45. [PMID: 22758612 PMCID: PMC3263478 DOI: 10.2174/157340311798220458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/19/2011] [Accepted: 04/21/2011] [Indexed: 01/19/2023] Open
Abstract
Echocardiography is a non-invasive tool, aimed towards the anatomical and functional characterization of the heart. In Intensive Care it is considered nowadays as a necessary tool for patient evaluation. However, the information obtained using echocardiography is not the same as provided by other means, namely the invasive ones. In recent years there has been a significant evolution in the general concepts of haemodynamic support for the critically ill patient. In this new environment, echocardiography has gained particular relevance. In this text the new positioning of echocardiography in the light of the new concepts for hemodynamic support is described, as well as, the need for a specific formative program directed towards Intensive Care physicians. A new generation of biomarkers can also add relevant information and start a new era in haemodynamic support. They may help to further characterize the disease process, identifying patients at risk, as well as, characterize specific organ failure as well as monitoring therapy.
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Cytomegalovirus and herpes simplex virus effect on the prognosis of mechanically ventilated patients suspected to have ventilator-associated pneumonia. PLoS One 2012; 7:e51340. [PMID: 23236477 PMCID: PMC3517464 DOI: 10.1371/journal.pone.0051340] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 11/07/2012] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Cytomegalovirus (CMV) and herpes simplex virus (HSV) are common viruses that can affect critically ill patients who are not immunocompromised. The aim of this study was to determine whether the identification of CMV and/or HSV in mechanically ventilated critically ill patients suspected of having pneumonia was associated with an increased mortality. DESIGN Prospective epidemiological study. SETTING Medical intensive care unit of a tertiary medical center. PATIENTS Ninety-three patients with suspected pneumonia. INTERVENTIONS Patients with suspected pneumonia had bronchoalveolar lavage and blood samples taken to confirm the diagnosis. Antigenemia was used to detect CMV in the blood. Bronchoalveolar lavage samples were submitted to testing using quantitative real-time Polymerase Chain Reaction. MEASUREMENTS AND MAIN RESULTS We identified 22 patients with a CMV infection, 26 patients with an HSV infection and 45 patients without CMV or HSV infection (control group). Mortality at day 60 was higher in patients with a CMV infection than in patients from the control group (55% vs. 20%, P<0.01). Mortality at day 60 was not significantly increased in the group with HSV infection. Duration of ICU stay and ICU mortality were significantly higher in patients with CMV infections when compared to patients from the control group, whereas ventilator free days were significantly lower in patients with CMV infections when compared to patients from the control group. CONCLUSIONS In critically ill patients, a CMV infection is associated with an increased mortality. Further interventional studies are needed to evaluate whether treatment could improve the prognosis.
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Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients. Crit Care Med 2012; 40:2304-9. [PMID: 22809906 DOI: 10.1097/ccm.0b013e318251517a] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To test the usefulness of procalcitonin serum level for the reduction of antibiotic consumption in intensive care unit patients. DESIGN Single-center, prospective, randomized controlled study. SETTING Five intensive care units from a tertiary teaching hospital. PATIENTS All consecutive adult patients hospitalized for >48 hrs in the intensive care unit during a 9-month period. INTERVENTIONS Procalcitonin serum level was obtained for all consecutive patients suspected of developing infection either on admission or during intensive care unit stay. The use of antibiotics was more or less strongly discouraged or recommended according to the Muller classification. Patients were randomized into two groups: one using the procalcitonin results (procalcitonin group) and one being blinded to the procalcitonin results (control group). The primary end point was the reduction of antibiotic use expressed as a proportion of treatment days and of daily defined dose per 100 intensive care unit days using a procalcitonin-guided approach. Secondary end points included: a posteriori assessment of the accuracy of the infectious diagnosis when using procalcitonin in the intensive care unit and of the diagnostic concordance between the intensive care unit physician and the infectious-disease specialist. MEASUREMENTS AND MAIN RESULTS There were 258 patients in the procalcitonin group and 251 patients in the control group. A significantly higher amount of withheld treatment was observed in the procalcitonin group of patients classified by the intensive care unit clinicians as having possible infection. This, however, did not result in a reduction of antibiotic consumption. The treatment days represented 62.6±34.4% and 57.7±34.4% of the intensive care unit stays in the procalcitonin and control groups, respectively (p=.11). According to the infectious-disease specialist, 33.8% of the cases in which no infection was confirmed, had a procalcitonin value>1µg/L and 14.9% of the cases with confirmed infection had procalcitonin levels<0.25 µg/L. The ability of procalcitonin to differentiate between certain or probable infection and possible or no infection, upon initiation of antibiotic treatment was low, as confirmed by the receiving operating curve analysis (area under the curve=0.69). Finally, procalcitonin did not help improve concordance between the diagnostic confidence of the infectious-disease specialist and the ICU physician. CONCLUSIONS Procalcitonin measuring for the initiation of antimicrobials did not appear to be helpful in a strategy aiming at decreasing the antibiotic consumption in intensive care unit patients.
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Use of the clinical pulmonary infection score to guide therapy for ventilator-associated pneumonia risks antibiotic overexposure in patients with trauma. J Trauma Acute Care Surg 2012; 73:52-8; discussion 58-9. [PMID: 22743372 DOI: 10.1097/ta.0b013e31825ac37b] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The clinical pulmonary infection score (CPIS) has been advocated to guide both the diagnosis and duration of therapy in ventilator-associated pneumonia (VAP). However, the clinical, physiologic, and radiologic components of the CPIS may be difficult to differentiate from the systemic effects of injury and inflammation, unnecessarily prolonging VAP therapy. This study evaluates the use of CPIS in determining the appropriate duration of antimicrobial therapy for VAP in patients with critical illness and trauma. METHODS Patients with VAP (≥10 CFU/mL in bronchoalveolar lavage [BAL] effluent) over 6 years were evaluated. Duration of antimicrobial therapy was determined by microbiologic resolution (≤10 CFU/mL) on repeated BAL. Recurrence was defined as >10 CFU/mL on BAL performed within 2 weeks of appropriate therapy. A CPIS of less than 6 was used as a threshold for VAP resolution. RESULTS Of the patients with VAP, 1,028 were identified: 523 had community-acquired pathogens (mean CPIS, 6.9), and 505 had hospital-acquired (HA) pathogens (mean CPIS, 6.3). Using a CPIS of less than 6 yielded a sensitivity and specificity of 69% and 51% for community-acquired pathogens and 72% and 53% for HA pathogens, respectively. Antimicrobial therapy would have continued inappropriately in 59% of patients. Overall recurrence was 1%, occurring only with HA pathogens (mean CPIS, 5.9). CONCLUSION CPIS should not be used to determine VAP resolution in patients with critical injury and trauma. It cannot reliably differentiate VAP from the systemic inflammatory response syndrome in the face of confounding clinical factors. Using CPIS to determine appropriate duration of antimicrobial therapy for patients with trauma is costly and could be harmful by unnecessarily prolonging exposure to antibiotics. LEVEL OF EVIDENCE Therapeutic study, level III.
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Abstract
PURPOSE OF REVIEW Sepsis is relevant due to its high morbidity and mortality. For both sepsis diagnosis and outcome prediction many biomarkers have been described in the literature. Most of these markers are objects of scientific interest rather than being introduced into daily clinical practice. However, due to their unspecific character and their insufficient predictive value for the individual person, research focus is still on new aspects in sepsis-related biomarkers. RECENT FINDINGS Beyond the widely used acute-phase proteins C-reactive protein (CRP) and procalcitonin (PCT), many new molecules have been studied deriving from different organs or cells affected, due to the systemic nature of sepsis. Cytokines, coagulation factors/characteristics, vasoactive hormones, and several others have been recently proved to be relevant in sepsis syndrome and probably useful for outcome prediction. However, single time point measurements may be less predictive than consideration of the time-dependent course of parameters. Clinical decision just based on a biomarker is still not feasible because of the huge inter-individual differences in the inflammatory response. SUMMARY Many biomarkers display relevant correlation with the clinical outcome of patients with severe sepsis and septic shock. Consideration of their time courses may be more reliable than absolute levels. Clinical decision should not be based only on biomarkers but organ dysfunctions, for example, should also be taken into account.
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Abstract
Meticillin-resistant Staphylococcus aureus causes an evolving clinical presentation of pneumonia. Health-care-acquired infection differs from community-associated disease, with important implications for treatment. Current antibiotics are less than ideal, and broader management strategies are crucial to prevent complacency.
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Affiliation(s)
- B Edwards
- Department of Medical Microbiology, Southern General Hospital, Glasgow G51 4TF
| | - IM Gould
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen
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Les prélèvements microbiologiques ont-ils encore une place dans le diagnostic de pneumopathie acquise sous ventilation mécanique ? MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0337-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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[Causes of early mortality after liver transplantation: a twenty-years single centre experience]. ACTA ACUST UNITED AC 2011; 30:899-904. [PMID: 22035834 DOI: 10.1016/j.annfar.2011.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/21/2011] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To define the causes of mortality of patients who died within the first three months after a liver transplantation. TYPE OF STUDY Retrospective, observational, and single centre study. PATIENTS AND METHODS Between March 1989 and July 2010, all patients who died within three months after a liver transplantation were included. Demographic characteristics, preoperative and peroperative data, donor characteristics, postoperative complications and causes of mortality were collected. RESULTS Among the 788 performed liver transplantations, 76 patients died in intensive care unit (11%). The main indications of liver transplantation were alcoholic cirrhosis (30%), hepatitis C (28%), hepatocarcinoma (15%), primitive or secondary biliary cirrhosis (10%). Fifty percent of the patients were categorized as Child C. The main causes of death were non-function or dysfunction with retransplantation contra-indication graft (18%), sepsis (18%), neurological complications (12%), hemorrhagic shock (13%), (9%), multiorgan failures (5%), cardiac complications (6%). CONCLUSION In this study, the main causes of mortality were infectious, neurological and hemorrhagic. These results emphasize the necessity for better control of sepsis, haemorrhage and immunosupressors.
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Too much of a good thing is not necessarily better*. Crit Care Med 2011; 39:2182-3. [DOI: 10.1097/ccm.0b013e3182207c13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Luyt CE, Combes A, Trouillet JL, Chastre J. Biomarkers to Optimize Antibiotic Therapy for Pneumonia Due To Multidrug-Resistant Pathogens. Clin Chest Med 2011; 32:431-8. [DOI: 10.1016/j.ccm.2011.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Pneumonia occurring more than 48 h after induction of mechanical ventilation is called ventilator-associated pneumonia (VAP). VAP is the most common nosocomial infection in intensive care medicine and is associated with prolonged intensive care and hospital stay and a higher mortality. The main pathomechanism for development of ventilator-associated pneumonia is not so much the mechanical ventilation per se but more the pathogens passing along the tube towards the lungs. Avoidance of tracheal intubation, strict hygienic measures, reduction of oropharyngeal colonization and the avoidance of microaspiration are the most promising prevention strategies. Therapeutic success in treatment of VAP is coupled to an early diagnosis and therapy. Suspicion of pneumonia is based on clinical and radiologic criteria. Biomarkers and microbiological findings are important for follow-up and reevaluation of the suspected diagnosis.
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Abstract
OBJECTIVE To assess the predictive accuracy of serum procalcitonin in distinguishing bacterial aspiration pneumonia from aspiration pneumonitis. DESIGN Prospective observational study. SETTING Intensive care unit of a university-affiliated hospital. PATIENTS Sixty-five consecutive patients admitted with pulmonary aspiration and seven control subjects intubated for airway protection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Quantitative cultures from bronchoalveolar lavage fluid were conducted on all participants at the time of admission. Serial serum procalcitonin levels were measured on day 1 and day 3 using the procalcitonin enzyme-linked fluorescent assay. There were no differences in the median serum concentrations of procalcitonin between patients with positive bronchoalveolar lavage cultures (n = 32) and patients with negative bronchoalveolar lavage cultures (n = 33) on either day 1 or day 3 postadmission. The areas under the receiver operator characteristic curves were 0.59 (95% confidence interval, 0.47-0.72) and 0.63 (95% confidence interval, 0.5-0.75), respectively (p = .74). However, duration of mechanical ventilation and antibiotic therapy were shorter in those who had a decrease in their procalcitonin levels on day 3 from baseline compared with those who did not (6.7 ± 7.1 days and 11.1 ± 13.5 days, p = .03; and 8.2 ± 2.6 days vs. 12.8 ± 4.6 days; p < .001, respectively). Hospital mortality was associated with radiographic multilobar disease (adjusted odds ratio, 1.14; 95% confidence interval, 1.01-1.31; p = .04) and increasing procalcitonin levels (adjusted odds ratio, 5.63; 95% confidence interval, 1.56-20.29; p = .008). CONCLUSION Serum procalcitonin levels had poor diagnostic value in separating bacterial aspiration pneumonia from aspiration pneumonitis based on quantitative bronchoalveolar lavage culture. However, serial measurements of serum procalcitonin may be helpful in predicting survival from pulmonary aspiration.
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[Antibiotic treatment of nosocomial pneumonia]. Anaesthesist 2011; 60:269-81; quiz 282-3. [PMID: 21424312 DOI: 10.1007/s00101-011-1861-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Nosocomial pneumonia is one of the most common infectious diseases acquired in hospital and is often caused by resistant pathogens. For treatment of nosocomial pneumonia an appropriate initial antibiotic therapy is essential and exact knowledge of the specific pathogen spectrum is essential for the correct choice of the empirically calculated antibiotics. In line with a critical reevaluation of the primary treatment, pathogen-specific de-escalation therapy, a diagnosis of possible pulmonary complications (e. g. pleural empyema) and the identification and appropriate rehabilitation measures of non-pulmonary infections are necessary. To attain the best possible outcome the respective therapy concept needs to be adjusted to the individual risk characteristics. Appropriate initial antibiotic therapy, duration of mechanical ventilation and comorbidities are the key factors for patient outcome. This approach helps to avoid the development of resistant pathogens and saves economic resources.
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Year in review in Intensive Care Medicine 2010: II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea. Intensive Care Med 2011; 37:196-213. [PMID: 21225240 PMCID: PMC3029678 DOI: 10.1007/s00134-010-2123-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 12/27/2010] [Indexed: 12/14/2022]
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Wolff M, Bouadma L. What procalcitonin brings to management of sepsis in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:1007. [PMID: 21138601 PMCID: PMC3220031 DOI: 10.1186/cc9330] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In inflammatory states, particularly in response to infectious stimuli, local procalcitonin (PCT) production rises, and because these tissues cannot further process PCT into calcitonin, serum levels increase. In the critical care setting, PCT should be considered a useful tool to help physicians in some specific, although frequent, situations. Serial measurements of PCT levels may indicate the effectiveness of medical decisions such as the appropriateness of antibiotic therapy, the detection of new infections, and the exclusion of a diagnosis of sepsis. PCT-guided algorithms may also help to decrease the duration of antimicrobial therapy. However, the role of PCT as a prognostic marker in critically ill patients is controversial. In a study by Karlsson and colleagues, PCT concentrations did not differ between hospital survivors and nonsurvivors, but the outcome was better in patients whose PCT concentrations decreased more than 50%. The study of PCT kinetics thus could offer an individual risk assessment in patients with severe sepsis.
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Affiliation(s)
- Michel Wolff
- Service de Réanimation Médicale et des Maladies Infectieuses and EA 3964, Université Paris 7-Paris Diderot, Hôpital Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Guervilly C, Coisel Y, Botelho-Nevers E, Dizier S, Castanier M, Lepaul-Ercole R, Brissy O, Roch A, Forel JM, Papazian L. Significance of high levels of procalcitonin in patients with influenza A (H1N1) pneumonia. J Infect 2010; 61:355-8. [PMID: 20670651 DOI: 10.1016/j.jinf.2010.07.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 07/20/2010] [Accepted: 07/21/2010] [Indexed: 10/19/2022]
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