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de la Varga-Martínez O, Martín-Fernández M, Heredia-Rodríguez M, Ceballos F, Cubero-Gallego H, Priede-Vimbela JM, Bardají-Carrillo M, Sánchez-de Prada L, López-Herrero R, Jorge-Monjas P, Tamayo E, Gómez-Sánchez E. Influence of Renal Dysfunction on the Differential Behaviour of Procalcitonin for the Diagnosis of Postoperative Infection in Cardiac Surgery. J Clin Med 2022; 11:jcm11247274. [PMID: 36555891 PMCID: PMC9781060 DOI: 10.3390/jcm11247274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/26/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
Background: procalcitonin is a valuable marker in the diagnosis of bacterial infections; however, the impairment of renal function can influence its diagnostic precision. The objective of this study is to evaluate the differential behaviour of procalcitonin, as well as its usefulness in the diagnosis of postoperative pulmonary infection after cardiac surgery, depending on the presence or absence of impaired renal function. Materials and methods: A total of 805 adult patients undergoing cardiac surgery with extracorporeal circulation (CBP) were prospectively recruited, comparing the behaviour of biomarkers between the groups with and without postoperative pneumonia and according to the presence or absence of renal dysfunction. Results: Pulmonary infection was diagnosed in 42 patients (5.21%). In total, 228 patients (28.32%) presented postoperative renal dysfunction. Procalcitonin was significantly higher in infected patients, even in the presence of renal dysfunction. The optimal procalcitonin threshold differed markedly in patients with renal dysfunction compared to patients without renal dysfunction (1 vs. 0.78 ng/mL p < 0.05). The diagnostic accuracy of procalcitonin increased significantly when the procalcitonin threshold was adapted to renal function. Conclusions: Procalcitonin is an accurate marker of postoperative infection in cardiac surgery, even in the presence of renal dysfunction. Renal function is an important determinant of procalcitonin levels and, therefore, its diagnostic thresholds must be adapted in the presence of renal dysfunction.
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Affiliation(s)
- Olga de la Varga-Martínez
- Department of Anaesthesiology, Infanta Leonor University Hospital, Gran Via del Este 80, 28031 Madrid, Spain
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Ramon y Cajal Ave. 7, 47005 Valladolid, Spain
- Correspondence: ; Tel.: +34-911918000
| | - Marta Martín-Fernández
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Ramon y Cajal Ave. 7, 47005 Valladolid, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Carlos III Health Institute, 28029 Madrid, Spain
- Department of Medicine, Faculty of Medicine, Universidad de Valladolid, 47005 Valladolid, Spain
| | - María Heredia-Rodríguez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Ramon y Cajal Ave. 7, 47005 Valladolid, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Carlos III Health Institute, 28029 Madrid, Spain
- Department of Anaesthesiology, Clinical University Hospital of Salamanca, P.° de San Vicente, 58, 37007 Salamanca, Spain
| | - Francisco Ceballos
- Viral Infection and Immunity Unit, National Center for Microbiology, Carlos III Health Institute, 28029 Madrid, Spain
| | - Hector Cubero-Gallego
- Interventional Cardiology Unit, Cardiology Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Juan Manuel Priede-Vimbela
- Department of Anaesthesiology, Clinic University Hospital of Valladolid, Ramon y Cajal Ave. 3, 47003 Valladolid, Spain
| | - Miguel Bardají-Carrillo
- Department of Anaesthesiology, Clinic University Hospital of Valladolid, Ramon y Cajal Ave. 3, 47003 Valladolid, Spain
| | - Laura Sánchez-de Prada
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Ramon y Cajal Ave. 7, 47005 Valladolid, Spain
- Microbiology and Immunology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Rocío López-Herrero
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Ramon y Cajal Ave. 7, 47005 Valladolid, Spain
- Department of Anaesthesiology, Clinic University Hospital of Valladolid, Ramon y Cajal Ave. 3, 47003 Valladolid, Spain
| | - Pablo Jorge-Monjas
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Ramon y Cajal Ave. 7, 47005 Valladolid, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Carlos III Health Institute, 28029 Madrid, Spain
- Department of Anaesthesiology, Clinic University Hospital of Valladolid, Ramon y Cajal Ave. 3, 47003 Valladolid, Spain
- Department of Surgery, Faculty of Medicine, Universidad de Valladolid, 47005 Valladolid, Spain
| | - Eduardo Tamayo
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Ramon y Cajal Ave. 7, 47005 Valladolid, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Carlos III Health Institute, 28029 Madrid, Spain
- Department of Anaesthesiology, Clinic University Hospital of Valladolid, Ramon y Cajal Ave. 3, 47003 Valladolid, Spain
- Department of Surgery, Faculty of Medicine, Universidad de Valladolid, 47005 Valladolid, Spain
| | - Esther Gómez-Sánchez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Ramon y Cajal Ave. 7, 47005 Valladolid, Spain
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Carlos III Health Institute, 28029 Madrid, Spain
- Department of Anaesthesiology, Clinic University Hospital of Valladolid, Ramon y Cajal Ave. 3, 47003 Valladolid, Spain
- Department of Surgery, Faculty of Medicine, Universidad de Valladolid, 47005 Valladolid, Spain
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Rothe K, Spinner CD, Waschulzik B, Janke C, Schneider J, Schneider H, Braitsch K, Smith C, Schmid RM, Busch DH, Katchanov J. A diagnostic algorithm for detection of urinary tract infections in hospitalized patients with bacteriuria: The "Triple F" approach supported by Procalcitonin and paired blood and urine cultures. PLoS One 2020; 15:e0240981. [PMID: 33091046 PMCID: PMC7580978 DOI: 10.1371/journal.pone.0240981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/06/2020] [Indexed: 11/18/2022] Open
Abstract
For acute medicine physicians, distinguishing between asymptomatic bacteriuria (ABU) and clinically relevant urinary tract infections (UTI) is challenging, resulting in overtreatment of ABU and under-recognition of urinary-source bacteraemia without genitourinary symptoms (USB). We conducted a retrospective analysis of ED encounters in a university hospital between October 2013 and September 2018 who met the following inclusion criteria: Suspected UTI with simultaneous collection of paired urinary cultures and blood cultures (PUB) and determination of Procalcitonin (PCT). We sought to develop a simple algorithm based on clinical signs and PCT for the management of suspected UTI. Individual patient presentations were retrospectively evaluated by a clinical "triple F" algorithm (F1 ="fever", F2 ="failure", F3 ="focus") supported by PCT and PUB. We identified 183 ED patients meeting the inclusion criteria. We introduced the term UTI with systemic involvement (SUTI) with three degrees of diagnostic certainty: bacteremic UTI (24.0%; 44/183), probable SUTI (14.2%; 26/183) and possible SUTI (27.9%; 51/183). In bacteremic UTI, half of patients (54.5%; 24/44) presented without genitourinary symptoms. Discordant bacteraemia was diagnosed in 16 patients (24.6% of all bacteremic patients). An alternative focus was identified in 67 patients, five patients presented with S. aureus bacteremia. 62 patients were diagnosed with possible UTI (n = 20) or ABU (n = 42). Using the proposed "triple F" algorithm, dichotomised PCT of < 0.25 pg/ml had a negative predictive value of 88.7% and 96.2% for bacteraemia und accordant bacteraemia respectively. The application of the algorithm to our cohort could have resulted in 33.3% reduction of BCs. Using the diagnostic categories "possible" or "probable" SUTI as a trigger for initiation of antimicrobial treatment would have reduced or streamlined antimicrobial use in 30.6% and 58.5% of cases, respectively. In conclusion, the "3F" algorithm supported by PCT and PUB is a promising diagnostic and antimicrobial stewardship tool.
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Affiliation(s)
- Kathrin Rothe
- Institute for Medical Microbiology, Immunology and Hygiene, School of Medicine, Technical University of Munich, Munich, Germany
- * E-mail:
| | - Christoph D. Spinner
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Birgit Waschulzik
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Janke
- Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Jochen Schneider
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Heike Schneider
- Department of Clinical Chemistry and Pathobiochemistry, School of Medicine, Technical University of Munich, Munich, Germany
| | - Krischan Braitsch
- Department of Internal Medicine III, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christopher Smith
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki, Japan
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roland M. Schmid
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dirk H. Busch
- Institute for Medical Microbiology, Immunology and Hygiene, School of Medicine, Technical University of Munich, Munich, Germany
- German Centre for Infection Research (DZIF), partner site Munich, Munich, Germany
| | - Juri Katchanov
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, Munich, Germany
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Covino M, Manno A, Merra G, Simeoni B, Piccioni A, Carbone L, Forte E, Ojetti V, Franceschi F, Murri R. Reduced utility of early procalcitonin and blood culture determination in patients with febrile urinary tract infections in the emergency department. Intern Emerg Med 2020; 15:119-125. [PMID: 31650435 DOI: 10.1007/s11739-019-02212-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/03/2019] [Indexed: 01/10/2023]
Abstract
To investigate the prognostic role of procalcitonin (PCT) assessment and blood culture (BC) acquisition in the emergency department (ED) in patients with urinary tract infection (UTI) or urosepsis. We enrolled patients admitted for UTI to our ED over a 10-year period. Mortality and in hospital length of stay (LOS) were compared between patients with UTI or urosepsis who had sampling for PCT levels and BC taken in the ED (ePCT group-eBC group) and those who had not (no-ePCT group-no-eBC group). 1029 patients were analyzed, 52.7% of which were female. Median age was 77 [65-83]; 139 patients (13.5%) had complicated UTI. Median LOS was 10 [7-17] days. In the ePCT group, LOS was 10 [7-16] days, vs. 10 [7-17] (p = 0.428) in the no-ePCT group. In the eBC group, LOS was 10 [6-16] days vs. 10 [7-17] days (p = 0.369) in the no-eBC group. The overall mortality rate was 6.6%. The mortality rate was not affected by early PCT determination (6% in the ePCT group vs. 6.9% in the no-ePCT group, p = 0.584). Similarly, the mortality rate was not different in the eBC group as compared to the no-eBC group (5.4% vs. 6.9%, p = 0.415). Performance of ePCT or eBC testing made no significant difference in terms of improvement of mortality rates in septic patients (11.4% vs. 7.2%; p = 0.397 and 8.8% vs. 9.8%; p = 0.845, respectively). The prognostic relevance of early evaluation of PCT and BC in the ED of patients with febrile UTI appears limited. In complicated UTI patients, PCT and BC testing may be more appropriate in the context of improving antibiotic stewardship, or as an integral component of PCT-guided standardized protocols.
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Affiliation(s)
- Marcello Covino
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Alberto Manno
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Giuseppe Merra
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Benedetta Simeoni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Luigi Carbone
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Evelina Forte
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Veronica Ojetti
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rita Murri
- Department of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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The Prevalence and Clinical Significance of Low Procalcitonin Levels Among Patients With Severe Sepsis or Septic Shock in the Emergency Department. Shock 2018; 46:37-43. [PMID: 27299586 DOI: 10.1097/shk.0000000000000566] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The aims of this study were to evaluate the prevalence of low procalcitonin (PCT) levels among patients with severe sepsis or septic shock, and to investigate clinical characteristics and outcomes associated with low PCT levels. METHODS We analyzed data from the sepsis registry for patients with severe sepsis or septic shock in the emergency department. Based on a specific PCT cutoff value, patients were classified into two groups: a low PCT group, PCT <0.25 ng/mL; and a high PCT group, PCT ≥0.25 ng/mL. The primary endpoint was 28-day mortality. A multivariable logistic regression model was used to evaluate independent factors associated with low PCT and 28-day mortality. RESULTS A total of 1,212 patients were included. Of the eligible patients, 154 (12.7%) were assigned to the low PCT group, and 1,058 (87.3%) to the high PCT group. The 28-day mortality was 4.6% in the low PCT group and 13.5% in the high PCT group (P < 0.01). The adjusted odds ratio of the low PCT group for 28-day mortality was 0.43 (95% CI 0.19-0.98; P = 0.04). There was no trend of increasing mortality among higher PCT level patients. In a logistic regression model, factors associated with low PCT were pneumonia, lower C-reactive protein levels, lower lactate levels, the absence of bacteremia, and the absence of organ failure. Intra-abdominal infection and obesity were associated with high PCT. CONCLUSION Initial low PCT levels were common among patients diagnosed with severe sepsis or septic shock in the emergency department, suggesting favorable outcomes. The prevalence of low PCT levels was significantly different according to obesity, the source of infection, C-reactive protein levels, lactate levels, bacteremia, and organ failure.
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Ko YH, Ji YS, Park SY, Kim SJ, Song PH. Procalcitonin determined at emergency department as na early indicator of progression to septic shock in patient with sepsis associated with ureteral calculi. Int Braz J Urol 2017; 42:270-6. [PMID: 27256181 PMCID: PMC4871387 DOI: 10.1590/s1677-5538.ibju.2014.0465] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 06/09/2015] [Indexed: 12/16/2022] Open
Abstract
Introduction: To investigate the role of initial procalcitonin (PCT) level as an early predictor of septic shock for the patient with sepsis induced by acute pyelonephritis (APN) secondary to ureteral calculi. Materials and Methods: The data from 49 consecutive patients who met criteria of sepsis due to APN following ureteral stone were collected and divided into two groups: with (n=15) or without (n=34) septic shock. The clinical variables including PCT level for this outcome were retrospectively compared by univariate analysis, followed by multivariable logistic regression model. Results: All subjects had hydronephrosis, and were hospitalized with the mean of 11.8 days (3–42 days). The mean size of the ureteral stones was 7.5mm (3–30mm), and 57% were located in upper ureter. At univariate analysis, patients with septic shock were significantly older, a higher proportion had hypertension, lower platelet count and serum albumin level, higher CRP and PCT level, and higher positive blood culture rate. Multivariate models indicated that lower platelet count and higher PCT level are independent risk factors (p=0.043 and 0.046, respectively). In ROC curve, the AUC was significantly wider in PCT (0.929), compared with the platelet count (0.822, p=0.004). At the cut-off of 0.52ng/mL, the sensitivity and specificity were 86.7% and 85.3%. Conclusion: Our study demonstrated elevated initial PCT levels as an early independent predictor to progress into septic shock in patients with sepsis associated with ureteral calculi.
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Affiliation(s)
- Young Hwii Ko
- Department of Urology, College of Medicine, Yeungnam University, Daegu, Korea
| | - Yoon Seob Ji
- Department of Urology, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sin-Youl Park
- Department of Emergency medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Su Jin Kim
- Department of Emergency medicine, Korea University Anam Hospital, Seoul, Korea
| | - Phil Hyun Song
- Department of Urology, College of Medicine, Yeungnam University, Daegu, Korea
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Abstract
PURPOSE OF REVIEW To review the recent advances in the diagnostic and therapeutic approach to adults presenting with febrile urinary tract infection (UTI) in the emergency department (ED). RECENT FINDINGS Recent research suggests overdiagnosis and therefore overtreatment of UTI in the ED, especially in the elderly. Antimicrobial pretreatment, an indwelling catheter, and malignancy are independent risk factors for bacteremia with uropathogens that cannot be cultured from urine. A simple clinical prediction rule can predict clinically relevant radiologic findings in patients with invasive UTI. Procalcitonin is a marker for bacteremia; pro-adrenomedullin predicts a complicated course and 30-day mortality in complicated UTI. Several reports have identified the risk factors for resistant uropathogens in community-acquired febrile UTI. Adherence to the guidelines and early culture-guided intravenous-to-oral switch reduces the length of hospitalization. SUMMARY An effective strategy is needed to improve the diagnosis of UTIs in acute care. Further research regarding biomarker-guided triage might improve the management of patients with febrile UTI. Future efforts should be directed toward the improvement of adherence to UTI treatment guidelines.
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Park JH, Wee JH, Choi SP, Park KN. Serum procalcitonin level for the prediction of severity in women with acute pyelonephritis in the ED: value of procalcitonin in acute pyelonephritis. Am J Emerg Med 2013; 31:1092-7. [DOI: 10.1016/j.ajem.2013.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 04/03/2013] [Accepted: 04/04/2013] [Indexed: 11/29/2022] Open
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Ha YE, Kang CI, Wi YM, Chung DR, Kang ES, Lee NY, Song JH, Peck KR. Diagnostic usefulness of procalcitonin as a marker of bacteremia in patients with acute pyelonephritis. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:444-8. [PMID: 23772894 DOI: 10.3109/00365513.2013.803231] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute pyelonephritis (APN) is one of the most common community-acquired infections and frequently accompanies bacteremia. The purpose of this study was to investigate the diagnostic role of procalcitonin in predicting bacteremia in patients with APN. METHODS We conducted a retrospective study of patients with APN who visited the emergency department (ED) at Samsung Medical Center, Seoul. Predictors of bacteremia were analyzed and receiver operating characteristics (ROC) curves were plotted for procalcitonin, C-reactive protein (CRP), and leukocytes. RESULTS During the study period, a total of 147 patients who had microbiologically proven APN and available initial procalcitonin concentrations were identified. Of these, bacteremia was present in 84 patients. Multivariate analysis showed that age, hypotension, and higher procalcitonin concentrations independently predicted the presence of bacteremia. Procalcitonin had better discriminative power than CRP, as reflected by area under the ROC curve analysis (0.746 [95% CI, 0.667-0.826] vs. 0.602 [95% CI, 0.509-0.694], p = 0.02). At a cut-off value of 1.63 μg/L, procalcitonin predicted bacteremia with a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 61.9, 81.0, 81.3, 61.4 and 70.1%, respectively. CONCLUSION Procalcitonin concentration could be used as a reliable marker to predict bacteremia in patients with APN in the ED.
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Affiliation(s)
- Young Eun Ha
- Division of Infectious Diseases, Samsung Medical Center, Korea
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Abstract
Urinary tract infection remains a common problem for many populations. Recent studies have expanded our understanding of the host innate immune response and its role in the familial association observed for recurrent uncomplicated urinary tract infection in healthy women. Therapeutic management for uncomplicated infection has been compromised by increasing antimicrobial resistance, particularly global dissemination of the CTXM-15 extended spectrum β-lactamase (ESBL) producing Escherichia coli ST-131 strain. Prevention strategies exploring non-antimicrobial approaches continue to show limited promise, and approaches to limit empiric antimicrobials are now being explored. For complicated urinary tract infection, increasing antimicrobial resistance limits therapeutic options for many patients. In addition to ESBL producing E. coli, NDM-1 E. coli and Klebsiella pneumoniae and other resistant Gram negatives, such as Acinetobacter species, are being isolated more frequently. There has been renewed interest in catheter-acquired urinary tract infection, the most common health-care associated infection, with several recent evidence-based guidelines for infection prevention available. However, technologic progress in development of adherence-resistant catheter materials remains disappointing.
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Évaluation statistique d’un biomarqueur. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0087-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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van Nieuwkoop C, Bonten TN, van't Wout JW, Kuijper EJ, Groeneveld GH, Becker MJ, Koster T, Wattel-Louis GH, Delfos NM, Ablij HC, Leyten EMS, van Dissel JT. Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome: a prospective observational study. CRITICAL CARE (LONDON, ENGLAND) 2010. [PMID: 21083886 DOI: 10.1186/cc9328.epub] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Guidelines recommend that two blood cultures be performed in patients with febrile urinary tract infection (UTI), to detect bacteremia and help diagnose urosepsis. The usefulness and cost-effectiveness of this practice have been criticized. This study aimed to evaluate clinical characteristics and the biomarker procalcitonin (PCT) as an aid in predicting bacteremia. METHODS A prospective observational multicenter cohort study included consecutive adults with febrile UTI in 35 primary care units and 8 emergency departments of 7 regional hospitals. Clinical and microbiological data were collected and PCT and time to positivity (TTP) of blood culture were measured. RESULTS Of 581 evaluable patients, 136 (23%) had bacteremia. The median age was 66 years (interquartile range 46 to 78 years) and 219 (38%) were male. We evaluated three different models: a clinical model including seven bed-side characteristics, the clinical model plus PCT, and a PCT only model. The diagnostic abilities of these models as reflected by area under the curve of the receiver operating characteristic were 0.71 (95% confidence interval (CI): 0.66 to 0.76), 0.79 (95% CI: 0.75 to 0.83) and 0.73 (95% CI: 0.68 to 0.77) respectively. Calculating corresponding sensitivity and specificity for the presence of bacteremia after each step of adding a significant predictor in the model yielded that the PCT > 0.25 μg/l only model had the best diagnostic performance (sensitivity 0.95; 95% CI: 0.89 to 0.98, specificity 0.50; 95% CI: 0.46 to 0.55). Using PCT as a single decision tool, this would result in 40% fewer blood cultures being taken, while still identifying 94 to 99% of patients with bacteremia.The TTP of E. coli positive blood cultures was linearly correlated with the PCT log value; the higher the PCT the shorter the TTP (R(2) = 0.278, P = 0.007). CONCLUSIONS PCT accurately predicts the presence of bacteremia and bacterial load in patients with febrile UTI. This may be a helpful biomarker to limit use of blood culture resources.
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Affiliation(s)
- Cees van Nieuwkoop
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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van Nieuwkoop C, Bonten TN, van't Wout JW, Kuijper EJ, Groeneveld GH, Becker MJ, Koster T, Wattel-Louis GH, Delfos NM, Ablij HC, Leyten EMS, van Dissel JT. Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R206. [PMID: 21083886 PMCID: PMC3220019 DOI: 10.1186/cc9328] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 07/08/2010] [Accepted: 11/17/2010] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Guidelines recommend that two blood cultures be performed in patients with febrile urinary tract infection (UTI), to detect bacteremia and help diagnose urosepsis. The usefulness and cost-effectiveness of this practice have been criticized. This study aimed to evaluate clinical characteristics and the biomarker procalcitonin (PCT) as an aid in predicting bacteremia. METHODS A prospective observational multicenter cohort study included consecutive adults with febrile UTI in 35 primary care units and 8 emergency departments of 7 regional hospitals. Clinical and microbiological data were collected and PCT and time to positivity (TTP) of blood culture were measured. RESULTS Of 581 evaluable patients, 136 (23%) had bacteremia. The median age was 66 years (interquartile range 46 to 78 years) and 219 (38%) were male. We evaluated three different models: a clinical model including seven bed-side characteristics, the clinical model plus PCT, and a PCT only model. The diagnostic abilities of these models as reflected by area under the curve of the receiver operating characteristic were 0.71 (95% confidence interval (CI): 0.66 to 0.76), 0.79 (95% CI: 0.75 to 0.83) and 0.73 (95% CI: 0.68 to 0.77) respectively. Calculating corresponding sensitivity and specificity for the presence of bacteremia after each step of adding a significant predictor in the model yielded that the PCT > 0.25 μg/l only model had the best diagnostic performance (sensitivity 0.95; 95% CI: 0.89 to 0.98, specificity 0.50; 95% CI: 0.46 to 0.55). Using PCT as a single decision tool, this would result in 40% fewer blood cultures being taken, while still identifying 94 to 99% of patients with bacteremia.The TTP of E. coli positive blood cultures was linearly correlated with the PCT log value; the higher the PCT the shorter the TTP (R(2) = 0.278, P = 0.007). CONCLUSIONS PCT accurately predicts the presence of bacteremia and bacterial load in patients with febrile UTI. This may be a helpful biomarker to limit use of blood culture resources.
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Affiliation(s)
- Cees van Nieuwkoop
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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Claessens YE, Schmidt J, Batard E, Grabar S, Jegou D, Hausfater P, Kierzek G, Guérin S, Pourriat JL, Dhainaut JF, Ginsburg C. Can C-reactive protein, procalcitonin and mid-regional pro-atrial natriuretic peptide measurements guide choice of in-patient or out-patient care in acute pyelonephritis? Biomarkers In Sepsis (BIS) multicentre study. Clin Microbiol Infect 2009; 16:753-60. [PMID: 19747215 DOI: 10.1111/j.1469-0691.2009.02955.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Whereas C-reactive protein (CRP), procalcitonin (PCT) and mid-regional pro-atrial natriuretic peptide (ANP) may be of use at the bedside in the management of adult patients with infectious disorders, their usefulness has not been established in the setting of acute pyelonephritis. To assess the effectiveness of CRP, PCT and ANP measurements in guiding emergency physicians' decisions whether to admit to hospital patients with acute pyelonephritis, we conducted a multicentre, prospective, observational study in 12 emergency departments in France; 582 consecutive patients were included. The reference standard for admission was defined by experts' advice combined with necessity of admission or death during the 28-day follow-up. Baseline CRP, PCT and ANP were measured and their accuracy in identifying the necessity of admission was analysed using area under curves (AUC) of receiver-operating characteristic (ROC) plots. According to the reference standard, 126 (22%) patients required admission. ANP (AUC 0.75, 95% CI 0.69-0.80) and PCT (AUC 0.75, 95% CI 0.71-0.80) more accurately predicted this than did CRP (AUC 0.69, 95% CI 0.64-0.74). The positive and negative likelihood ratios for each biomarker remained clinically irrelevant whatever the threshold. Our results did not support the use of these markers to help physicians in deciding about admission of patients experiencing acute pyelonephritis in daily practice.
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Affiliation(s)
- Y-E Claessens
- Department of Emergency Medicine, Hôpital Cochin, APHP and Université Paris Descartes, Paris, France.
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Influence of renal dysfunction on the accuracy of procalcitonin for the diagnosis of postoperative infection after vascular surgery. Crit Care Med 2008; 36:1147-54. [DOI: 10.1097/ccm.0b013e3181692966] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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15
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Delerme S, Chenevier-Gobeaux C, Doumenc B, Ray P. Useulness of B Natriuretic Peptides and Procalcitonin in Emergency Medicine. Biomark Insights 2008; 3:203-217. [PMID: 19578505 PMCID: PMC2688345 DOI: 10.4137/bmi.s499] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presented to an emergency department (ED), and it is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. For diagnosing CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in elderly population, and in patients with renal dysfunction. They might have also a prognostic value. Studies demonstrated that the use of BNP or NT-proBNP in dyspneic patients early in the ED reduced the time to discharge, total treatment cost. BNP and NT-proBNP should be available in every ED 24 hours a day, because literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. Etiologic diagnosis of febrile patients who present to an ED is complex and sometimes difficult. However, new evidence showed that there are interventions (including early appropriate antibiotics), which could reduce mortality rate in patients with sepsis. For diagnosing sepsis, procalcitonin (PCT) is more accurate than C-reactive protein. Thus, because of its excellent specificity and positive predictive value, an elevated PCT concentration (higher than 0.5 ng/mL) indicates ongoing and potentially severe systemic infection, which needs early antibiotics (e.g. meningitis). In lower respiratory tract infections, CAP or COPD exacerbation, PCT guidance reduced total antibiotic exposure and/or antibiotic treatment duration.
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Affiliation(s)
- S Delerme
- Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance-Publique Hôpitaux de Paris (AP-HP), 47-83 boulevard de l'hôpital, 75013 Paris, Université Pierre et Marie Curie Paris 6, France
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Uncomplicated Urinary Tract Infection in Adults Including Uncomplicated Pyelonephritis. Urol Clin North Am 2008; 35:1-12, v. [DOI: 10.1016/j.ucl.2007.09.004] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Bang SH, Chang IH, Han JH, Ahn SH. C-reactive Protein is a Useful Marker to Predict the Severity and Early Response of Acute Pyelonephritis in Women. Korean J Urol 2007. [DOI: 10.4111/kju.2007.48.11.1143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sung Hak Bang
- Department of Urology, Hanil General Hospital, Seoul, Korea
| | - In Ho Chang
- Department of Urology, Hanil General Hospital, Seoul, Korea
| | - Jun Hyun Han
- Department of Urology, Hanil General Hospital, Seoul, Korea
| | - Seung Hyun Ahn
- Department of Urology, Hanil General Hospital, Seoul, Korea
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