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Chen LL, Weng H. Clinical significance of lower respiratory tract culture within 48 h of admission in patients with viral pneumonia: an observational study. BMC Pulm Med 2024; 24:372. [PMID: 39085852 PMCID: PMC11293002 DOI: 10.1186/s12890-024-03162-y] [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: 04/12/2023] [Accepted: 07/11/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND The aim of this retrospective study was to examine the risk factors of positive lower respiratory tract cultures and to investigate whether nosocomial infections are common in patients with positive lower respiratory tract cultures. METHODS We enrolled 86 patients diagnosed with influenza A-related critical illness who were treated at Fuzhou Pulmonary Hospital of Fujian in China between 1st October 2013 and 31st March 2019. The of admission were used to divide the enrolled patients into two groups. Sputum and bronchoalveolar lavage fluid specimens were collected within 48 h after admission for culture. All samples were cultured immediately after sampling. Nosocomial infections are defined as any symptom or sign of pulmonary infiltration, confirmed by X-ray, after 5 days of admission and positive results from one or more cultures. RESULTS The average age of this cohort was (54.13 ± 16.52) years. Based on the culture results, Staphylococcus aureus and Candida albicans had the highest positive rates (3.40% (3/86) and 20.90% (18/86), respectively). In patients with positive lower respiratory tract cultures, the incidence of nosocomial infection was 73.30% (22/30) five days after admission. However, the incidence of nosocomial infection was lower (42.80%, 24/56) in patients with negative lower respiratory tract cultures. Hemoptysis, systolic pressure at admission, and blood urea nitrogen level at admission were all independent risk factors for positive lower respiratory tract cultures within 48 h of admission. CONCLUSION Our data showed that a significant proportion of patients with pneumonia exhibited co-infections with bacteria or fungi within five days of hospital admission. Hemoptysis, systolic pressure, and blood urea nitrogen levels at admission emerged as the key risk factors. These findings underscore the necessity of closely monitoring patients with influenza infection, particularly for positive bacterial or fungal cultures within the initial 48 h of admission.
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Affiliation(s)
- Lu-Lu Chen
- Department of Respiratory Diseases, People' Hospital Affiliated to Fujian University of Traditional Chinese Medicine, No 602, 817 Middle Road, Taijiang District, Fuzhou, 350009, China
| | - Heng Weng
- Department of Respiratory Diseases, People' Hospital Affiliated to Fujian University of Traditional Chinese Medicine, No 602, 817 Middle Road, Taijiang District, Fuzhou, 350009, China.
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Valenzuela-Sánchez F, Valenzuela-Méndez B, Rodríguez-Gutiérrez JF, Estella Á. Latest developments in early diagnosis and specific treatment of severe influenza infection. JOURNAL OF INTENSIVE MEDICINE 2024; 4:160-174. [PMID: 38681787 PMCID: PMC11043645 DOI: 10.1016/j.jointm.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Influenza pandemics are unpredictable recurrent events with global health, economic, and social consequences. The objective of this review is to provide an update on the latest developments in early diagnosis and specific treatment of the disease and its complications, particularly with regard to respiratory organ failure. Despite advances in treatment, the rate of mortality in the intensive care unit remains approximately 30%. Therefore, early identification of potentially severe viral pneumonia is extremely important to optimize treatment in these patients. The pathogenesis of influenza virus infection depends on viral virulence and host response. Thus, in some patients, it is associated with an excessive systemic response mediated by an authentic cytokine storm. This process leads to severe primary pneumonia and acute respiratory distress syndrome. Initial prognostication in the emergency department based on comorbidities, vital signs, and biomarkers (e.g., procalcitonin, ferritin, human leukocyte antigen-DR, mid-regional proadrenomedullin, and lactate) is important. Identification of these biomarkers on admission may facilitate clinical decision-making to determine early admission to the hospital or the intensive care unit. These decisions are reached considering pathophysiological circumstances that are associated with a poor prognosis (e.g., bacterial co-infection, hyperinflammation, immune paralysis, severe endothelial damage, organ dysfunction, and septic shock). Moreover, early implementation is important to increase treatment efficacy. Based on a limited level of evidence, all current guidelines recommend using oseltamivir in this setting. The possibility of drug resistance should also be considered. Alternative options include other antiviral drugs and combination therapies with monoclonal antibodies. Importantly, it is not recommended to use corticosteroids in the initial treatment of these patients. Furthermore, the implementation of supportive measures for respiratory failure is essential. Current recommendations are limited, heterogeneous, and not regularly updated. Early intubation and mechanical ventilation is the basic treatment for patients with severe respiratory failure. Prone ventilation should be promptly performed in patients with acute respiratory distress syndrome, while early tracheostomy should be considered in case of planned prolonged mechanical ventilation. Clinical trials on antiviral treatment and respiratory support measures specifically for these patients, as well as specific recommendations for different at-risk populations, are necessary to improve outcomes.
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Affiliation(s)
- Francisco Valenzuela-Sánchez
- Intensive Care Unit, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Haematology Department, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Centro de Investigación Biomédica en Red, Enfermedades respiratorias, CIBERES, Instituto de Salud Carlos III, Av. de Monforte de Lemos, Madrid, Spain
| | - Blanca Valenzuela-Méndez
- Department of Oncological Surgery, Institut du Cancer de Montpellier (ICM), Parc Euromédecine, 208 Av. des Apothicaires,Montpellier, France
| | | | - Ángel Estella
- Intensive Care Unit, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Department of Medicine, Faculty of Medicine, University of Cádiz, Calle Doctor Marañón, Cádiz, Spain
- Instituto de Investigación e Innovación Biomédica de Cádiz (INIBiCA), Avenida Ana de Viya 21, Cádiz, Spain
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Doubravská L, Htoutou Sedláková M, Fišerová K, Klementová O, Turek R, Langová K, Kolář M. Bacterial Community- and Hospital-Acquired Pneumonia in Patients with Critical COVID-19-A Prospective Monocentric Cohort Study. Antibiotics (Basel) 2024; 13:192. [PMID: 38391578 PMCID: PMC10886267 DOI: 10.3390/antibiotics13020192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024] Open
Abstract
The impact of bacterial pneumonia on patients with COVID-19 infection remains unclear. This prospective observational monocentric cohort study aims to determine the incidence of bacterial community- and hospital-acquired pneumonia (CAP and HAP) and its effect on mortality in critically ill COVID-19 patients admitted to the intensive care unit (ICU) at University Hospital Olomouc between 1 November 2020 and 31 December 2022. The secondary objectives of this study include identifying the bacterial etiology of CAP and HAP and exploring the capabilities of diagnostic tools, with a focus on inflammatory biomarkers. Data were collected from the electronic information hospital system, encompassing biomarkers, microbiological findings, and daily visit records, and subsequently evaluated by ICU physicians and clinical microbiologists. Out of 171 patients suffering from critical COVID-19, 46 (27%) had CAP, while 78 (46%) developed HAP. Critically ill COVID-19 patients who experienced bacterial CAP and HAP exhibited higher mortality compared to COVID-19 patients without any bacterial infection, with rates of 38% and 56% versus 11%, respectively. In CAP, the most frequent causative agents were chlamydophila and mycoplasma; Enterobacterales, which were multidrug-resistant in 71% of cases; Gram-negative non-fermenting rods; and Staphylococcus aureus. Notably, no strains of Streptococcus pneumoniae were detected, and only a single strain each of Haemophilus influenzae and Moraxella catarrhalis was isolated. The most frequent etiologic agents causing HAP were Enterobacterales and Gram-negative non-fermenting rods. Based on the presented results, commonly used biochemical markers demonstrated poor predictive and diagnostic accuracy. To confirm the diagnosis of bacterial CAP in our patient cohort, it was necessary to assess the initial values of inflammatory markers (particularly procalcitonin), consider clinical signs indicative of bacterial infection, and/or rely on positive microbiological findings. For HAP diagnostics, it was appropriate to conduct regular detailed clinical examinations (with a focus on evaluating respiratory functions) and closely monitor the dynamics of inflammatory markers (preferably Interleukin-6).
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Affiliation(s)
- Lenka Doubravská
- Department of Anaesthesiology, Resuscitation and Intensive Care, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Anaesthesiology, Resuscitation and Intensive Care, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Miroslava Htoutou Sedláková
- Department of Microbiology, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Kateřina Fišerová
- Department of Microbiology, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Olga Klementová
- Department of Anaesthesiology, Resuscitation and Intensive Care, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Anaesthesiology, Resuscitation and Intensive Care, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Radovan Turek
- Department of Anaesthesiology, Resuscitation and Intensive Care, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Kateřina Langová
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
| | - Milan Kolář
- Department of Microbiology, University Hospital Olomouc, Zdravotniku 248/7, 779 00 Olomouc, Czech Republic
- Department of Microbiology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Hnevotinska 3, 779 00 Olomouc, Czech Republic
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Patel KD, Aden JK, Sobieszczyk MJ, Marcus JE. The utility of procalcitonin for identifying secondary infections in patients with influenza or COVID-19 receiving extracorporeal membrane oxygenation. Ther Adv Infect Dis 2024; 11:20499361241255873. [PMID: 38883923 PMCID: PMC11177733 DOI: 10.1177/20499361241255873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/02/2024] [Indexed: 06/18/2024] Open
Abstract
Background Identifying secondary infections in patients receiving extracorporeal membrane oxygenation (ECMO) presents challenges due to the ECMO circuit's influence on traditional signs of infection. Objectives This study evaluates procalcitonin as a diagnostic marker for secondary infections in patients receiving ECMO with influenza or COVID-19 infection. Design Single-center retrospective cohort study. Methods All adult patients receiving veno-venous ECMO with underlying influenza or COVID-19 from November 2017 to October 2021 were included. Patient demographics, time receiving ECMO, culture data, and procalcitonin levels were examined. The first procalcitonin within 3 days of infection was compared to negative workups that were collected at least 10 days from the last positive culture. Furthermore, we compared procalcitonin levels by the type of pathogen and site of infection. Results In this study, 84 patients with influenza or COVID-19 who received ECMO were included. A total of 276 procalcitonin labs were ordered in this cohort, with 33/92 (36%) of the secondary infections having an associated procalcitonin value. When comparing procalcitonin levels, there was no significant difference between the infection and negative workup groups [1 ng/mL (interquartile ranges, IQR: 0.4-1.2) versus 1.3 (0.5-4.3), p = 0.19]. Using 0.5 ng/mL as the cut-off, the sensitivity of procalcitonin was 67% and the specificity was 30%. In our cohort, the positive predictive value of procalcitonin was 14.5% and the negative predictive value was 84%. There was no difference in procalcitonin by type of organism or site of infection. Procalcitonin levels did not routinely decline even after an infection was identified. Conclusion While procalcitonin is a proposed potential diagnostic marker for secondary infections in patients receiving ECMO, this single-center study demonstrated low sensitivity and specificity of procalcitonin in identifying secondary infections. Furthermore, there was no association of procalcitonin levels with etiology of infection when one was present. Procalcitonin should be used cautiously in identifying infections in veno-venous ECMO.
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Affiliation(s)
- Kajal D Patel
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, USA
| | - James K Aden
- Biostatistics, San Antonio Uniformed Services Health Education Consortium, Joint Base San Antonio-Fort Sam Houston, TX, USA
| | - Michal J Sobieszczyk
- Pulmonary Service, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, USA
| | - Joseph E Marcus
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234-4504, USA
- Department of Medicine, Uniformed Services University, Bethesda, MD, USA
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Antuori A, Giménez M, Linares G, Cardona PJ. Characterization of respiratory bacterial co-infection and assessment of empirical antibiotic treatment in patients with COVID-19 at hospital admission. Sci Rep 2023; 13:19302. [PMID: 37935785 PMCID: PMC10630415 DOI: 10.1038/s41598-023-46692-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 11/03/2023] [Indexed: 11/09/2023] Open
Abstract
Accurate characterization of respiratory bacterial co-infection is critical for guiding empirical antibiotic treatment for hospitalised patients with coronavirus disease 2019 (COVID-19). We retrospectively assessed the clinical and analytical predictors of respiratory bacterial co-infection and described the empirical use of antibiotics in COVID-19 hospitalised patients. Respiratory bacterial co-infection was documented in 6.9% (80/1157) of the patients. The predominant bacteria isolates were Haemophilus influenzae, followed by Streptococcus pneumoniae and Pseudomonas aeruginosa. Respiratory bacterial co-infection was associated with having had a positive culture for a respiratory pathogen in the last year (OR = 25.89), dyslipidaemia (OR = 2.52), heart failure (OR = 7.68), ferritin levels < 402 ng/mL (OR = 2.28), leukocyte count > 8.7 × 109/L (OR = 2.4), and patients with chronic obstructive pulmonary disease treated with inhaled corticosteroids (OR = 12.94). Empirical antibiotic treatment was administered in 42.33% of patients, although it declined across the distinct study periods (p < 0.001). Patients admitted to intensive care units harbouring co-infection exhibited worse outcomes and more bacterial secondary infections. In conclusion, respiratory bacterial co-infection prevalence was low, although it could lead to unfavourable outcomes. Moreover, the percentage of empirical antibiotic treatment remained high. The study's findings allowed the identification of several predictors for respiratory bacterial co-infection and could help implement adequate antibiotic stewardship measures.
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Affiliation(s)
- Adrián Antuori
- Microbiology Department, Clinical Laboratory North Metropolitan Area, Germans Trias i Pujol University Hospital, 08916, Badalona, Spain.
| | - Montserrat Giménez
- Microbiology Department, Clinical Laboratory North Metropolitan Area, Germans Trias i Pujol University Hospital, 08916, Badalona, Spain
| | - Georgina Linares
- Microbiology Department, Clinical Laboratory North Metropolitan Area, Germans Trias i Pujol University Hospital, 08916, Badalona, Spain
| | - Pere-Joan Cardona
- Microbiology Department, Clinical Laboratory North Metropolitan Area, Germans Trias i Pujol University Hospital, 08916, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), 28029, Madrid, Spain
- Genetics and Microbiology Department, Universitat Autònoma de Barcelona, 08913, Cerdanyola del Vallès, Spain
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Papp M, Kiss N, Baka M, Trásy D, Zubek L, Fehérvári P, Harnos A, Turan C, Hegyi P, Molnár Z. Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis. Crit Care 2023; 27:394. [PMID: 37833778 PMCID: PMC10576288 DOI: 10.1186/s13054-023-04677-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients. METHODS We searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes. RESULTS We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79 days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95% CI: - 3.13, 0.67, respectively). CONCLUSIONS PCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.
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Affiliation(s)
- Márton Papp
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Saint John's Hospital, Budapest, Hungary
| | - Nikolett Kiss
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Máté Baka
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
| | - Domonkos Trásy
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
| | - László Zubek
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Andrea Harnos
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Caner Turan
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary.
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Poznan University of Medical Sciences, Poznan, Poland.
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Essmann L, Wirz Y, Gregoriano C, Schuetz P. One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers. Expert Rev Mol Diagn 2023; 23:739-752. [PMID: 37505928 DOI: 10.1080/14737159.2023.2242782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals. AREAS COVERED In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care. EXPERT OPINION In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.
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Affiliation(s)
- Lennart Essmann
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Yannick Wirz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
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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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Ozbay S, Ayan M, Ozsoy O, Akman C, Karcioglu O. Diagnostic and Prognostic Roles of Procalcitonin and Other Tools in Community-Acquired Pneumonia: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13111869. [PMID: 37296721 DOI: 10.3390/diagnostics13111869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Community-acquired pneumonia (CAP) is among the most common causes of death and one of the leading healthcare concerns worldwide. It can evolve into sepsis and septic shock, which have a high mortality rate, especially in critical patients and comorbidities. The definitions of sepsis were revised in the last decade as "life-threatening organ dysfunction caused by a dysregulated host response to infection". Procalcitonin (PCT), C-reactive protein (CRP), and complete blood count, including white blood cells, are among the most commonly analyzed sepsis-specific biomarkers also used in pneumonia in a broad range of studies. It appears to be a reliable diagnostic tool to expedite care of these patients with severe infections in the acute setting. PCT was found to be superior to most other acute phase reactants and indicators, including CRP as a predictor of pneumonia, bacteremia, sepsis, and poor outcome, although conflicting results exist. In addition, PCT use is beneficial to judge timing for the cessation of antibiotic treatment in most severe infectious states. The clinicians should be aware of strengths and weaknesses of known and potential biomarkers in expedient recognition and management of severe infections. This manuscript is intended to present an overview of the definitions, complications, and outcomes of CAP and sepsis in adults, with special regard to PCT and other important markers.
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Affiliation(s)
- Sedat Ozbay
- Department of Emergency Medicine, Sivas Numune Education and Research Hospital, Sivas 58040, Turkey
| | - Mustafa Ayan
- Department of Emergency Medicine, Sivas Numune Education and Research Hospital, Sivas 58040, Turkey
| | - Orhan Ozsoy
- Department of Emergency Medicine, Sivas Numune Education and Research Hospital, Sivas 58040, Turkey
| | - Canan Akman
- Department of Emergency Medicine, Canakkale Onsekiz Mart University, Canakkale 17100, Turkey
| | - Ozgur Karcioglu
- Department of Emergency Medicine, University of Health Sciences, Taksim Education and Research Hospital, Beyoglu, Istanbul 34098, Turkey
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The Role of Procalcitonin as an Antimicrobial Stewardship Tool in Patients Hospitalized with Seasonal Influenza. Antibiotics (Basel) 2023; 12:antibiotics12030573. [PMID: 36978440 PMCID: PMC10044820 DOI: 10.3390/antibiotics12030573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Up to 60% of the antibiotics prescribed to patients hospitalized with seasonal influenza are unnecessary. Procalcitonin (PCT) has the potential as an antimicrobial stewardship program (ASP) tool because it can differentiate between viral and bacterial etiology. We aimed to explore the role of PCT as an ASP tool in hospitalized seasonal influenza patients. Methods: We prospectively included 116 adults with seasonal influenza from two influenza seasons, 2018–2020. All data was obtained from a single clinical setting and analyzed by descriptive statistics and regression models. Results: In regression analyses, we found a positive association of PCT with 30 days mortality and the amount of antibiotics used. Influenza diagnosis was associated with less antibiotic use if the PCT value was low. Patients with a low initial PCT (<0.25 µg/L) had fewer hospital and intensive care unit (ICU) days and fewer positive chest X-rays. PCT had a negative predictive value of 94% for ICU care stay, 98% for 30 days mortality, and 88% for bacterial coinfection. Conclusion: PCT can be a safe rule-out test for bacterial coinfection. Routine PCT use in seasonal influenza patients with an uncertain clinical picture, and rapid influenza PCR testing, may be efficient as ASP tools.
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Antimicrobial Stewardship Techniques for Critically Ill Patients with Pneumonia. Antibiotics (Basel) 2023; 12:antibiotics12020295. [PMID: 36830205 PMCID: PMC9952097 DOI: 10.3390/antibiotics12020295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
Pneumonia is common in the intensive care unit (ICU), infecting 27% of all critically ill patients. Given the high prevalence of this disease state in the ICU, optimizing antimicrobial therapy while minimizing toxicities is of utmost importance. Inappropriate antimicrobial use can increase the risk of antimicrobial resistance, Clostridiodes difficile infection, allergic reaction, and other complications from antimicrobial use (e.g., QTc prolongation, thrombocytopenia). This review article aims to discuss methods to optimize antimicrobial treatment in patients with pneumonia, including the following: procalcitonin use, utilization of methicillin-resistant Staphylococcus aureus nares testing to determine need for vancomycin therapy, utilization of the Biofire® FilmArray® pneumonia polymerase chain reaction (PCR), and microbiology reporting techniques.
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12
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The Role of Biomarkers in Influenza and COVID-19 Community-Acquired Pneumonia in Adults. Antibiotics (Basel) 2023; 12:antibiotics12010161. [PMID: 36671362 PMCID: PMC9854478 DOI: 10.3390/antibiotics12010161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Pneumonia is a growing problem worldwide and remains an important cause of morbidity, hospitalizations, intensive care unit admission and mortality. Viruses are the causative agents in almost a fourth of cases of community-acquired pneumonia (CAP) in adults, with an important representation of influenza virus and SARS-CoV-2 pneumonia. Moreover, mixed viral and bacterial pneumonia is common and a risk factor for severity of disease. It is critical for clinicians the early identification of the pathogen causing infection to avoid inappropriate antibiotics, as well as to predict clinical outcomes. It has been extensively reported that biomarkers could be useful for these purposes. This review describe current evidence and provide recommendations about the use of biomarkers in influenza and SARS-CoV-2 pneumonia, focusing mainly on procalcitonin (PCT) and C-reactive protein (CRP). Evidence was based on a qualitative analysis of the available scientific literature (meta-analyses, randomized controlled trials, observational studies and clinical guidelines). Both PCT and CRP levels provide valuable information about the prognosis of influenza and SARS-CoV-2 pneumonia. Additionally, PCT levels, considered along with other clinical, radiological and laboratory data, are useful for early diagnosis of mixed viral and bacterial CAP, allowing the proper management of the disease and adequate antibiotics prescription. The authors propose a practical PCT algorithm for clinical decision-making to guide antibiotic initiation in cases of influenza and SARS-CoV-2 pneumonia. Further well-design studies are needed to validate PCT algorithm among these patients and to confirm whether other biomarkers are indeed useful as diagnostic or prognostic tools in viral pneumonia.
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13
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Mayne ES, George JA, Louw S. Assessing Biomarkers in Viral Infection. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1412:159-173. [PMID: 37378766 DOI: 10.1007/978-3-031-28012-2_8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Current biomarkers to assess the risk of complications of both acute and chronic viral infection are suboptimal. Prevalent viral infections like human immunodeficiency virus (HIV), hepatitis B and C virus, herpes viruses, and, more recently, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) may be associated with significant sequelae including the risk of cardiovascular disease, other end-organ diseases, and malignancies. This review considers some biomarkers which have been investigated in diagnosis and prognosis of key viral infections including inflammatory cytokines, markers of endothelial dysfunction and activation and coagulation, and the role that more conventional diagnostic markers, such as C-reactive protein and procalcitonin, can play in predicting these secondary complications, as markers of severity and to distinguish viral and bacterial infection. Although many of these are still only available in the research setting, these markers show promise for incorporation in diagnostic algorithms which may assist to predict adverse outcomes and to guide therapy.
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Affiliation(s)
- Elizabeth S Mayne
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town and National Health Laboratory Service, Cape Town, South Africa.
| | - Jaya A George
- National Health Laboratory Service and Wits Diagnostic Innovation Hub, University of Witwatersrand, Johannesburg, South Africa
| | - Susan Louw
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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14
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Saura O, Chommeloux J, Levy D, Assouline B, Lefevre L, Luyt CE. Updates in the management of respiratory virus infections in ICU patients: revisiting the non-SARS-CoV-2 pathogens. Expert Rev Anti Infect Ther 2022; 20:1537-1550. [PMID: 36220790 DOI: 10.1080/14787210.2022.2134116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although viruses are an underestimated cause of community-acquired pneumonias (CAP) and hospital-acquired pneumonias (HAP)/ventilator-associated pneumonias (VAP) in intensive care unit (ICU) patients, they have an impact on morbidity and mortality. AREAS COVERED In this perspective article, we discuss the available data regarding the management of severe influenza CAP and herpesviridae HAP/VAP. We review diagnostic and therapeutic strategies in order to give clear messages and address unsolved questions. EXPERT OPINION Influenza CAP affects yearly thousands of people; however, robust data regarding antiviral treatment in the most critical forms are scarce. While efficacy of oseltamivir has been investigated in randomized controlled trials (RCT) in uncomplicated influenza, only observational data are available in ICU patients. Herpesviridae are an underestimated cause of HAP/VAP in ICU patients. Whilst incidence of herpesviridae identification in samples from lower respiratory tract of ICU patients is relatively high (from 20% to 50%), efforts should be made to differentiate local reactivation from true lung infection. Only few randomized controlled trials evaluated the efficacy of antiviral treatment in herpesviridae reactivation/infection in ICU patients and all were exploratory or negative. Further studies are needed to evaluate the impact of such treatment in specific populations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Juliette Chommeloux
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David Levy
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lucie Lefevre
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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15
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Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2022; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
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Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - VAP-Rapid investigators
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
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16
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Patel N, Adams C, Brunetti L, Bargoud C, Teichman AL, Choron RL. Evaluation of Procalcitonin's Utility to Predict Concomitant Bacterial Pneumonia in Critically Ill COVID-19 Patients. J Intensive Care Med 2022; 37:1486-1492. [PMID: 35711161 PMCID: PMC9207592 DOI: 10.1177/08850666221108636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Historically, procalcitonin(PCT) has been used as a
predictor of bacterial infection and to guide antibiotic therapy in hospitalized
patients. The purpose of this study was to determine PCT's diagnostic utility in
predicting secondary bacterial pneumonia in critically ill patients with severe
COVID-19 pneumonia. Methods: A retrospective cohort study was
conducted in COVID-19 adults admitted to the ICU between March 2020, and March
2021. All included patients had a PCT level within 72 h of presentation and
serum creatinine of <1.5mg/dL. A PCT threshold of 0.5ng/mL was used to
compare patients with high( ≥ 0.5ng/mL) versus low(< 0.5ng/mL) PCT. Bacterial
pneumonia was defined by positive respiratory culture. A receiver operating
characteristics (ROC) curve was utilized to evaluate PCT as a diagnostic test
for bacterial pneumonia, with an area under the curve(AUC) threshold of 0.7 to
signify an accurate diagnostic test. A multivariable model was constructed to
identify variables associated with in-hospital mortality. Results:
There were 165 patients included: 127 low PCT versus 38 high PCT. There was no
significant difference in baseline characteristics, vital signs, severity of
disease, or outcomes among low versus high PCT groups (all
p > 0.05). While there was no difference in bacterial
pneumonia in low versus high groups (34(26.8%) versus 12(31.6%),
p = 0.562), more patients in the high PCT
group had bacteremia (19(15%) versus 11(28.9%),
p = 0.050). Sensitivity was 26.1% and
specificity was 78.2% for PCT to predict bacterial pneumonia coinfection in ICU
patients with COVID-19 pneumonia. ROC yielded an AUC 0.54
(p = 0.415). After adjusting for LDH>350U/L and creatinine
in multivariable regression, PCT did not enhance performance of the regression
model. Conclusions: PCT offers little to no predictive utility in
diagnosing concomitant bacterial pneumonia in critically ill patients with
COVID-19 nor in predicting increased severity of disease or worse outcomes
including mortality.
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Affiliation(s)
- Nandini Patel
- 15484Ernest Mario School of Pharmacy, Piscataway, NJ 08854, USA
| | - Christopher Adams
- 15484Ernest Mario School of Pharmacy, Piscataway, NJ 08854, USA.,43982Robert Wood Johnson University Hospital Somerset, Somerville, NJ 08876, USA
| | - Luigi Brunetti
- 15484Ernest Mario School of Pharmacy, Piscataway, NJ 08854, USA.,43982Robert Wood Johnson University Hospital Somerset, Somerville, NJ 08876, USA
| | | | - Amanda L Teichman
- 43982Robert Wood Johnson University Hospital Somerset, Somerville, NJ 08876, USA.,43982Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Rachel L Choron
- 43982Robert Wood Johnson University Hospital Somerset, Somerville, NJ 08876, USA.,43982Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
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17
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Kim JY, Yang KS, Chung Y, Lee KB, Suh JW, Kim SB, Sohn JW, Yoon YK. Epidemiologic Characteristics and Clinical Significance of Respiratory Viral Infections Among Adult Patients Admitted to the Intensive Care Unit. Front Med (Lausanne) 2022; 9:829624. [PMID: 35685411 PMCID: PMC9171106 DOI: 10.3389/fmed.2022.829624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background The diagnosis of respiratory viral infections (RVIs) in critically ill patients is important for determining treatment options and adhering to infection-control protocols. However, data on the incidence and occurrence patterns of RVIs are scarce. We investigated the epidemiology and clinical impact of RVIs in critically ill patients. Methods This retrospective observational study was conducted in a tertiary hospital in South Korea between November 2014 and September 2020. Adult patients (≥ 18 years of age) who tested positive for an RVI by multiplex polymerase chain reaction (mPCR) and were admitted to the intensive care unit (ICU) were included in the study. Clinical characteristics and outcomes were obtained by reviewing electronic medical records. Pearson's χ2 test and Fisher's exact test, Mann-Whitney U test was used to compare between groups of patients. Trend analysis and the χ2-based Q test was used to analyze test behavior of physicians performing mPCR test. Results Among 22,517 patients admitted to the ICU during the study period, 2,222 (9.9%) underwent mPCR testing for an RVI. The median timing of mPCR testing after ICU admission was 1 day (IQR, 0-2). A total of 335 (15.1%) non-duplicative RVI-positive cases were included in the analysis. The incidence rate of RVIs in ICU patients was 30.45 per 10,000 patient-days. The most frequently detected RVI was influenza A (27.8%), followed by rhinovirus (25.4%). Thirty-two (9.6%) RVI-positive patients were diagnosed with upper respiratory infections, 193 (64.1%) with community-acquired, and 108 (35.9%) with hospital-acquired pneumonia. All-cause mortality and mortality related to respiratory tract infection (RTI) were 30.7% and 22.1%, respectively. The initial presentation of septic shock, requirement for mechanical ventilation, and lymphocytopenia were significant predictors of RTI-related mortality. Of the RVI-positive patients, 151 (45.1%) had nonviral coinfections and presented with higher clinical severity and longer hospital stays than patients infected solely with viral pathogens. Conclusion The incidence of RVIs in ICU patients is common. ICU patients with RVIs had high mortality and frequently presented with coinfections with nonviral pathogens, which were associated with a higher clinical severity than sole RVI. Increased testing for RVIs will enhance infection-control efforts and improve patient care.
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Affiliation(s)
- Jeong Yeon Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Kyung Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, South Korea
| | - Youseung Chung
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Ki-Byung Lee
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jin Woong Suh
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Sun Bean Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jang Wook Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, South Korea
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18
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Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2022; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2022] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
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Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - VAP-Rapid investigators
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
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Wrotek A, Wrotek O, Jackowska T. Low Levels of Procalcitonin Are Related to Decreased Antibiotic Use in Children Hospitalized Due to Influenza. Diagnostics (Basel) 2022; 12:diagnostics12051148. [PMID: 35626302 PMCID: PMC9140075 DOI: 10.3390/diagnostics12051148] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/23/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Procalcitonin increases in bacterial infections, which are often suspected (though rarely confirmed) in paediatric influenza. We retrospectively verified procalcitonin’s usefulness in antibiotic guidance in children hospitalized due to laboratory-confirmed influenza. The ROC curve analysis evaluated procalcitonin’s performance in terms of antibiotic implementation or continuation in patients who were naive or had been receiving antibiotic treatment prior to hospital admission. We also assessed the procalcitonin’s usefulness to predict lower-respiratory-tract infections (LRTI), the presence of radiologically confirmed pneumonia, an intensive care unit transfer and a fatal outcome. Multiple regression models were built to verify the previously reported procalcitonin cut-off values. The study enrolled 371 children (median age 33 months). The AUC (area under the curve) for antibiotic implementation reached 0.66 (95%CI: 0.58–0.73) and 0.713 (95%CI: 0.6–0.83) for antibiotic continuation; optimal cut-offs (0.4 and 0.23 ng/mL, respectively) resulted in a negative predictive value (NPV) of 79.7% (95%CI: 76.2–82.9%) and 54.6% (95%CI: 45.8–63%), respectively. The use of 0.25 ng/mL as a reference decreased the odds of antibiotic treatment by 67% (95%CI: 43–81%) and 91% (95%CI: 56–98%), respectively. Procalcitonin showed lower AUC for the prediction of LRTI and pneumonia (0.6, 95%CI: 0.53–0.66, and 0.63, 95%CI: 0.56–0.7, respectively), with a moderately high NPV in the latter case (83%, 95%CI: 79.3–86.1%). Procalcitonin use may decrease the antibiotic frequency in hospitalized influenza cases both in terms of antibiotic administration and continuation. Procalcitonin concentrations may suggest bacterial suprainfections at lower concentrations than in adults, and a focus on its rule-out value is of special interest.
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Affiliation(s)
- August Wrotek
- Department of Pediatrics, Centre of Postgraduate Medical Education, Marymoncka 99/103, 01-813 Warsaw, Poland
- Department of Pediatrics, Bielanski Hospital, Cegłowska 80, 01-809 Warsaw, Poland
- Correspondence: (A.W.); (T.J.); Tel.: +48-864-1167 (T.J.)
| | - Oliwia Wrotek
- Student Research Group at the Bielanski Hospital, 01-809 Warsaw, Poland;
| | - Teresa Jackowska
- Department of Pediatrics, Centre of Postgraduate Medical Education, Marymoncka 99/103, 01-813 Warsaw, Poland
- Department of Pediatrics, Bielanski Hospital, Cegłowska 80, 01-809 Warsaw, Poland
- Correspondence: (A.W.); (T.J.); Tel.: +48-864-1167 (T.J.)
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García-Río F, Alcázar-Navarrete B, Castillo-Villegas D, Cilloniz C, García-Ortega A, Leiro-Fernández V, Lojo-Rodriguez I, Padilla-Galo A, Quezada-Loaiza CA, Rodriguez-Portal JA, Sánchez-de-la-Torre M, Sibila O, Martínez-García MA. [Translated article] Biological Biomarkers in Respiratory Diseases. ARCHIVOS DE BRONCONEUMOLOGÍA 2022. [DOI: 10.1016/j.arbres.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Plasma Levels of Mid-Regional Proadrenomedullin Accurately Identify H1N1pdm09 Influenza Virus Patients with Risk of Intensive Care Admission and Mortality in the Emergency Department. J Pers Med 2022; 12:jpm12010084. [PMID: 35055399 PMCID: PMC8777718 DOI: 10.3390/jpm12010084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/24/2021] [Accepted: 12/28/2021] [Indexed: 12/19/2022] Open
Abstract
Early identification of severe viral pneumonia in influenza virus A (H1N1pdm09) patients is extremely important for prompt admission to the ICU. The objective is to evaluate the usefulness of MR-proadrenomedullin (MR-proADM) compared to C reactive protein (CRP), procalcitonin (PCT), and ferritin in the prognosis of influenza A pneumonia. This prospective, observational, multicenter study included one hundred thirteen patients with confirmed influenza virus A (H1N1pdm09) admitted to an Emergency Department and ICUs of six hospitals in Spain. Measurements and Main Results: one-hundred thirteen patients with confirmed influenza virus A (H1N1pdm09) were enrolled. Seventy-five subjects (mortality 29.3%) with severe pneumonia caused by influenza A H1N1pdm09 virus (H1N1vIPN) were compared with 38 controls (CG).The median MR-proADM levels at hospital admission were 1.2 nmol/L (IQR (0.8–2.6) vs. 0.5 nmol/L (IQR 0.2–0.9) in the CG (p = 0.01), and PCT levels were 0.43 μg/L (IQR 0.2–1.2) in the H1N1vIPN group and 0.1 μg/L (IQR 0.1–0.2) in the CG (p < 0.01). CRP levels at admission were 15.5 mg/dL(IQR 9.2–24.9) in H1N1vIPN and 8.6 mg/dL(IQR 3–17.3) in the CG (p < 0.01). Ferritin levels at admission were 558.1 ng/mL(IQR 180–1880) in H1N1vIPN and 167.7 ng/mL(IQR 34.8–292.9) in the CG (p < 0.01). A breakpoint for hospital admission of MR-proADM of 1.1 nmol/L showed a sensitivity of 55% and a specificity of 90% (AUC-ROC0.822). Non-survivors showed higher MR-proADM levels: median of 2.5 nmol/L vs. 0.9 nmol/L among survivors (p < 0.01). PCT, CRP, and ferritin levels also showed significant differences in predicting mortality. The MR-proADM AUC-ROC for mortality was 0.853 (p < 0.01). In a Cox proportional hazards model, MR-proADM levels > 1.2 nmol/L at hospital admission were significant predictive factors for ICU and 90-day mortality (HR: 1.3). Conclusions: the initial MR-proADM, ferritin, CRP, and PCT levels effectively determine adverse outcomes and risk of ICU admission and mortality in patients with influenza virus pneumonia. MR-proADM has the highest potency for survival prediction.
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22
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Garcia-Rio F, Alcázar B, Castillo D, Cilloniz C, García-Ortega A, Leiro-Fernández V, Lojo-Rodriguez I, Padilla A, Quezada CA, Rodriguez-Portal JA, Sánchez-de-la-Torre M, Sibila O, Martinez-Garcia MA. Biomarcadores biológicos en las enfermedades respiratorias. Arch Bronconeumol 2022; 58:323-333. [DOI: 10.1016/j.arbres.2022.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
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Abstract
Influenza infection causes severe illness in 3 to 5 million people annually, with up to an estimated 650,000 deaths per annum. As such, it represents an ongoing burden to health care systems and human health. Severe acute respiratory infection can occur, resulting in respiratory failure requiring intensive care support. Herein we discuss diagnostic approaches, including development of CLIA-waived point of care tests that allow rapid diagnosis and treatment of influenza. Bacterial and fungal coinfections in severe influenza pneumonia are associated with worse outcomes, and we summarize the approach and treatment options for diagnosis and treatment of bacterial and Aspergillus coinfection. We discuss the available drug options for the treatment of severe influenza, and treatments which are no longer supported by the evidence base. Finally, we describe the supportive management and ventilatory approach to patients with respiratory failure as a result of severe influenza in the intensive care unit.
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Affiliation(s)
- Liam S O'Driscoll
- Department of Intensive Care Medicine, St. James's University Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, St. James's University Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland.,Respiratory Medicine, Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
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24
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Xu HG, Tian M, Pan SY. Clinical utility of procalcitonin and its association with pathogenic microorganisms. Crit Rev Clin Lab Sci 2021; 59:93-111. [PMID: 34663176 DOI: 10.1080/10408363.2021.1988047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In this review, we summarize the relationship of PCT with pathogens, evaluate the clinical utility of PCT in the diagnosis of clinical diseases, condition monitoring and evaluation, and guiding medical decision-making, and explore current knowledge on the mechanisms by which pathogens cause changes in PCT levels. The lipopolysaccharides of the microorganisms stimulate cytokine production in host cells, which in turn stimulates production of serum PCT. Pathogens have different virulence mechanisms that lead to variable host inflammatory responses, and differences in the specific signal transduction pathways result in variable serum PCT concentrations. The mechanisms of signal transduction have not been fully elucidated. Further studies are necessary to ascertain the PCT fluctuation range of each pathogen. PCT levels are helpful in distinguishing between certain pathogens, in deciding if antibiotics are indicated, and in monitoring response to antibiotics.
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Affiliation(s)
- Hua-Guo Xu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Meng Tian
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shi-Yang Pan
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2021; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
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Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - VAP-Rapid investigators
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
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Understanding the Host in the Management of Pneumonia. An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2021; 18:1087-1097. [PMID: 34242148 PMCID: PMC8328365 DOI: 10.1513/annalsats.202102-209st] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Pneumonia causes a significant burden of disease worldwide. Although all populations are at risk of pneumonia, those at extremes of age and those with immunosuppressive disorders, underlying respiratory disease, and critical illness are particularly vulnerable. Although clinical practice guidelines addressing the management and treatment of pneumonia exist, few of the supporting studies focus on the crucial contributions of the host in pneumonia pathogenesis and recovery. Such essential considerations include the host risk factors that lead to susceptibility to lung infections; biomarkers reflecting the host response and the means to pursue host-directed pneumonia therapy; systemic effects of pneumonia on the host; and long-term health outcomes after pneumonia. To address these gaps, the Pneumonia Working Group of the Assembly on Pulmonary Infection and Tuberculosis led a workshop held at the American Thoracic Society meeting in May 2018 with overarching objectives to foster attention, stimulate research, and promote funding for short-term and long-term investigations into the host contributions to pneumonia. The workshop involved participants from various disciplines with expertise in lung infection, pneumonia, sepsis, immunocompromised patients, translational biology, data science, genomics, systems biology, and clinical trials. This workshop report summarizes the presentations and discussions and important recommendations for future clinical pneumonia studies. These recommendations include establishing consensus disease and outcome definitions, improved phenotyping, development of clinical study networks, standardized data and biospecimen collection and protocols, and development of innovative trial designs.
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Voiriot G, Fartoukh M, Durand-Zaleski I, Berard L, Rousseau A, Armand-Lefevre L, Verdet C, Argaud L, Klouche K, Megarbane B, Patrier J, Richard JC, Reignier J, Schwebel C, Souweine B, Tandjaoui-Lambiotte Y, Simon T, Timsit JF. Combined use of a broad-panel respiratory multiplex PCR and procalcitonin to reduce duration of antibiotics exposure in patients with severe community-acquired pneumonia (MULTI-CAP): a multicentre, parallel-group, open-label, individual randomised trial conducted in French intensive care units. BMJ Open 2021; 11:e048187. [PMID: 34408046 PMCID: PMC8375718 DOI: 10.1136/bmjopen-2020-048187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION At the time of the worrying emergence and spread of bacterial resistance, reducing the selection pressure by reducing the exposure to antibiotics in patients with community-acquired pneumonia (CAP) is a public health issue. In this context, the combined use of molecular tests and biomarkers for guiding antibiotics discontinuation is attractive. Therefore, we have designed a trial comparing an integrated approach of diagnosis and treatment of severe CAP to usual care. METHODS AND ANALYSIS The multiplex PCR and procalcitonin to reduce duration of antibiotics exposure in patients with severe-CAP (MULTI-CAP) trial is a multicentre (n=20), parallel-group, superiority, open-label, randomised trial. Patients are included if adult admitted to intensive care unit for a CAP. Diagnosis of pneumonia is based on clinical criteria and a newly appeared parenchymal infiltrate. Immunocompromised patients are excluded. Subjects are randomised (1:1 ratio) to either the intervention arm (experimental strategy) or the control arm (usual strategy). In the intervention arm, the microbiological diagnosis combines a respiratory multiplex PCR (mPCR) and conventional microbiological investigations. An algorithm of early antibiotic de-escalation or discontinuation is recommended, based on mPCR results and the procalcitonin value. In the control arm, only conventional microbiological investigations are performed and antibiotics de-escalation remains at the clinician's discretion. The primary endpoint is the number of days alive without any antibiotic from the randomisation to day 28. Based on our hypothesis of 2 days gain in the intervention arm, we aim to enrol a total of 450 patients over a 30-month period. ETHICS AND DISSEMINATION The MULTI-CAP trial is conducted according to the principles of the Declaration of Helsinki, is registered in Clinical Trials and has been approved by the Committee for Protection of Persons and the National French Drug Safety Agency. Written informed consents are obtained from all the patients (or representatives). The results will be disseminated through educational institutions, submitted to peer-reviewed journals for publication and presented at medical congresses. TRIAL REGISTRATION NUMBER NCT03452826; Pre-results.
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Affiliation(s)
- Guillaume Voiriot
- Service de Médecine Intensive Réanimation, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Muriel Fartoukh
- Service de Médecine Intensive Réanimation, Assistance Publique-Hopitaux de Paris, Paris, France
| | | | - Laurence Berard
- Unité de Recherche Clinique de l'Est Parisien, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Alexandra Rousseau
- Unité de Recherche Clinique de l'Est Parisien, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Laurence Armand-Lefevre
- Département de Microbiologie, Hôpital Bichat, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Charlotte Verdet
- Département de Microbiologie, Hôpital Saint-Antoine, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Laurent Argaud
- Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Université de Lyon, Lyon, France
| | - Kada Klouche
- Intensive Care Medicine Department, Universite de Montpellier, Montpellier, France
| | - Bruno Megarbane
- Service de Médecine Intensive Réanimation, Hôpital Lariboisière, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Juliette Patrier
- Service de Réanimation Infectieuse, Hôpital Bichat, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive Réanimation, Hôpital de la Croix-Rousse, Université de Lyon, Lyon, France
| | - Jean Reignier
- Médecine intensive réanimation, CHU Nantes, Nantes, Pays de la Loire, France
| | - Carole Schwebel
- Service de Médecine Intensive Réanimation, CHU Grenoble Alpes, Grenoble, Auvergne-Rhone-Alpes, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, CHU Gabriel-Montpied, Clermont-Ferrand, France
| | - Yacine Tandjaoui-Lambiotte
- Service de Réanimation médico-chirurgicale, Hôpital Avicennes, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
| | - Tabassome Simon
- Clinical Research Platform (URC-CRB-CRC), Assistance Publique-Hôpitaux de Paris, Saint Antoine Hospital, Paris, France
- Clinical Pharmacology-Research Platform, Université Pierre et Marie Curie, Paris, France
| | - Jean-François Timsit
- Service de Réanimation Infectieuse, Hôpital Bichat, Assistance Publique-Hopitaux de Paris, Paris, Île-de-France, France
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Kaal A, Snel L, Dane M, van Burgel N, Ottens T, Broekman W, El Bouazzaoui L, Kolfschoten N, Schippers E, Steyerberg E, Meziyerh S, van Nieuwkoop C. Diagnostic yield of bacteriological tests and predictors of severe outcome in adult patients with COVID-19 presenting to the emergency department. Emerg Med J 2021; 38:685-691. [PMID: 34289966 PMCID: PMC8300553 DOI: 10.1136/emermed-2020-211027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 07/11/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Guidelines recommend maximal efforts to obtain blood and sputum cultures in patients with COVID-19, as bacterial coinfection is associated with worse outcomes. The aim of this study was to evaluate the yield of bacteriological tests, including blood and sputum cultures, and the association of multiple biomarkers and the Pneumonia Severity Index (PSI) with clinical and microbiological outcomes in patients with COVID-19 presenting to the emergency department (ED). METHODS This is a substudy of a large observational cohort study (PredictED study). The PredictED included adult patients from whom a blood culture was drawn at the ED of Haga Teaching Hospital, The Netherlands. For this substudy, all patients who tested positive for SARS-CoV-2 by PCR in March and April 2020 were included. The primary outcome was the incidence of bacterial coinfection. We used logistic regression analysis for associations of procalcitonin, C reactive protein (CRP), ferritin, lymphocyte count and PSI score with a severe disease course, defined as intensive care unit admission and/or 30-day mortality. The area under the receiver operating characteristics curve (AUC) quantified the discriminatory performance. RESULTS We included 142 SARS-CoV-2 positive patients. On presentation, the median duration of symptoms was 8 days. 41 (29%) patients had a severe disease course and 24 (17%) died within 30 days. The incidence of bacterial coinfection was 2/142 (1.4%). None of the blood cultures showed pathogen growth while 6.3% was contaminated. The AUCs for predicting severe disease were 0.76 (95% CI 0.68 to 0.84), 0.70 (0.61 to 0.79), 0.62 (0.51 to 0.74), 0.62 (0.51 to 0.72) and 0.72 (0.63 to 0.81) for procalcitonin, CRP, ferritin, lymphocyte count and PSI score, respectively. CONCLUSION Blood cultures appear to have limited value while procalcitonin and the PSI appear to be promising tools in helping physicians identify patients at risk for severe disease course in COVID-19 at presentation to the ED.
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Affiliation(s)
- Anna Kaal
- Internal Medicine, Haga Teaching Hospital, Den Haag, The Netherlands
| | - Lars Snel
- Internal Medicine, Haga Teaching Hospital, Den Haag, The Netherlands
| | - Martijn Dane
- Clinical Chemistry, Haga Teaching Hospital, Den Haag, The Netherlands
| | | | - Thomas Ottens
- Intensive Care, Haga Teaching Hospital, Den Haag, The Netherlands
| | | | | | - Nikki Kolfschoten
- Emergency Medicine, Haga Teaching Hospital, Den Haag, The Netherlands
| | - Emile Schippers
- Internal Medicine, Haga Teaching Hospital, Den Haag, The Netherlands
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Soufian Meziyerh
- Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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[58/m-fever, cough and severe hypoxemia : Preparation for the medical specialist examination: part 65]. Internist (Berl) 2021; 62:435-439. [PMID: 34264361 PMCID: PMC8280596 DOI: 10.1007/s00108-021-01096-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/09/2022]
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Abstract
Community-acquired pneumonia (CAP) is the prominent cause of mortality and morbidity with important clinical impact across the globe. India accounts for 23 per cent of global pneumonia burden with case fatality rates between 14 and 30 per cent, and Streptococcus pneumoniae is considered a major bacterial aetiology. Emerging pathogens like Burkholderia pseudomallei is increasingly recognized as an important cause of CAP in Southeast Asian countries. Initial management in the primary care depends on clinical assessment while the hospitalized patients require combinations of clinical scores, chest radiography and various microbiological and biomarker assays. This comprehensive diagnostic approach together with additional sampling and molecular tests in selected high-risk patients should be practiced. Inappropriate therapy in CAP in hospitalized patients lengthens hospital stay and increases cost and mortality. In addition, emergence of multidrug-resistant organisms poses tough challenges in deciding empirical as well as definitive therapy. Developing local evidence on the cause and management should be a priority to improve health outcomes in CAP.
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Affiliation(s)
- Vandana Kalwaje Eshwara
- Department of Microbiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Chiranjay Mukhopadhyay
- Department of Microbiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Jordi Rello
- Department of Critical Care, Vall d'Hebron Research Institute; Clinical Research & Innovation in Pneumonia and Sepsis, Barcelona, Spain
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Mason CY, Kanitkar T, Richardson CJ, Lanzman M, Stone Z, Mahungu T, Mack D, Wey EQ, Lamb L, Balakrishnan I, Pollara G. Exclusion of bacterial co-infection in COVID-19 using baseline inflammatory markers and their response to antibiotics. J Antimicrob Chemother 2021; 76:1323-1331. [PMID: 33463683 PMCID: PMC7928909 DOI: 10.1093/jac/dkaa563] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/22/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND COVID-19 is infrequently complicated by bacterial co-infection, but antibiotic prescriptions are common. We used community-acquired pneumonia (CAP) as a benchmark to define the processes that occur in bacterial pulmonary infections, testing the hypothesis that baseline inflammatory markers and their response to antibiotic therapy could distinguish bacterial co-infection from COVID-19. METHODS Retrospective cohort study of CAP (lobar consolidation on chest radiograph) and COVID-19 (PCR detection of SARS-CoV-2) patients admitted to Royal Free Hospital (RFH) and Barnet Hospital (BH), serving as independent discovery and validation cohorts. All CAP and >90% COVID-19 patients received antibiotics on hospital admission. RESULTS We identified 106 CAP and 619 COVID-19 patients at RFH. Compared with COVID-19, CAP was characterized by elevated baseline white cell count (WCC) [median 12.48 (IQR 8.2-15.3) versus 6.78 (IQR 5.2-9.5) ×106 cells/mL, P < 0.0001], C-reactive protein (CRP) [median 133.5 (IQR 65-221) versus 86.0 (IQR 42-160) mg/L, P < 0.0001], and greater reduction in CRP 48-72 h into admission [median ΔCRP -33 (IQR -112 to +3.5) versus +14 (IQR -15.5 to +70.5) mg/L, P < 0.0001]. These observations were recapitulated in the independent validation cohort at BH (169 CAP and 181 COVID-19 patients). A multivariate logistic regression model incorporating WCC and ΔCRP discriminated CAP from COVID-19 with AUC 0.88 (95% CI 0.83-0.94). Baseline WCC >8.2 × 106 cells/mL or falling CRP identified 94% of CAP cases, and excluded bacterial co-infection in 46% of COVID-19 patients. CONCLUSIONS We propose that in COVID-19, absence of both elevated baseline WCC and antibiotic-related decrease in CRP can exclude bacterial co-infection and facilitate antibiotic stewardship efforts.
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Affiliation(s)
- Claire Y Mason
- Department of Infection, Royal Free London NHS Trust, London, UK
| | - Tanmay Kanitkar
- Department of Infection, Royal Free London NHS Trust, London, UK
| | | | - Marisa Lanzman
- Department of Pharmacy, Royal Free London NHS Trust, London, UK
| | - Zak Stone
- Department of Pharmacy, Royal Free London NHS Trust, London, UK
| | - Tabitha Mahungu
- Department of Infection, Royal Free London NHS Trust, London, UK
| | - Damien Mack
- Department of Infection, Royal Free London NHS Trust, London, UK
| | - Emmanuel Q Wey
- Department of Infection, Royal Free London NHS Trust, London, UK
- Division of Infection & Immunity, University College London, London, UK
| | - Lucy Lamb
- Department of Infection, Royal Free London NHS Trust, London, UK
- Academic Department of Defence Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - Gabriele Pollara
- Department of Infection, Royal Free London NHS Trust, London, UK
- Division of Infection & Immunity, University College London, London, UK
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Džupová O, Moravec M, Bartoš H, Brestovanský P, Tencer T, Hyánek T, Beroušek J, Krupková Z, Mošna F, Vymazal T, Beneš J. COVID-19 severe pneumonia: Prospective multicentre study on demands on intensive care capacities. Cent Eur J Public Health 2021; 29:3-8. [PMID: 33831279 DOI: 10.21101/cejph.a6672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/05/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The aim of the study was to obtain data on demands on the intensive care capacities to treat COVID-19 patients, and to identify predictors for in-hospital mortality. METHODS The prospective observational multicentre study carried out from 1 March till 30 June 2020 included adult patients with confirmed SARS-CoV-2 infection with respiratory failure requiring ventilatory support or high-flow nasal oxygen therapy (HFNO). RESULTS Seventy-four patients, 46 males and 28 females, median age 67.5 (Q1-Q3: 56-75) years, were included. Sixty-four patients (86.5%) had comorbidity. Sixty-six patients (89.2%) were mechanically ventilated, four of them received extracorporeal membrane oxygenation therapy. Eight patients (10.8%) were treated with non-invasive ventilation and HFNO only. The median of intensive care unit (ICU) stay was 22.5 days. Eighteen patients (24.3%) needed continuous renal replacement therapy. Thirty patients (40.5%) died. Age and acute kidney injury were identified as independent predictors of in-hospital death, and chronic kidney disease showed trend towards statistical significance for poor outcome. CONCLUSIONS Sufficient number of intensive care beds, organ support equipment and well-trained staff is a decisive factor in managing the COVID-19 epidemic. The study focused on the needs of intensive care in the COVID-19 patients. Advanced age and acute kidney injury were identified as independent predictors for in-hospital mortality. When compared to clinical course and ICU management of patients with severe community-acquired pneumonia caused by other pathogens, we observed prolonged need for ventilatory support, high rate of progression to acute respiratory distress syndrome and significant mortality in studied population.
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Affiliation(s)
- Olga Džupová
- Third Faculty of Medicine, Charles University, and Department of Infectious Diseases, Hospital Na Bulovce, Prague, Czech Republic
| | - Michal Moravec
- First Faculty of Medicine, Charles University, and Department of Anaesthesiology and Critical Care, Thomayer Hospital, Prague, Czech Republic
| | - Hynek Bartoš
- Third Faculty of Medicine, Charles University, and Department of Infectious Diseases, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Peter Brestovanský
- First Faculty of Medicine, Charles University, and Department of Anaesthesiology, Resuscitation and Intensive Medicine, General University Hospital, Prague, Czech Republic
| | - Tomáš Tencer
- Third Faculty of Medicine, Charles University, and Department of Anaesthesiology, Resuscitation and Intensive Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Tomáš Hyánek
- Department of Anaesthesiology and Reanimation, Hospital Na Homolce, Prague, Czech Republic
| | - Jan Beroušek
- Second Faculty of Medicine, Charles University, and Department of Anaesthesiology, Resuscitation and Intensive Medicine, Motol University Hospital, Prague, Czech Republic
| | - Zdeňka Krupková
- Department of Anaesthesiology and Resuscitation, Hospital Na Bulovce, Prague, Czech Republic
| | - František Mošna
- Second Faculty of Medicine, Charles University, and Department of Cardiology, Motol University Hospital, Prague, Czech Republic
| | - Tomáš Vymazal
- Second Faculty of Medicine, Charles University, and Department of Anaesthesiology, Resuscitation and Intensive Medicine, Motol University Hospital, Prague, Czech Republic
| | - Jiří Beneš
- Third Faculty of Medicine, Charles University, and Department of Infectious Diseases, Hospital Na Bulovce, Prague, Czech Republic
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Increased antimicrobial resistance during the COVID-19 pandemic. Int J Antimicrob Agents 2021; 57:106324. [PMID: 33746045 PMCID: PMC7972869 DOI: 10.1016/j.ijantimicag.2021.106324] [Citation(s) in RCA: 221] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 02/09/2021] [Accepted: 03/13/2021] [Indexed: 01/08/2023]
Abstract
In addition to SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection itself, an increase in the incidence of antimicrobial resistance poses collateral damage to the current status of the COVID-19 (coronavirus disease 2019) pandemic. There has been a rapid increase in multidrug-resistant organisms (MDROs), including extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae, carbapenem-resistant New Delhi metallo-β-lactamase (NDM)-producing Enterobacterales, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA), pan-echinocandin-resistant Candida glabrata and multi-triazole-resistant Aspergillus fumigatus. The cause is multifactorial and is particularly related to high rates of antimicrobial agent utilisation in COVID-19 patients with a relatively low rate of co- or secondary infection. Appropriate prescription and optimised use of antimicrobials according to the principles of antimicrobial stewardship as well as quality diagnosis and aggressive infection control measures may help prevent the occurrence of MDROs during this pandemic.
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Gilbert DN. Neglected Variables in the Interpretation of Serum Procalcitonin Levels in Patients With Septic Shock. J Infect Dis 2021; 222:S96-S102. [PMID: 32691829 DOI: 10.1093/infdis/jiaa204] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The interpretation of serum procalcitonin (PCT) levels in septic patients is facilitated by reviewing the known stimuli that activate the PCT family of genes. Herein we describe 7 pathways that, alone or in combination, can increase serum PCT levels. As a marker of activation of innate immunity, high PCT levels affect clinical diagnosis, can be trended as a measure of "source" control, and can guide duration of antibacterial therapy in septic patients. Low PCT levels reflect little to no activation of an innate immune response, influence the differential diagnosis, and support the discontinuation of empiric antibiotic therapy. Understanding the pathways that result in elevated serum PCT levels is necessary for interpretation and subsequent clinical management.
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Affiliation(s)
- David N Gilbert
- Department of Medical Education, Providence Portland Medical Center and Oregon Health & Sciences University, Portland, Oregon
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35
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Daubin C, Fournel F, Thiollière F, Daviaud F, Ramakers M, Polito A, Flocard B, Valette X, Du Cheyron D, Terzi N, Fartoukh M, Allouche S, Parienti JJ. Ability of procalcitonin to distinguish between bacterial and nonbacterial infection in severe acute exacerbation of chronic obstructive pulmonary syndrome in the ICU. Ann Intensive Care 2021; 11:39. [PMID: 33675432 PMCID: PMC7936235 DOI: 10.1186/s13613-021-00816-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/27/2021] [Indexed: 12/23/2022] Open
Abstract
Background To assess the ability of procalcitonin (PCT) to distinguish between bacterial and nonbacterial causes of patients with severe acute exacerbation of COPD (AECOPD) admitted to the ICU, we conducted a retrospective analysis of two prospective studies including 375 patients with severe AECOPD with suspected lower respiratory tract infections. PCT levels were sequentially assessed at the time of inclusion, 6 h after and at day 1, using a sensitive immunoassay. The patients were classified according to the presence of a documented bacterial infection (including bacterial and viral coinfection) (BAC + group), or the absence of a documented bacterial infection (i.e., a documented viral infection alone or absence of a documented pathogen) (BAC- group). The accuracy of PCT levels in predicting bacterial infection (BAC + group) vs no bacterial infection (BAC- group) at different time points was evaluated by receiver operating characteristic (ROC) analysis. Results Regarding the entire cohort (n = 375), at any time, the PCT levels significantly differed between groups (Kruskal–Wallis test, p < 0.001). A pairwise comparison showed that PCT levels were significantly higher in patients with bacterial infection (n = 94) than in patients without documented pathogens (n = 218) (p < 0.001). No significant difference was observed between patients with bacterial and viral infection (n = 63). For example, the median PCT-H0 levels were 0.64 ng/ml [0.22–0.87] in the bacterial group vs 0.24 ng/ml [0.15–0.37] in the viral group and 0.16 ng/mL [0.11–0.22] in the group without documented pathogens. With a c-index of 0.64 (95% CI; 0.58–0.71) at H0, 0.64 [95% CI 0.57–0.70] at H6 and 0.63 (95% CI; 0.56–0.69) at H24, PCT had a low accuracy for predicting bacterial infection (BAC + group). Conclusion Despite higher PCT levels in severe AECOPD caused by bacterial infection, PCT had a poor accuracy to distinguish between bacterial and nonbacterial infection. Procalcitonin might not be sufficient as a standalone marker for initiating antibiotic treatment in this setting.
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Affiliation(s)
- Cédric Daubin
- Department of Medical Intensive Care, CHU de Caen, 14000, Caen, France.
| | - François Fournel
- Department of Biostatistics and Clinical Research, CHU de Caen, 14000, Caen, France
| | - Fabrice Thiollière
- Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, Hospices Civils de Lyon, France
| | - Fabrice Daviaud
- Department of Medial Intensive Care, Cochin University Hospital, Paris, France
| | - Michel Ramakers
- Department of Intensive Care Medicine, General Hospital, Saint Lô, France
| | - Andréa Polito
- Service de Médecine Intensive Et Réanimation, General Intensive Care Unit, Hôpital Raymond Poincaré (APHP), Raymond Poincaré Hospital, Garches, France.,Laboratoire Infection & Inflammation, U1173 Université de Versailles SQY-Paris Saclay - INSERM, Garches, France
| | - Bernard Flocard
- Department of Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Xavier Valette
- Department of Medical Intensive Care, CHU de Caen, 14000, Caen, France
| | - Damien Du Cheyron
- Department of Medical Intensive Care, CHU de Caen, 14000, Caen, France
| | - Nicolas Terzi
- Department of Medical Intensive Care, CHU de Grenoble Alpes, 38000, Grenoble, France.,INSERM, U1042, University of Grenoble-Alpes, HP2, 38000, Grenoble, France
| | - Muriel Fartoukh
- Service de Medecine Intensive Reanimation, AP-HP, Sorbonne université, Hôpital Tenon, Groupe de Recherche Clinique CARMAS, collegium Gallilée, Paris, France
| | - Stephane Allouche
- Universite Caen Normandie, Medical School, EA 4650, Signalisation, Electrophysiologie et Imagerie des lésions d'Ischemie-reperfusion Myocardique, 14000, Caen, France
| | - Jean-Jacques Parienti
- Department of Biostatistics and Clinical Research, CHU de Caen, 14000, Caen, France.,EA2656 Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Université Caen Normandie, Caen, France
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Heffernan AJ, Denny KJ. Host Diagnostic Biomarkers of Infection in the ICU: Where Are We and Where Are We Going? Curr Infect Dis Rep 2021; 23:4. [PMID: 33613126 DOI: 10.1007/s11908-021-00747-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 02/06/2023]
Abstract
Purpose of Review Early identification of infection in the critically ill patient and initiation of appropriate treatment is key to reducing morbidity and mortality. On the other hand, the indiscriminate use of antimicrobials leads to harms, many of which may be exaggerated in the critically ill population. The current method of diagnosing infection in the intensive care unit relies heavily on clinical gestalt; however, this approach is plagued by biases. Therefore, a reliable, independent biomarker holds promise in the accurate determination of infection. We discuss currently used host biomarkers used in the intensive care unit and review new and emerging approaches to biomarker discovery. Recent Findings White cell count (including total white cell count, left shift, and the neutrophil-leucocyte ratio), C-reactive protein, and procalcitonin are the most common host diagnostic biomarkers for sepsis used in current clinical practice. However, their utility in the initial diagnosis of infection, and their role in the subsequent decision to commence treatment, remains limited. Novel approaches to biomarker discovery that are currently being investigated include combination biomarkers, host 'sepsis signatures' based on differential gene expression, site-specific biomarkers, biomechanical assays, and incorporation of new and pre-existing host biomarkers into machine learning algorithms. Summary To date, no single reliable independent biomarker of infection exists. Whilst new approaches to biomarker discovery hold promise, their clinical utility may be limited if previous mistakes that have afflicted sepsis biomarker research continue to be repeated.
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Affiliation(s)
- Aaron J Heffernan
- School of Medicine, Griffith University, Gold Coast, QLD Australia
- Centre for Translational Anti-infective Pharmacodynamics, Faculty of Medicine, University of Queensland, Herston, QLD Australia
| | - Kerina J Denny
- Department of Intensive Care, Gold Coast University Hospital, Gold Coast, QLD Australia
- School of Clinical Medicine, Faculty of Medicine, University of Queensland, Herston, QLD Australia
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Jones B, Waterer G. Advances in community-acquired pneumonia. Ther Adv Infect Dis 2020; 7:2049936120969607. [PMID: 33224494 PMCID: PMC7656869 DOI: 10.1177/2049936120969607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/07/2020] [Indexed: 12/24/2022] Open
Abstract
Community-acquired pneumonia is one of the commonest and deadliest of the infectious diseases, yet our understanding of it remains relatively poor. The recently published American Thoracic Society and Infectious Diseases Society of America Community-acquired pneumonia guidelines acknowledged that most of what we accept as standard of care is supported only by low quality evidence, highlighting persistent uncertainty and deficiencies in our knowledge. However, progress in diagnostics, translational research, and epidemiology has changed our concept of pneumonia, contributing to a gradual improvement in prevention, diagnosis, treatment, and outcomes for our patients. The emergence of considerable evidence about adverse long-term health outcomes in pneumonia survivors has also challenged our concept of pneumonia as an acute disease and what treatment end points are important. This review focuses on advances in the research and care of community-acquired pneumonia in the past two decades. We summarize the evidence around our understanding of pathogenesis and diagnosis, discuss key contentious management issues including the role of procalcitonin and the use or non-use of corticosteroids, and explore the relationships between pneumonia and long-term outcomes including cardiovascular and cognitive health.
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Affiliation(s)
- Barbara Jones
- Division of Pulmonary and Critical Care, University of Utah and Salt Lake City VA Healthcare System, Salt Lake City, UT, USA
| | - Grant Waterer
- University of Western Australia, Royal Perth Hospital, Perth, WA 6009, Australia
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Azar MM, Shin JJ, Kang I, Landry M. Diagnosis of SARS-CoV-2 infection in the setting of the cytokine release syndrome. Expert Rev Mol Diagn 2020; 20:1087-1097. [PMID: 32990479 DOI: 10.1080/14737159.2020.1830760] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Coronavirus disease (COVID-19) can trigger a cytokine response storm (CRS) that is associated with high mortality but for which the underlying pathophysiology and diagnostics are not yet well characterized. This review provides an overview of the underlying immune profile of COVID-19-related CRS as well as laboratory markers for acute diagnosis and chronic follow-up of patients with SARS-CoV-2 and CRS. AREAS COVERED Innate and acquired immune profiles in COVID-19-CRS, RNA-detection methods for SARS-CoV-2 in the setting of CRS including factors that affect assay performance, serology for SARS-CoV-2 in the setting of CRS, and other biomarkers for COVID-19 will be discussed. EXPERT OPINION Studies support the implication of CRS in the pathogenesis, clinical severity and outcome of COVID-19 through the production of multiple inflammatory cytokines and chemokines from activated innate and adaptive immune cells. Although these inflammatory molecules, including IL-6, IL-2 R, IL-10, IP-10 and MCP-1, often correlate with disease severity as possible biomarkers, the pathogenic contributions of individual molecules and the therapeutic benefits of targeting them are yet to be demonstrated. Detection of SARS-CoV-2 RNA is the gold standard method for diagnosis of COVID-19 in the context of CRS but assay performance varies and is susceptible to false-negative results even as patients clinically deteriorate due to decreased viral shedding in the setting of CRS. Biomarkers including CRP, ferritin, D-dimer and procalcitonin may provide early clues about progression to CRS and help identify thrombotic and infectious complications of COVID-19.
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Affiliation(s)
- Marwan M Azar
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine , New Haven, CT, USA
| | - Junghee J Shin
- Department of Internal Medicine, Section of Rheumatology, Allergy & Immunology, Yale School of Medicine , New Haven, CT, USA
| | - Insoo Kang
- Department of Internal Medicine, Section of Rheumatology, Allergy & Immunology, Yale School of Medicine , New Haven, CT, USA
| | - Marie Landry
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine , New Haven, CT, USA.,Department of Laboratory Medicine, Yale School of Medicine , New Haven, CT, USA
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Gautam S, Cohen AJ, Stahl Y, Valda Toro P, Young GM, Datta R, Yan X, Ristic NT, Bermejo SD, Sharma L, Restrepo MI, Dela Cruz CS. Severe respiratory viral infection induces procalcitonin in the absence of bacterial pneumonia. Thorax 2020; 75:974-981. [PMID: 32826284 DOI: 10.1136/thoraxjnl-2020-214896] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Procalcitonin expression is thought to be stimulated by bacteria and suppressed by viruses via interferon signalling. Consequently, during respiratory viral illness, clinicians often interpret elevated procalcitonin as evidence of bacterial coinfection, prompting antibiotic administration. We sought to evaluate the validity of this practice and the underlying assumption that viral infection inhibits procalcitonin synthesis. METHODS We conducted a retrospective cohort study of patients hospitalised with pure viral infection (n=2075) versus bacterial coinfection (n=179). The ability of procalcitonin to distinguish these groups was assessed. In addition, procalcitonin and interferon gene expression were evaluated in murine and cellular models of influenza infection. RESULTS Patients with bacterial coinfection had higher procalcitonin than those with pure viral infection, but also more severe disease and higher mortality (p<0.001). After matching for severity, the specificity of procalcitonin for bacterial coinfection dropped substantially, from 72% to 61%. In fact, receiver operating characteristic curve analysis showed that procalcitonin was a better indicator of multiple indices of severity (eg, organ failures and mortality) than of coinfection. Accordingly, patients with severe viral infection had elevated procalcitonin. In murine and cellular models of influenza infection, procalcitonin was also elevated despite bacteriologic sterility and correlated with markers of severity. Interferon signalling did not abrogate procalcitonin synthesis. DISCUSSION These studies reveal that procalcitonin rises during pure viral infection in proportion to disease severity and is not suppressed by interferon signalling, in contrast to prior models of procalcitonin regulation. Applied clinically, our data suggest that procalcitonin represents a better indicator of disease severity than bacterial coinfection during viral respiratory infection.
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Affiliation(s)
- Samir Gautam
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Avi J Cohen
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Yannick Stahl
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Patricia Valda Toro
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Grant M Young
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rupak Datta
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xiting Yan
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nicholas T Ristic
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Santos D Bermejo
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lokesh Sharma
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marcos I Restrepo
- Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health, San Antonio, Texas, USA.,Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Charles S Dela Cruz
- Section of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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40
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[Procalcitonin in the intensive care unit : Differential diagnostic and differential therapeutic possibilities]. Med Klin Intensivmed Notfmed 2020; 116:561-569. [PMID: 32601786 PMCID: PMC7323366 DOI: 10.1007/s00063-020-00703-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 02/05/2023]
Abstract
Prokalzitonin (PCT) wird bei systemischen Inflammationszuständen IL6-, IL8- und TNF-α-vermittelt in multiplen Organen und Strukturen des Körpers gebildet. Dabei werden insbesondere bei der Sepsis deutlich erhöhte Werte gemessen. Die Höhe des PCT korreliert dabei gut mit der Krankheitsschwere, ein signifikanter Abfall unter Therapie mit der Prognose. In der differenzialdiagnostischen Abklärung kann die PCT-Bestimmung zwischen bakteriellen und viralen Infektionen unterscheiden. Nichtinfektiösbedingte inflammatorische Reaktionen können jedoch moderat erhöhte PCT-Werte zeigen. Cut-off-Werte sind abhängig von der renalen und hepatischen Funktion. Ein Therapiealgorithmus zur Antibiotikadauer mit PCT-Verlaufsbestimmungen kann den Antibiotikagebrauch reduzieren. In dieser Arbeit sollen die differenzialdiagnostischen und differenzialtherapeutischen Möglichkeiten einer Prokalzitoninbestimmung bei kritisch kranken Patienten erörtert werden.
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2020; 200:e45-e67. [PMID: 31573350 PMCID: PMC6812437 DOI: 10.1164/rccm.201908-1581st] [Citation(s) in RCA: 1789] [Impact Index Per Article: 447.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
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MESH Headings
- Adult
- Ambulatory Care
- Anti-Bacterial Agents/therapeutic use
- Antigens, Bacterial/urine
- Blood Culture
- Chlamydophila Infections/diagnosis
- Chlamydophila Infections/drug therapy
- Chlamydophila Infections/metabolism
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Culture Techniques
- Drug Therapy, Combination
- Haemophilus Infections/diagnosis
- Haemophilus Infections/drug therapy
- Haemophilus Infections/metabolism
- Hospitalization
- Humans
- Legionellosis/diagnosis
- Legionellosis/drug therapy
- Legionellosis/metabolism
- Macrolides/therapeutic use
- Moraxellaceae Infections/diagnosis
- Moraxellaceae Infections/drug therapy
- Moraxellaceae Infections/metabolism
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/metabolism
- Pneumonia, Pneumococcal/diagnosis
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/metabolism
- Pneumonia, Staphylococcal/diagnosis
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/metabolism
- Radiography, Thoracic
- Severity of Illness Index
- Sputum
- United States
- beta-Lactams/therapeutic use
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42
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Bourgoin P, Lediagon G, Arnoux I, Bernot D, Morange PE, Michelet P, Malergue F, Markarian T. Flow cytometry evaluation of infection-related biomarkers in febrile subjects in the emergency department. Future Microbiol 2020; 15:189-201. [PMID: 32065550 DOI: 10.2217/fmb-2019-0256] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: In an Emergency Department (ED), the etiological identification of infected subjects is essential. 13 infection-related biomarkers were assessed using a new flow cytometry procedure. Materials & methods: If subjects presented with febrile symptoms at the ED, 13 biomarkers' levels, including CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), were tested and compared with clinical records. Results: Among 50 subjects, 78% had bacterial infections and 8% had viral infections. nCD64 showed 82% sensitivity and 91% specificity for identifying subjects with bacterial infections. mCD169, HLA-ABC ratio and HLA-DR on monocytes had high values in subjects with viral infections. Conclusion: Biomarkers showed promising performances to improve the ED's infectious stratification.
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Affiliation(s)
- Pénélope Bourgoin
- Department of Research & Development, Beckman Coulter Life Sciences-Immunotech, 130 Avenue de Lattre de Tassigny, 13009 Marseille, France.,C2VN INSERM-INRA, Aix-Marseille University, 27 Boulevard Jean Moulin, 13385 Marseille, France
| | - Guillaume Lediagon
- Adult Emergency Unit, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Isabelle Arnoux
- Hematology Laboratory, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Denis Bernot
- Hematology Laboratory, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Pierre-Emmanuel Morange
- C2VN INSERM-INRA, Aix-Marseille University, 27 Boulevard Jean Moulin, 13385 Marseille, France.,Hematology Laboratory, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Pierre Michelet
- Adult Emergency Unit, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Fabrice Malergue
- Department of Research & Development, Beckman Coulter Life Sciences-Immunotech, 130 Avenue de Lattre de Tassigny, 13009 Marseille, France
| | - Thibaut Markarian
- Adult Emergency Unit, La Timone Hospital, APHM, 264 Rue Saint Pierre, 13385 Marseille, France
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Using the kinetics of C-reactive protein response to improve the differential diagnosis between acute bacterial and viral infections. Infection 2019; 48:241-248. [PMID: 31873850 DOI: 10.1007/s15010-019-01383-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/13/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Differential diagnosis between acute viral and bacterial infection is an emerging common challenge for a physician in the emergency department. Serum C-reactive protein (CRP) is used to support diagnosis of bacterial infection, but in patients admitted with low CRP, its ability to discriminate between viral and bacterial infections is limited. We aimed to use two consecutive CRP measurements in order to improve differential diagnosis between bacterial and viral infection. METHODS A single-center retrospective cohort (n = 1629) study of adult patients admitted to the emergency department with a subsequent microbiological confirmation of either viral or bacterial infection. Trend of CRP was defined as the absolute difference between the first two measurements of CRP divided by the time between them, and we investigated the ability of this parameter to differentiate between viral and bacterial infection. RESULTS In patients with relatively low initial CRP concentration (< 60 mg/L, n = 634 patients), where the uncertainty regarding the type of infection is the highest, the trend improved diagnosis accuracy (AUC 0.83 compared to 0.57 for the first CRP measurement). Trend values above 3.47 mg/L/h discriminated bacterial from viral infection with 93.8% specificity and 50% sensitivity. CONCLUSIONS The proposed approach for using the kinetics of CRP in patients whose first CRP measurement is low can assist in differential diagnosis between acute bacterial and viral infection.
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Bourgoin P, Soliveres T, Ahriz D, Arnoux I, Meisel C, Unterwalder N, Morange PE, Michelet P, Malergue F, Markarian T. Clinical research assessment by flow cytometry of biomarkers for infectious stratification in an Emergency Department. Biomark Med 2019; 13:1373-1386. [PMID: 31617736 DOI: 10.2217/bmm-2019-0214] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aim: Management of patients with infections within the Emergency Department (ED) is challenging for practitioners, as the identification of infectious causes remains difficult with current techniques. A new combination of two biomarkers was tested with a new rapid flow cytometry technique. Materials & methods: Subjects from the ED were tested for their CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169) levels and results were compared to their clinical records. Results: Among 139 patients, 29% had confirmed bacterial infections and 5% viral infections. nCD64 and mCD169 respectively showed 88 and 86% sensitivity and 90 and 100% specificity for identifying subjects in bacterial or viral conditions. Conclusion: This point-of-care technique could allow better management of patients in the ED.
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Affiliation(s)
- Pénélope Bourgoin
- Department of Research & Development, Beckman Coulter Life Sciences-Immunotech, 130 Avenue de Lattre de Tassigny, 13009 Marseille, France.,C2VN Department, INSERM-INRA, Aix-Marseille University, 27 Boulevard Jean Moulin, 13385 Marseille, France
| | - Thomas Soliveres
- Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Dalia Ahriz
- Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Isabelle Arnoux
- Hematology Laboratory Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Christian Meisel
- Department of Medical Immunology, Charité - University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.,Department of Immunology, Labor Berlin - Charité Vivantes GmbH, Sylter Strasse 2, 13353 Berlin, Germany
| | - Nadine Unterwalder
- Department of Immunology, Labor Berlin - Charité Vivantes GmbH, Sylter Strasse 2, 13353 Berlin, Germany
| | - Pierre-Emmanuel Morange
- C2VN Department, INSERM-INRA, Aix-Marseille University, 27 Boulevard Jean Moulin, 13385 Marseille, France.,Hematology Laboratory Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Pierre Michelet
- Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
| | - Fabrice Malergue
- Department of Research & Development, Beckman Coulter Life Sciences-Immunotech, 130 Avenue de Lattre de Tassigny, 13009 Marseille, France
| | - Thibaut Markarian
- Adult Emergency Department, La Timone Hospital, 264 Rue Saint Pierre, 13385 Marseille, France
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Severiche-Bueno D, Parra-Tanoux D, Reyes LF, Waterer GW. Hot topics and current controversies in community-acquired pneumonia. Breathe (Sheff) 2019; 15:216-225. [PMID: 31508159 PMCID: PMC6717612 DOI: 10.1183/20734735.0205-2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Community-acquired pneumonia (CAP) is one of the most common infectious diseases, as well as a major cause of death both in developed and developing countries, and it remains a challenge for physicians around the world. Several guidelines have been published to guide clinicians in how to diagnose and take care of patients with CAP. However, there are still many areas of debate and uncertainty where research is needed to advance patient care and improve clinical outcomes. In this review we highlight current hot topics in CAP and present updated evidence around these areas of controversy. Community-acquired pneumonia is the most frequent cause of infectious death worldwide; however, there are several areas of controversy that should be addressed to improve patient care. This review presents the available data on these topics.http://bit.ly/2ShnH7A
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Affiliation(s)
- Diego Severiche-Bueno
- Infectious Diseases and Critical Care Depts, Universidad de La Sabana, Chía, Colombia
| | - Daniela Parra-Tanoux
- Infectious Diseases and Critical Care Depts, Universidad de La Sabana, Chía, Colombia
| | - Luis F Reyes
- Infectious Diseases and Critical Care Depts, Universidad de La Sabana, Chía, Colombia
| | - Grant W Waterer
- Royal Perth Bentley Hospital Group, University of Western Australia, Perth, Australia
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Waterer G, Chalmers J. The Elusive Hunt for a Reliable Biomarker in Community-acquired Pneumonia. Are We Searching for Something That Can't Exist? Am J Respir Crit Care Med 2019; 198:300-302. [PMID: 29558164 DOI: 10.1164/rccm.201803-0462ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Grant Waterer
- 1 University of Western Australia Perth, Australia.,2 Northwestern University Chicago, Illinois
| | - James Chalmers
- 3 University of Dundee Dundee, United Kingdom and.,4 Ninewells Hospital Dundee, United Kingdom
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Ni W, Bao J, Yang D, Xi W, Wang K, Xu Y, Zhang R, Gao Z. Potential of serum procalcitonin in predicting bacterial exacerbation and guiding antibiotic administration in severe COPD exacerbations: a systematic review and meta-analysis. Infect Dis (Lond) 2019; 51:639-650. [PMID: 31355690 DOI: 10.1080/23744235.2019.1644456] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The value of procalcitonin (PCT) in the diagnosis of bacterial infections and for determining antibiotic usage among patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is currently unclear. Methods: We systematically reviewed the literature and selected studies that evaluated PCT as a biomarker for predicting bacterial infection and compared PCT-based protocols to determine its application in the initiation or discontinuation of antibiotics. Guidance for systematic reviews from Cochrane and the GRADE were followed to perform this study. Data were pooled and analyzed by using a random-effects or a fixed-effects model based on the heterogeneity. Results: The pooled sensitivity and specificity of PCT in diagnosing respiratory bacterial infections were 0.60 and 0.76, respectively, with the area under the summary receiver operating characteristic curve of 0.77. Subgroup analysis showed that the sensitivity and specificity of PCT for patients in ICU were 0.48 and 0.69, respectively. PCT-based protocols decreased antibiotic prescription (relative risk = 0.66, 95% CI: 0.62-0.71) and total antibiotic exposure (mean difference = -2.60, 95% CI: -4.48-0.72), without affecting clinical outcomes such as treatment failure, length of hospitalization and rates of re-exacerbation or overall mortality. Conclusions: PCT has a moderate ability to distinguish bacterial respiratory infection in patients with AECOPD. PCT-guided algorithm can reduce unnecessary administration of antibiotics without increasing adverse outcomes. However, for patients requiring admission in the ICU, PCT may have a poor diagnostic value, and the PCT-guided algorithm may not effectively and safely reduce the antibiotic exposure.
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Affiliation(s)
- Wentao Ni
- a Department of Respiratory and Critical Care Medicine, Peking University People's Hospital , Beijing , China
| | - Jing Bao
- a Department of Respiratory and Critical Care Medicine, Peking University People's Hospital , Beijing , China
| | - Donghong Yang
- a Department of Respiratory and Critical Care Medicine, Peking University People's Hospital , Beijing , China
| | - Wen Xi
- a Department of Respiratory and Critical Care Medicine, Peking University People's Hospital , Beijing , China
| | - Keqiang Wang
- a Department of Respiratory and Critical Care Medicine, Peking University People's Hospital , Beijing , China
| | - Yu Xu
- a Department of Respiratory and Critical Care Medicine, Peking University People's Hospital , Beijing , China
| | - Rongbao Zhang
- a Department of Respiratory and Critical Care Medicine, Peking University People's Hospital , Beijing , China
| | - Zhancheng Gao
- a Department of Respiratory and Critical Care Medicine, Peking University People's Hospital , Beijing , China
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48
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Su'a B, Tutone S, MacFater W, Barazanchi A, Xia W, Zeng I, Hill AG. Diagnostic accuracy of procalcitonin for the early diagnosis of anastomotic leakage after colorectal surgery: a meta‐analysis. ANZ J Surg 2019; 90:675-680. [DOI: 10.1111/ans.15291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/06/2019] [Accepted: 04/11/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Bruce Su'a
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Senitila Tutone
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Wiremu MacFater
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Ahmed Barazanchi
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Weisi Xia
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
| | - Irene Zeng
- Department of SurgeryThe University of Auckland Auckland New Zealand
| | - Andrew G. Hill
- Department of SurgerySouth Auckland Clinical Campus, Middlemore Hospital, The University of Auckland Auckland New Zealand
- Department of General SurgeryMiddlemore Hospital, Counties‐Manukau District Health Board Auckland New Zealand
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Abstract
Pneumonia is a highly prevalent disease with considerable morbidity and mortality. However, diagnosis and therapy still rely on antiquated methods, leading to the vast overuse of antimicrobials, which carries risks for both society and the individual. Furthermore, outcomes in severe pneumonia remain poor. Genomic techniques have the potential to transform the management of pneumonia through deep characterization of pathogens as well as the host response to infection. This characterization will enable the delivery of selective antimicrobials and immunomodulatory therapy that will help to offset the disorder associated with overexuberant immune responses.
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Affiliation(s)
- Samir Gautam
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA
| | - Lokesh Sharma
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA
| | - Charles S Dela Cruz
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA.
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50
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Outcome prediction using the Mortality in Emergency Department Sepsis score combined with procalcitonin for influenza patients. Med Clin (Barc) 2019; 153:411-417. [PMID: 31174861 DOI: 10.1016/j.medcli.2019.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 02/19/2019] [Accepted: 03/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Severe influenza is often associated with bacterial coinfection and can trigger sepsis, which increases the severity, complexity and mortality of the disease. To determine an effective method for predicting 28-day mortality of emergency department (ED) patients with influenza, we investigated the Mortality in Emergency Department Sepsis (MEDS) score, procalcitonin (PCT) and other relevant biomarkers. METHODS We conducted a retrospective, observational, monocentric study, and the endpoint was 28-day mortality. Independent predictors were identified and a new combination predictive model was created both by logistic regression, and the model was evaluated by a receiver operating characteristic (ROC) curve. RESULTS A total of 364 consecutive ED admitted patients with influenza were enrolled and 45 patients died within 28 days. For predicting 28-day mortality, the MEDS score and PCT were independent predictors with adjusted odds ratio of 1.318 (95% CI 1.206-1.439) and 1.038 (95% CI 1.010-1.065), and with AUCs of 0.817 (95% CI 0.756-0.878) and 0.793 (95% CI 0.725-0.861), respectively. The new combination of the MEDS score with PCT significantly improved the efficacy for predicting 28-day mortality with an AUC of 0.857 (95% CI 0.809-0.905), and was superior to the SOFA score with an AUC of 0.837 (95% CI 0.779-0.894). CONCLUSION The MEDS score and PCT, especially when combined, perform well for predicting mortality of ED admitted patients with influenza.
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