1
|
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.
Collapse
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
| |
Collapse
|
2
|
Effah CY, Miao R, Drokow EK, Agboyibor C, Qiao R, Wu Y, Miao L, Wang Y. Machine learning-assisted prediction of pneumonia based on non-invasive measures. Front Public Health 2022; 10:938801. [PMID: 35968461 PMCID: PMC9371749 DOI: 10.3389/fpubh.2022.938801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Pneumonia is an infection of the lungs that is characterized by high morbidity and mortality. The use of machine learning systems to detect respiratory diseases via non-invasive measures such as physical and laboratory parameters is gaining momentum and has been proposed to decrease diagnostic uncertainty associated with bacterial pneumonia. Herein, this study conducted several experiments using eight machine learning models to predict pneumonia based on biomarkers, laboratory parameters, and physical features. Methods We perform machine-learning analysis on 535 different patients, each with 45 features. Data normalization to rescale all real-valued features was performed. Since it is a binary problem, we categorized each patient into one class at a time. We designed three experiments to evaluate the models: (1) feature selection techniques to select appropriate features for the models, (2) experiments on the imbalanced original dataset, and (3) experiments on the SMOTE data. We then compared eight machine learning models to evaluate their effectiveness in predicting pneumonia Results Biomarkers such as C-reactive protein and procalcitonin demonstrated the most significant discriminating power. Ensemble machine learning models such as RF (accuracy = 92.0%, precision = 91.3%, recall = 96.0%, f1-Score = 93.6%) and XGBoost (accuracy = 90.8%, precision = 92.6%, recall = 92.3%, f1-score = 92.4%) achieved the highest performance accuracy on the original dataset with AUCs of 0.96 and 0.97, respectively. On the SMOTE dataset, RF and XGBoost achieved the highest prediction results with f1-scores of 92.0 and 91.2%, respectively. Also, AUC of 0.97 was achieved for both RF and XGBoost models. Conclusions Our models showed that in the diagnosis of pneumonia, individual clinical history, laboratory indicators, and symptoms do not have adequate discriminatory power. We can also conclude that the ensemble ML models performed better in this study.
Collapse
Affiliation(s)
| | - Ruoqi Miao
- College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Emmanuel Kwateng Drokow
- Department of Radiation Oncology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Clement Agboyibor
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Ruiping Qiao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongjun Wu
- College of Public Health, Zhengzhou University, Zhengzhou, China
- *Correspondence: Yongjun Wu
| | - Lijun Miao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Lijun Miao
| | - Yanbin Wang
- Center of Health Management, General Hospital of Anyang Iron and Steel Group Co., Ltd, Anyang, China
- Yanbin Wang
| |
Collapse
|
3
|
Frequency and Types of Healthcare Encounters in the Week Preceding a Sepsis Hospitalization: A Systematic Review. Crit Care Explor 2022; 4:e0635. [PMID: 35141526 PMCID: PMC8820912 DOI: 10.1097/cce.0000000000000635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES: Early recognition and treatment are critical to improving sepsis outcomes. We sought to identify the frequency and types of encounters that patients have with the healthcare system in the week prior to a sepsis hospitalization. DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, and the Cochrane Library. STUDY SELECTION: Observational cohort studies of patients hospitalized with sepsis or septic shock that were assessed for an outpatient or emergency department encounter with the healthcare system in the week prior to hospital admission. DATA EXTRACTION: The primary outcome was the proportion of patients with a healthcare encounter in the time period assessed (up to 1 week) prior to a hospitalization with sepsis. DATA SYNTHESIS: Six retrospective observational studies encompassing 6,785,728 sepsis admissions were included for evaluation, ranging from a 263-patient single-center cohort to a large database evaluating 6,731,827 sepsis admissions. The average (unweighted) proportion of patients having an encounter with the healthcare system in the week prior to a sepsis hospitalization was 32.7% and ranged from 10.3% to 52.9%. These encounters commonly involved presentation or potential symptoms of infectious diseases, antibiotic prescriptions, and appeared to increase in frequency closer to a sepsis hospitalization admission. No consistent factors were identified that distinguished a healthcare encounter as more or less likely to precede a sepsis hospitalization in the subsequent week. CONCLUSIONS: Patients that present to the hospital with sepsis are frequently evaluated in the healthcare system in the week prior to admission. Further research is necessary to understand if these encounters offer earlier opportunities for intervention to prevent the transition from infection to sepsis, whether they merely reflect the comorbidities of sepsis patients with a high baseline rate of healthcare encounters, or the declining trajectory of a patient’s overall health in response to infection.
Collapse
|
4
|
Gentilotti E, De Nardo P, Cremonini E, Górska A, Mazzaferri F, Canziani LM, Hellou MM, Olchowski Y, Poran I, Leeflang M, Villacian J, Goossens H, Paul M, Tacconelli E. Diagnostic accuracy of point-of-care tests in acute community-acquired lower respiratory tract infections. A systematic review and meta-analysis. Clin Microbiol Infect 2021; 28:13-22. [PMID: 34601148 DOI: 10.1016/j.cmi.2021.09.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Point-of-care tests could be essential in differentiating bacterial and viral acute community-acquired lower respiratory tract infections and driving antibiotic stewardship in the community. OBJECTIVES To assess diagnostic test accuracy of point-of-care tests in community settings for acute community-acquired lower respiratory tract infections. DATA SOURCES Multiple databases (MEDLINE, EMBASE, Web of Science, Cochrane Library, Open Gray) from inception to 31 May 2021, without language restrictions. STUDY ELIGIBILITY CRITERIA Diagnostic test accuracy studies involving patients at primary care, outpatient clinic, emergency department and long-term care facilities with a clinical suspicion of acute community-acquired lower respiratory tract infections. The comparator was any test used as a comparison to the index test. In order not to limit the study inclusion, the comparator was not defined a priori. ASSESSMENT OF RISK OF BIAS Four investigators independently extracted data, rated risk of bias, and assessed the quality using QUADAS-2. METHODS OF DATA SYNTHESIS The measures of diagnostic test accuracy were calculated with 95% CI. RESULTS A total of 421 studies addressed at least one point-of-care test. The diagnostic performance of molecular tests was higher compared with that of rapid diagnostic tests for all the pathogens studied. The accuracy of stand-alone signs and symptoms or biomarkers was poor. Lung ultrasound showed high sensitivity and specificity (90% for both) for the diagnosis of bacterial pneumonia. Rapid antigen-based diagnostic tests for influenza, respiratory syncytial virus, human metapneumovirus, and Streptococcus pneumoniae had sub-optimal sensitivity (range 49%-84%) but high specificity (>80%). DISCUSSION Physical examination and host biomarkers are not sufficiently reliable as stand-alone tests to differentiate between bacterial and viral pneumonia. Lung ultrasound shows higher accuracy than chest X-ray for bacterial pneumonia at emergency department. Rapid antigen-based diagnostic tests cannot be considered fully reliable because of high false-negative rates. Overall, molecular tests for all the pathogens considered were found to be the most accurate.
Collapse
Affiliation(s)
- Elisa Gentilotti
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Pasquale De Nardo
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Eleonora Cremonini
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Anna Górska
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Fulvia Mazzaferri
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Lorenzo Maria Canziani
- Department of Biomedical Sciences, Humanitas University, Rozzano, Italy; Department of Internal Medicine, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | | | - Yudith Olchowski
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Itamar Poran
- Medicine E, Rabin Medical Centre, Beilinson Hospital, Petah-Tikva, Israel
| | - Mariska Leeflang
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, Netherlands
| | | | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine and Infectious Diseases Institute, University of Antwerp, Antwerp, Belgium
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy.
| |
Collapse
|
5
|
Zhou Q, MacArthur MR, He X, Wei X, Zarin P, Hanna BS, Wang ZH, Xiang X, Fish EN. Interferon-α2b Treatment for COVID-19 Is Associated with Improvements in Lung Abnormalities. Viruses 2020; 13:v13010044. [PMID: 33396578 PMCID: PMC7824252 DOI: 10.3390/v13010044] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 12/28/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes coronavirus disease 2019 (COVID-19), a lung disease that may progress to systemic organ involvement and in some cases, death. The identification of the earliest predictors of progressive lung disease would allow for therapeutic intervention in those cases. In an earlier clinical study, individuals with moderate COVID-19 were treated with either arbidol (ARB) or inhaled interferon (IFN)-α2b +/−ARB. IFN treatment resulted in accelerated viral clearance from the upper airways and in a reduction in the circulating levels of the inflammatory biomarkers IL-6 and C-reactive protein (CRP). We have extended the analysis of this study cohort to determine whether IFN treatment had a direct effect on virus-induced lung abnormalities and also to ascertain whether any clinical or immune parameters are associated with worsening of lung abnormalities. Evidence is provided that IFN-α2b treatment limits the development of lung abnormalities associated with COVID-19, as assessed by CT images. Clinical predictors associated with worsening of lung abnormalities include low CD8+ T cell numbers, low levels of circulating albumin, high numbers of platelets, and higher levels of circulating interleukin (IL)-10, IL-6, and C-reactive protein (CRP). Notably, in this study cohort, IFN treatment resulted in a higher percentage of CD8+ T cells, lower tumor necrosis factor (TNF)-α levels and, as reported earlier, lower IL-6 levels. Independent of treatment, age and circulating levels of albumin and CRP emerged as the strongest predictors of the severity of lung abnormalities.
Collapse
Affiliation(s)
- Qiong Zhou
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (Q.Z.); (X.H.); (X.W.); (Z.-H.W.); (X.X.)
| | - Michael R. MacArthur
- Department of Health Sciences & Technology, ETH Zurich, 8603 Zurich, Switzerland;
| | - Xinliang He
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (Q.Z.); (X.H.); (X.W.); (Z.-H.W.); (X.X.)
| | - Xiaoshan Wei
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (Q.Z.); (X.H.); (X.W.); (Z.-H.W.); (X.X.)
| | - Payam Zarin
- Department of Immunology, Harvard Medical School, Boston, MA 02115, USA; (P.Z.); (B.S.H.)
| | - Bola S. Hanna
- Department of Immunology, Harvard Medical School, Boston, MA 02115, USA; (P.Z.); (B.S.H.)
| | - Zi-Hao Wang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (Q.Z.); (X.H.); (X.W.); (Z.-H.W.); (X.X.)
| | - Xuan Xiang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (Q.Z.); (X.H.); (X.W.); (Z.-H.W.); (X.X.)
| | - Eleanor N. Fish
- Toronto General Hospital Research Institute, University Health Network and Department of Immunology, University of Toronto, Toronto, ON M5G 2M1, Canada
- Correspondence:
| |
Collapse
|
6
|
Hayden AJ, Shah NV, Stroud SG, Penny GS, Burekhovich SA, Shah AT, Kuehn E, Yang A, Diebo BG, Koehler SM. Characterizing Hand Infections in an Underserved Population: The Role of Diabetic Status in Antibiotic Choice and Infection Location. J Hand Microsurg 2020; 12:13-18. [PMID: 32280176 DOI: 10.1055/s-0039-1692323] [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: 11/20/2018] [Accepted: 04/10/2019] [Indexed: 10/26/2022] Open
Abstract
Introduction Patients with diabetes mellitus (DM) in underserved communities are at greater risk for hand infections. We aimed to describe the features of hand infections presenting to an urban hospital via laboratories, microbiology, and antibiotic choice with respect to diabetic status. Materials and Methods Patients presenting with any hand infection were reviewed and stratified by DM status and infection location. Labs, culture results, antibiotic regimens, and significant predictors of laboratories or infection location were analyzed. Results Fifty-three patients were included: DM ( n = 24), no-DM ( n = 24), and unknown status ( n = 5). Culture rates were comparable between all groups. Mean erythrocyte sedimentation rate (ESR) was significantly higher in DM (76.19 vs. 51.33); mean white blood cell count (WBC) and C-reactive protein (CRP) were comparable. Diabetics had higher odds of increased ESR (odds ratio [OR] = 1.03). Diabetics received vancomycin/piperacillin/tazobactam (VAN/PTZ) significantly more often (52% vs. 8%). Providers treated DM with VAN/PTZ or any VAN-containing regimen more often than with any other regimen. Proximal infections had significantly higher mean CRP (136.9 vs. 50.5) and WBC (5.19 vs. 3.9) and higher CRP (OR = 1.02). Conclusion This study highlights the need for systematic criteria to better risk- stratify patients for appropriate antibiotic treatment. It may not be appropriate to treat both groups differently, as overly aggressive antibiotic selection may contribute to drug-resistance development.
Collapse
Affiliation(s)
- Andrew J Hayden
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| | - Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| | - Sarah G Stroud
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| | - Gregory S Penny
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| | - Steven A Burekhovich
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| | - Aadit T Shah
- Department of Orthopaedic Surgery, Stony Brook School of Medicine, Health Sciences Center, Stony Brook, New York, United States
| | - Erika Kuehn
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| | - Andrew Yang
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| | - Bassel G Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York, United States
| |
Collapse
|
7
|
Venge P, Eriksson AK, Holmgren S, Douhan-Håkansson L, Peterson C, Xu S, Eriksson S, Garwicz D, Larsson A, Pauksen K. HNL (Human Neutrophil Lipocalin) and a multimarker approach to the distinction between bacterial and viral infections. J Immunol Methods 2019; 474:112627. [PMID: 31242445 DOI: 10.1016/j.jim.2019.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The distinction between bacterial and viral causes of acute infections is a major clinical challenge. In this report we investigate the diagnostic performance in this regard of nine candidate biomarkers together with HNL (Human Neutrophil Lipocalin). METHODS Blood was obtained from patients with symptoms of infectious (n = 581). HNL was measured in whole blood (B-HNL) after pre-activation with the neutrophil activator fMLP or in plasma (P-HNL). Azurocidin also known as heparin-binding protein (HBP), Calprotectin, PMN-CD64, CRP (C-reactive protein), IP-10 (Interferon γ-induced Protein 10 kDa), PCT (Procalcitonin), TK1 (Thymidine kinase 1), TRAIL (TNF-related apoptosis-inducing ligand) were measured in plasma/serum. Area under the ROC (receiver operating characteristics) curve (AuROC) was used for the evaluation of the clinical performance of the biomarkers. RESULTS Side-by-side comparisons of the ten biomarkers showed large difference in the AuROC with B-HNL being the superior biomarker (0.91, 95% CI 0.86-0.95) and with the other nine biomarkers varying from AuROC of 0.63-0.79. The combination of B-HNL with IP-10 and/or TRAIL increased the diagnostic performance further to AuROCs of 0.94-0.97. The AuROCs of the combination of CRP with IP-10 and/or TRAIL were significantly lower than combinations with B-HNL 0.87 (95% CI 0.83-0.91). CONCLUSION The diagnostic performance of whole blood activated HNL was superior in the distinction between bacterial or viral infections. The addition of IP-10 and/or TRAIL to the diagnostic algorithm increased the performance of B-HNL further. The rapid analysis of HNL, reflecting bacterial infections, together with biomarkers reflecting viral infections may be the ideal combination of diagnostic biomarkers of acute infections.
Collapse
Affiliation(s)
- Per Venge
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden; Diagnostics Development a P&M Venge AB company, Uppsala, Sweden.
| | | | - Sofia Holmgren
- Diagnostics Development a P&M Venge AB company, Uppsala, Sweden
| | - Lena Douhan-Håkansson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Christer Peterson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden; Diagnostics Development a P&M Venge AB company, Uppsala, Sweden
| | - Shengyuan Xu
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden; Diagnostics Development a P&M Venge AB company, Uppsala, Sweden
| | | | - Daniel Garwicz
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Karlis Pauksen
- Department of Medical Sciences, Infectious Disease, Uppsala University, Uppsala, Sweden
| |
Collapse
|
8
|
Mangogna A, Agostinis C, Ricci G, Romano F, Bulla R. Overview of procalcitonin in pregnancy and in pre-eclampsia. Clin Exp Immunol 2019; 198:37-46. [PMID: 31081935 DOI: 10.1111/cei.13311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2019] [Indexed: 12/19/2022] Open
Abstract
Procalcitonin (PCT), a precursor for calcitonin, is a prohormone involved in the inflammatory processes, which has been poorly studied in the context of pregnancy. During severe inflammation, PCT derives from almost all cell types, including monocytes and parenchymal tissues, making it a good predictive and diagnostic marker of an inflammatory state with rapidly increased serum levels in inflammation or sepsis. In normal pregnancy, PCT is basally expressed at very low level by decidual cells, even if decidual macrophages, which in normal pregnancy are skewed to M2 macrophages, are resistant to lipopolysaccharide (LPS)-induced production of PCT. As PCT increase is associated with an inflammatory state, several research groups investigated whether PCT can be considered a marker of pre-eclampsia, a pregnancy disease characterized by systemic inflammation. The first aim of this review is to summarize what is already known about the tissues synthesizing PCT, about the stimuli that cause the increase of circulating PCT levels and how PCT acts as a proinflammatory stimulus by itself. Secondly, we will describe the role of this prohormone in normal pregnancy and in pregnancies complicated by pre-eclampsia, highlighting the involvement of the decidual macrophages and the proinflammatory cytokine tumor necrosis factor-α in the modulation of PCT expression in the decidual microenvironment.
Collapse
Affiliation(s)
- A Mangogna
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - C Agostinis
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste, Italy
| | - G Ricci
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste, Italy.,Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - F Romano
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste, Italy
| | - R Bulla
- Department of Life Sciences, University of Trieste, Trieste, Italy
| |
Collapse
|
9
|
Schuetz P, Stolz D. Guiding antibiotic treatment with inflammatory biomarkers in COPD? Another brick in the wall. Eur Respir J 2019; 53:53/5/1900562. [DOI: 10.1183/13993003.00562-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 11/05/2022]
|
10
|
Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta-review. Sci Rep 2019; 9:7600. [PMID: 31110214 PMCID: PMC6527561 DOI: 10.1038/s41598-019-44145-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/09/2019] [Indexed: 12/16/2022] Open
Abstract
Pneumonia results in significant morbidity and mortality worldwide. However, chest radiography may not be accessible in primary care setting. We aimed to evaluate clinical features and its diagnostic value to identify pneumonia among adults in primary care settings. Three academic databases were searched and included studies that assessed clinical predictors of pneumonia, adults without serious illness, have CXR and have conducted in primary care settings. We calculated sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio of each index test and the pool estimates for index tests. We identified 2,397 articles, of which 13 articles were included. In our meta-analysis, clinical features with the best pooled positive likelihood ratios were respiratory rate ≥20 min−1 (3.47; 1.46–7.23), temperature ≥38 °C (3.21; 2.36–4.23), pulse rate >100 min−1 (2.79; 1.71–4.33), and crackles (2.42; 1.19–4.69). Laboratory testing showed highest pooled positive likelihood ratios with PCT >0.25 ng/ml (7.61; 3.28–15.1) and CRP > 20 mg/l (3.76; 2.3–5.91). Cough, pyrexia, tachycardia, tachypnea, and crackles are limited as a single predictor for diagnosis of radiographic pneumonia among adults. Development of clinical decision rule that combine these clinical features together with molecular biomarkers may further increase overall accuracy for diagnosis of radiographic pneumonia among adults in primary care setting.
Collapse
|
11
|
Joseph P, Godofsky E. Outpatient Antibiotic Stewardship: A Growing Frontier-Combining Myxovirus Resistance Protein A With Other Biomarkers to Improve Antibiotic Use. Open Forum Infect Dis 2018; 5:ofy024. [PMID: 29479553 PMCID: PMC5815119 DOI: 10.1093/ofid/ofy024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/29/2018] [Indexed: 12/20/2022] Open
Abstract
Background The majority of oral antibiotics are prescribed in outpatient primary and urgent care clinics for acute respiratory infections. Effective antibiotic stewardship must include proper prescribing for outpatients as well as for those in a hospital or long-term care facility. Methods Major databases, including MEDLINE and the Cochrane Library, were searched for prospective human clinical studies, including children and/or adults published between January 1966 and November 2017 that evaluated Myxovirus resistance protein A (MxA) as a biomarker for diagnosing viral infections as well as both C-reactive protein (CRP) and procalcitonin (PCT) as potential biomarkers for identifying and differentiating true bacterial upper respiratory infection (URI) from colonization. Results Ten prospective human studies, totaling 1683 patients, were identified that evaluated MxA as a viral biomarker in children and/or adults. Both systematic review articles, meta-analyses, and randomized controlled clinical trials that examined CRP and/or PCT as a biomarker for identifying clinically significant bacterial infections and supporting antibiotic stewardship were identified. Conclusions Quick and accurate differentiation between a viral and bacterial respiratory infection is critical to effectively combat antibiotic misuse. MxA expression in peripheral blood is a highly specific marker for viral infection. Combining MxA with other inflammatory biomarkers to test for respiratory infections offers enhanced sensitivity and specificity, forming an excellent tool for antibiotic stewardship in the outpatient setting.
Collapse
Affiliation(s)
- Patrick Joseph
- Private Practice to California Infection Control Consultants, San Ramon, California
| | | |
Collapse
|
12
|
Odermatt J, Friedli N, Kutz A, Briel M, Bucher HC, Christ-Crain M, Burkhardt O, Welte T, Mueller B, Schuetz P. Effects of procalcitonin testing on antibiotic use and clinical outcomes in patients with upper respiratory tract infections. An individual patient data meta-analysis. Clin Chem Lab Med 2017; 56:170-177. [PMID: 28665787 DOI: 10.1515/cclm-2017-0252] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/02/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Several trials found procalcitonin (PCT) helpful for guiding antibiotic treatment in patients with lower respiratory tract infections and sepsis. We aimed to perform an individual patient data meta-analysis on the effects of PCT guided antibiotic therapy in upper respiratory tract infections (URTI). METHODS A comprehensive search of the literature was conducted using PubMed (MEDLINE) and Cochrane Library to identify relevant studies published until September 2016. We reanalysed individual data of adult URTI patients with a clinical diagnosis of URTI. Data of two trials were used based on PRISMA-IPD guidelines. Safety outcomes were (1) treatment failure defined as death, hospitalization, ARI-specific complications, recurrent or worsening infection at 28 days follow-up; and (2) restricted activity within a 14-day follow-up. Secondary endpoints were initiation of antibiotic therapy, and total days of antibiotic exposure. RESULTS In total, 644 patients with a follow up of 28 days had a final diagnosis of URTI and were thus included in this analysis. There was no difference in treatment failure (33.1% vs. 34.0%, OR 1.0, 95% CI 0.7-1.4; p=0.896) and days with restricted activity between groups (8.0 vs. 8.0 days, regression coefficient 0.2 (95% CI -0.4 to 0.9), p=0.465). However, PCT guided antibiotic therapy resulted in lower antibiotic prescription (17.8% vs. 51.0%, OR 0.2, 95% CI 0.1-0.3; p<0.001) and in a 2.4 day (95% CI -2.9 to -1.9; p<0.001) shorter antibiotic exposure compared to control patients. CONCLUSIONS PCT guided antibiotic therapy in the primary care setting was associated with reduced antibiotic exposure in URTI patients without compromising outcomes.
Collapse
|
13
|
Schuetz P, Wirz Y, Sager R, Christ-Crain M, Stolz D, Tamm M, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Kristoffersen KB, Burkhardt O, Welte T, Schroeder S, Nobre V, Wei L, Bucher HC, Annane D, Reinhart K, Falsey AR, Branche A, Damas P, Nijsten M, de Lange DW, Deliberato RO, Oliveira CF, Maravić-Stojković V, Verduri A, Beghé B, Cao B, Shehabi Y, Jensen JUS, Corti C, van Oers JAH, Beishuizen A, Girbes ARJ, de Jong E, Briel M, Mueller B. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. THE LANCET. INFECTIOUS DISEASES 2017; 18:95-107. [PMID: 29037960 DOI: 10.1016/s1473-3099(17)30592-3] [Citation(s) in RCA: 286] [Impact Index Per Article: 40.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/14/2017] [Accepted: 09/19/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND In February, 2017, the US Food and Drug Administration approved the blood infection marker procalcitonin for guiding antibiotic therapy in patients with acute respiratory infections. This meta-analysis of patient data from 26 randomised controlled trials was designed to assess safety of procalcitonin-guided treatment in patients with acute respiratory infections from different clinical settings. METHODS Based on a prespecified Cochrane protocol, we did a systematic literature search on the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, and pooled individual patient data from trials in which patients with respiratory infections were randomly assigned to receive antibiotics based on procalcitonin concentrations (procalcitonin-guided group) or control. The coprimary endpoints were 30-day mortality and setting-specific treatment failure. Secondary endpoints were antibiotic use, length of stay, and antibiotic side-effects. FINDINGS We identified 990 records from the literature search, of which 71 articles were assessed for eligibility after exclusion of 919 records. We collected data on 6708 patients from 26 eligible trials in 12 countries. Mortality at 30 days was significantly lower in procalcitonin-guided patients than in control patients (286 [9%] deaths in 3336 procalcitonin-guided patients vs 336 [10%] in 3372 controls; adjusted odds ratio [OR] 0·83 [95% CI 0·70 to 0·99], p=0·037). This mortality benefit was similar across subgroups by setting and type of infection (pinteractions>0·05), although mortality was very low in primary care and in patients with acute bronchitis. Procalcitonin guidance was also associated with a 2·4-day reduction in antibiotic exposure (5·7 vs 8·1 days [95% CI -2·71 to -2·15], p<0·0001) and a reduction in antibiotic-related side-effects (16% vs 22%, adjusted OR 0·68 [95% CI 0·57 to 0·82], p<0·0001). INTERPRETATION Use of procalcitonin to guide antibiotic treatment in patients with acute respiratory infections reduces antibiotic exposure and side-effects, and improves survival. Widespread implementation of procalcitonin protocols in patients with acute respiratory infections thus has the potential to improve antibiotic management with positive effects on clinical outcomes and on the current threat of increasing antibiotic multiresistance. FUNDING National Institute for Health Research.
Collapse
Affiliation(s)
- Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Yannick Wirz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Ramon Sager
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Faculty of Medicine, University of Basel, Basel, Switzerland; Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Basel, Basel, Switzerland
| | - Daiana Stolz
- Faculty of Medicine, University of Basel, Basel, Switzerland; Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Michael Tamm
- Faculty of Medicine, University of Basel, Basel, Switzerland; Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Lila Bouadma
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Charles E Luyt
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean Chastre
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Florence Tubach
- Département de Biostatistique, Santé publique et Information médicale, AP-HP, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Sorbonne Universités, Paris, France
| | | | - Olaf Burkhardt
- Department of Pulmonary Medicine, Medizinische Hochschule Hannover, Member of the German Center of Lung Research, Hannover, Germany
| | - Tobias Welte
- Department of Pulmonary Medicine, Medizinische Hochschule Hannover, Member of the German Center of Lung Research, Hannover, Germany
| | - Stefan Schroeder
- Department of Anesthesiology and Intensive Care Medicine, Krankenhaus Dueren, Dueren, Germany
| | - Vandack Nobre
- Department of Intensive Care, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Long Wei
- Department of Internal and Geriatric Medicine, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Heiner C Bucher
- Faculty of Medicine, University of Basel, Basel, Switzerland; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Djillali Annane
- Critical Care Department, Hôpital Raymond Poincaré, AP-HP, Faculty of Health Science Simone Veil, UVSQ-University Paris Saclay, Garches, France
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Ann R Falsey
- Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Angela Branche
- Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Domaine Universitaire de Liège, Liège, Belgium
| | - Maarten Nijsten
- University Medical Centre, University of Groningen, Groningen, Netherlands
| | - Dylan W de Lange
- University Medical Center Utrecht and University of Utrecht, Utrecht, Netherlands
| | | | - Carolina F Oliveira
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Alessia Verduri
- Section of Respiratory Medicine, Department of Medical and Surgical Sciences, University Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Bianca Beghé
- Section of Respiratory Medicine, Department of Medical and Surgical Sciences, University Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Bin Cao
- Center for Respiratory Diseases, Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Yahya Shehabi
- Critical Care and Peri-operative Medicine, Monash Health, Melbourne, VIC, Australia; School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Jens-Ulrik S Jensen
- Centre of Excellence for Health, Immunity and Infections, Department of Infectious Diseases and Rheumatology, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Caspar Corti
- Department of Respiratory Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | | | | | | | | | - Matthias Briel
- Faculty of Medicine, University of Basel, Basel, Switzerland; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Beat Mueller
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland
| |
Collapse
|
14
|
Schuetz P, Wirz Y, Sager R, Christ‐Crain M, Stolz D, Tamm M, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Kristoffersen KB, Burkhardt O, Welte T, Schroeder S, Nobre V, Wei L, Bucher HCC, Bhatnagar N, Annane D, Reinhart K, Branche A, Damas P, Nijsten M, de Lange DW, Deliberato RO, Lima SSS, Maravić‐Stojković V, Verduri A, Cao B, Shehabi Y, Beishuizen A, Jensen JS, Corti C, Van Oers JA, Falsey AR, de Jong E, Oliveira CF, Beghe B, Briel M, Mueller B. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev 2017; 10:CD007498. [PMID: 29025194 PMCID: PMC6485408 DOI: 10.1002/14651858.cd007498.pub3] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Acute respiratory infections (ARIs) comprise of a large and heterogeneous group of infections including bacterial, viral, and other aetiologies. In recent years, procalcitonin (PCT), a blood marker for bacterial infections, has emerged as a promising tool to improve decisions about antibiotic therapy (PCT-guided antibiotic therapy). Several randomised controlled trials (RCTs) have demonstrated the feasibility of using procalcitonin for starting and stopping antibiotics in different patient populations with ARIs and different settings ranging from primary care settings to emergency departments, hospital wards, and intensive care units. However, the effect of using procalcitonin on clinical outcomes is unclear. This is an update of a Cochrane review and individual participant data meta-analysis first published in 2012 designed to look at the safety of PCT-guided antibiotic stewardship. OBJECTIVES The aim of this systematic review based on individual participant data was to assess the safety and efficacy of using procalcitonin for starting or stopping antibiotics over a large range of patients with varying severity of ARIs and from different clinical settings. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, and Embase, in February 2017, to identify suitable trials. We also searched ClinicalTrials.gov to identify ongoing trials in April 2017. SELECTION CRITERIA We included RCTs of adult participants with ARIs who received an antibiotic treatment either based on a procalcitonin algorithm (PCT-guided antibiotic stewardship algorithm) or usual care. We excluded trials if they focused exclusively on children or used procalcitonin for a purpose other than to guide initiation and duration of antibiotic treatment. DATA COLLECTION AND ANALYSIS Two teams of review authors independently evaluated the methodology and extracted data from primary studies. The primary endpoints were all-cause mortality and treatment failure at 30 days, for which definitions were harmonised among trials. Secondary endpoints were antibiotic use, antibiotic-related side effects, and length of hospital stay. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariable hierarchical logistic regression adjusted for age, gender, and clinical diagnosis using a fixed-effect model. The different trials were added as random-effects into the model. We conducted sensitivity analyses stratified by clinical setting and type of ARI. We also performed an aggregate data meta-analysis. MAIN RESULTS From 32 eligible RCTs including 18 new trials for this 2017 update, we obtained individual participant data from 26 trials including 6708 participants, which we included in the main individual participant data meta-analysis. We did not obtain individual participant data for four trials, and two trials did not include people with confirmed ARIs. According to GRADE, the quality of the evidence was high for the outcomes mortality and antibiotic exposure, and quality was moderate for the outcomes treatment failure and antibiotic-related side effects.Primary endpoints: there were 286 deaths in 3336 procalcitonin-guided participants (8.6%) compared to 336 in 3372 controls (10.0%), resulting in a significantly lower mortality associated with procalcitonin-guided therapy (adjusted OR 0.83, 95% CI 0.70 to 0.99, P = 0.037). We could not estimate mortality in primary care trials because only one death was reported in a control group participant. Treatment failure was not significantly lower in procalcitonin-guided participants (23.0% versus 24.9% in the control group, adjusted OR 0.90, 95% CI 0.80 to 1.01, P = 0.068). Results were similar among subgroups by clinical setting and type of respiratory infection, with no evidence for effect modification (P for interaction > 0.05). Secondary endpoints: procalcitonin guidance was associated with a 2.4-day reduction in antibiotic exposure (5.7 versus 8.1 days, 95% CI -2.71 to -2.15, P < 0.001) and lower risk of antibiotic-related side effects (16.3% versus 22.1%, adjusted OR 0.68, 95% CI 0.57 to 0.82, P < 0.001). Length of hospital stay and intensive care unit stay were similar in both groups. A sensitivity aggregate-data analysis based on all 32 eligible trials showed similar results. AUTHORS' CONCLUSIONS This updated meta-analysis of individual participant data from 12 countries shows that the use of procalcitonin to guide initiation and duration of antibiotic treatment results in lower risks of mortality, lower antibiotic consumption, and lower risk for antibiotic-related side effects. Results were similar for different clinical settings and types of ARIs, thus supporting the use of procalcitonin in the context of antibiotic stewardship in people with ARIs. Future high-quality research is needed to confirm the results in immunosuppressed patients and patients with non-respiratory infections.
Collapse
Affiliation(s)
- Philipp Schuetz
- Kantonsspital AarauMedical University DepartmentAarauSwitzerland
- Kantonsspital AarauDepartment of Endocrinology/Metabolism/Clinical Nutrition, Department of Internal MedicineAarauSwitzerland
- University of BaselMedical FacultyBaselSwitzerland
| | - Yannick Wirz
- Kantonsspital AarauMedical University DepartmentAarauSwitzerland
| | - Ramon Sager
- Kantonsspital AarauMedical University DepartmentAarauSwitzerland
| | - Mirjam Christ‐Crain
- University Hospital Basel, University of BaselClinic for Endocrinology, Diabetes and Metabolism, Department of Clinical ResearchPetersgraben 4BaselSwitzerlandCH‐4031
| | - Daiana Stolz
- University Hospital BaselClinic of Pneumology and Pulmonary Cell ResearchPetersgraben 4BaselSwitzerlandCH‐4031
| | - Michael Tamm
- University Hospital BaselClinic of Pneumology and Pulmonary Cell ResearchPetersgraben 4BaselSwitzerlandCH‐4031
| | - Lila Bouadma
- Hôpital Bichat‐Claude Bernard, Université Paris 7‐Denis‐DiderotService de Réanimation MédicaleParisFrance
| | - Charles E Luyt
- Groupe Hospitalier Pitié‐Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Paris 6‐Pierre‐et‐Marie‐CurieService de Réanimation MédicaleParisFrance
| | - Michel Wolff
- Université Paris 7‐Denis‐DiderotService de Réanimation MédicaleHôpital Bichat‐Claude‐BernardAssistance Publique‐Hôpitaux de Paris (AP‐HP)ParisFrance
| | - Jean Chastre
- Université Paris 6‐Pierre‐et‐Marie‐CurieService de Réanimation MédicaleHôpital Pitié?Salpêtrière (AP‐HP)ParisFrance
| | - Florence Tubach
- Santé Publique et Information Médicale, AP‐HP, Groupe Hospitalier Pitié‐Salpêtrière Charles‐Foix, INSERM CIC‐P 1421, Sorbonne Universités, UPMC Univ Paris 06Département BiostatistiqueParisFrance
| | - Kristina B Kristoffersen
- Aarhus University HospitalDepartment of Infectious DiseasesSkejbyBrendstrupgaardvej 100Aarhus NDenmark8200
| | - Olaf Burkhardt
- Medizinische Hochschule HannoverDepartment of Pulmonary MedicineCarl‐Neuberg‐Str. 1HannoverNiedersachsenGermany30625
| | - Tobias Welte
- Medizinische Hochschule HannoverDepartment of Pulmonary MedicineCarl‐Neuberg‐Str. 1HannoverNiedersachsenGermany30625
- German Center for Lung Reearch (DZL)Aulweg 130GießenGermany35392
| | - Stefan Schroeder
- Krankenhaus DuerenDepartment of Anesthesiology and Intensive Care MedicineDuerenGermany
| | - Vandack Nobre
- Universidade Federal de Minas GeraisDepartment of Internal Medicine, School of MedicineMinas GeraisBelo HorizonteBrazil
| | - Long Wei
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital (East campus)Department of Internal and Geriatric MedicineShanghaiChina
| | - Heiner C C Bucher
- University Hospital Basel and University of BaselBasel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical ResearchPetersgraben 4BaselSwitzerlandCH‐4031
- University Hospital BaselMedical FacultyBaselSwitzerland
| | - Neera Bhatnagar
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHamiltonONCanadaL8N 3Z5
| | - Djillali Annane
- Center for Neuromuscular Diseases; Raymond Poincaré Hospital (AP‐HP)Department of Critical Care, Hyperbaric Medicine and Home Respiratory UnitFaculty of Health Sciences Simone Veil, University of Versailles SQY‐ University of Paris Saclay104 Boulevard Raymond PoincaréGarchesFrance92380
| | - Konrad Reinhart
- Jena University HospitalDepartment of Anesthesiology and Intensive Care MedicineErlanger Allee 101JenaGermany07747
| | - Angela Branche
- University of Rochester School of MedicineDepartment of Medicine, Division of Infectious DiseasesRochesterNYUSA
| | - Pierre Damas
- University Hospital of Liege, Domaine universitaire de LiègeDepartment of General Intensive CareLiegeBelgium
| | - Maarten Nijsten
- University of GroningenUniversity Medical CentreGroningenNetherlands
| | - Dylan W de Lange
- University Medical Center UtrechtDepartment of Intensive CareHeidelberglaan 100UtrechtNetherlands3584 CX
| | | | - Stella SS Lima
- Universidade Federal de Minas GeraisGraduate Program in Infectious Diseases and Tropical Medicine, Department of Internal Medicine, School of MedicineBelo HorizonteBrazil
| | | | - Alessia Verduri
- University of Modena and Reggio EmiliaDepartment of Medical and Surgical Sciences, Policlinico di ModenaModenaItaly
| | - Bin Cao
- China‐Japan Friendship Hospital, National Clinical Research Center of Respiratory Diseases, Capital Medical UniversityCenter for Respiratory Diseases, Department of Pulmonary and Critical Care MedicineBeijingChina
| | - Yahya Shehabi
- Monash HealthCritical Care and Peri‐operative MedicineMelbourneVictoriaAustralia
- Monash UniversitySchool of Clinical Sciences, Faculty of Medicine Nursing and Health SciencesMelbourneVictoriaAustralia
| | | | - Jens‐Ulrik S Jensen
- Copenhagen University Hospital, Bispebjerg og FrederiksbergDepartment of Respiratory MedicineBispebjerg BakkeCopenhagen NVCapitol RegionDenmarkDK 2400
- Rigshospitalet, University of CopenhagenCHIP, Department of Infectious Diseases and Rheumatology, FinsencentretBlegdamsvej 9, DK‐2100CopenhagenDenmarkDK‐2100
| | - Caspar Corti
- Copenhagen University Hospital, Bispebjerg og FrederiksbergDepartment of Respiratory MedicineBispebjerg BakkeCopenhagen NVCapitol RegionDenmarkDK 2400
| | - Jos A Van Oers
- Elisabeth Tweesteden ZiekenhuisIntensive Care UnitTilburgNetherlands5022 GC
| | - Ann R Falsey
- University of Rochester School of MedicineDepartment of Medicine, Division of Infectious DiseasesRochesterNYUSA
| | - Evelien de Jong
- VU University Medical CenterDepartment of Intensive CareAmsterdamNetherlands1081HV
| | - Carolina F Oliveira
- Federal University of Minas GeraisDepartment of Internal Medicine, School of MedcineBelo HorizonteBrazil31130‐100
| | - Bianca Beghe
- AOU Policlinico di ModenaDepartment of Medical and Surgical SciencesModernaItaly41124
| | - Matthias Briel
- University of BaselMedical FacultyBaselSwitzerland
- University Hospital Basel and University of BaselBasel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical ResearchPetersgraben 4BaselSwitzerlandCH‐4031
| | - Beat Mueller
- Kantonsspital AarauMedical University DepartmentAarauSwitzerland
- Kantonsspital AarauDepartment of Endocrinology/Metabolism/Clinical Nutrition, Department of Internal MedicineAarauSwitzerland
- University of BaselMedical FacultyBaselSwitzerland
| | | |
Collapse
|
15
|
Human Neutrophil Lipocalin in Activated Whole Blood Is a Specific and Rapid Diagnostic Biomarker of Bacterial Infections in the Respiratory Tract. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2017; 24:CVI.00064-17. [PMID: 28468981 PMCID: PMC5498719 DOI: 10.1128/cvi.00064-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/30/2017] [Indexed: 12/25/2022]
Abstract
The distinction between bacterial and viral causes of infections of the respiratory tract is a major but important clinical challenge. We investigated the diagnostic performance of human neutrophil lipocalin (HNL) in respiratory tract infections compared to those of C-reactive protein (CRP) and procalcitonin (PCT). Patients were recruited from the emergency department and from a primary care unit (n = 162). The clinical diagnosis with regard to bacterial or viral cause of infection was complemented with objective microbiological/serological testing. HNL was measured in whole blood after preactivation with the neutrophil activator formyl-methionine-leucine-phenylalanine (fMLP) (B-HNL), and CRP and PCT were measured in plasma. Head-to-head comparisons of the three biomarkers showed that B-HNL was a superior diagnostic means to distinguish between causes of infections, with areas under the concentration-time curve (AUCs) of receiver operating characteristic (ROC) analysis for HNL of 0.91 (95% confidence interval [CI], 0.83 to 0.96) and 0.92 (95% CI, 0.82 to 0.97) for all respiratory infections and for upper respiratory infections, respectively, compared to 0.72 (95% CI, 0.63 to 0.80) and 0.68 (95% CI, 0.56 to 0.79) for CRP, respectively (P = 0.001). In relation to major clinical symptoms of respiratory tract infections (cough, sore throat, stuffy nose, and signs of sinusitis), AUCs varied between 0.88 and 0.93 in those patients with likely etiology (i.e., etiology is likely determined) of infection, compared to 0.63 and 0.71 for CRP, respectively, and nonsignificant AUCs for PCT. The diagnostic performance of B-HNL is superior to that of plasma CRP (P-CRP) and plasma PCT (P-PCT) in respiratory tract infections, and the activity specifically reflects bacterial challenge in the body. The rapid and accurate analysis of HNL by point-of-care technologies should be a major advancement in the diagnosis and management of respiratory infections with respect to antibiotic treatment.
Collapse
|
16
|
Cazzola M, Rogliani P, Aliberti S, Blasi F, Matera MG. An update on the pharmacotherapeutic management of lower respiratory tract infections. Expert Opin Pharmacother 2017; 18:973-988. [PMID: 28480770 DOI: 10.1080/14656566.2017.1328497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Our knowledge about lower respiratory tract infections (LRTIs) has improved substantially in the last years, but the management of respiratory infections is still a challenge and we are still far from using precision medicine in their treatment. Areas covered: The approaches developed in recent years to improve the pharmacotherapeutic management of LRTIs, such as novel diagnostic assays to facilitate medical decision-making, attempts for selecting an optimal empiric antibiotic regimen, and the role of new and possibly unproven adjunctive therapies, are described. Expert opinion: Early and appropriate antibiotics remain the cornerstone in the treatment of LRTIs. The updated trend is to apply antimicrobial stewardship principles and initiatives to optimize both the management and the outcomes of LTRIs. Biomarkers, mainly C-reactive protein (CRP) and procalcitonin (PCT), can improve the diagnostic and prognostic assessment of LRTIs and aid to guide antibiotic therapy. The widespread use of antimicrobial agents has greatly contributed to faster development of antibiotic resistance and the emergence of opportunistic pathogens, which substitute the indigenous microbiota. However, very few new antibiotics in development to overcome existing resistance and ensure continued success in the treatment of LRTIs have been approved, likely because antibiotic stewardship programs discourage the use of new agents.
Collapse
Affiliation(s)
- Mario Cazzola
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Paola Rogliani
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Stefano Aliberti
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Francesco Blasi
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Maria Gabriella Matera
- c Department of Experimental Medicine , Università degli Studi della Campania "Luigi Vanvitelli" , Naples , Italy
| |
Collapse
|
17
|
Sager R, Kutz A, Mueller B, Schuetz P. Procalcitonin-guided diagnosis and antibiotic stewardship revisited. BMC Med 2017; 15:15. [PMID: 28114931 PMCID: PMC5259962 DOI: 10.1186/s12916-017-0795-7] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/13/2017] [Indexed: 12/29/2022] Open
Abstract
Several controlled clinical studies have evaluated the potential of the infection biomarker procalcitonin (PCT) to improve the diagnostic work-up of patients with bacterial infections and its influence on decisions regarding antibiotic therapy. Most research has focused on lower respiratory tract infections and critically ill sepsis patients. A clinical utility for PCT has also been found for patients with urinary tract infections, postoperative infections, meningitis, and patients with acute heart failure with possible superinfection (i.e., pneumonia). In these indications, PCT levels measured on hospital admission were found to substantially reduce the initiation of antibiotic treatment in low-risk situations (i.e., bronchitis, chronic obstructive pulmonary disease exacerbation). For more severe infections (i.e., pneumonia, sepsis), antibiotic stewardship by monitoring of PCT kinetics resulted in shorter antibiotic treatment durations with early cessation of therapy. Importantly, these strategies appear to be safe without increasing the risk for mortality, recurrent infections, or treatment failures. PCT kinetics also proved to have prognostic value correlating with disease severity (i.e., pancreatitis, abdominal infection) and resolution of illness (i.e., sepsis). Although promising findings have been published in these different types of infections, there are a number of limitations regarding PCT, including suboptimal sensitivity and/or specificity, which makes a careful interpretation of PCT in the clinical context mandatory. This narrative review aims to update clinicians on the strengths and limitations of PCT for patient management, focusing on research conducted within the last 4 years.
Collapse
Affiliation(s)
- Ramon Sager
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Alexander Kutz
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Beat Mueller
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse, CH-5001, Aarau, Switzerland. .,Faculty of Medicine, University of Basel, Basel, Switzerland.
| |
Collapse
|
18
|
Conte L, Rossi A, Picariello C, Zuin M, Abbasciano RG, Rigatelli G, Roncon L. Silent large vegetative mitral-aortic enterococcal endocarditis. J Cardiovasc Med (Hagerstown) 2016; 17 Suppl 2:e199-e204. [PMID: 27652816 DOI: 10.2459/jcm.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: In spite of the evolution of diagnostic and imaging tools, infective endocarditis still remains a challenging diagnostic problem. We report the case of a 77-year-old heart failure patient with a very large mitral vegetative lesion but without fever or any other clinical or microbiological 'endocarditis criteria' except the echocardiographic findings. In this scenario, the second more likely differential diagnosis was neoformation of the mitral valve but despite an exhaustive preoperative diagnostic cardiac imaging, this hypothesis could not be excluded before surgical excision and microbiological examination of the surgical specimen.
Collapse
Affiliation(s)
- Luca Conte
- aDivision of Cardiology, Rovigo General Hospital, Rovigo bDivision of Cardiology cDivision of Cardiovascular Surgery, Verona University Hospital, Verona dCardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy
| | | | | | | | | | | | | |
Collapse
|
19
|
Meili M, Kutz A, Briel M, Christ-Crain M, Bucher HC, Mueller B, Schuetz P. Infection biomarkers in primary care patients with acute respiratory tract infections-comparison of Procalcitonin and C-reactive protein. BMC Pulm Med 2016; 16:43. [PMID: 27009083 PMCID: PMC4806430 DOI: 10.1186/s12890-016-0206-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/15/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is a lack of studies comparing the utility of C-reactive protein (CRP) with Procalcitonin (PCT) for the management of patients with acute respiratory tract infections (ARI) in primary care. Our aim was to study the correlation between these markers and to compare their predictive accuracy in regard to clinical outcome prediction. METHODS This is a secondary analysis using clinical and biomarker data of 458 primary care patients with pneumonic and non-pneumonic ARI. We used correlation statistics (spearman's rank test) and multivariable regression models to assess association of markers with adverse outcome, namely days with restricted activities and persistence of discomfort from infection at day 14. RESULTS At baseline, CRP and PCT did not correlate well in the overall population (r(2) = 0.16) and particularly in the subgroup of patients with non-pneumonic ARI (r(2) = 0.08). Low correlation of biomarkers were also found when comparing cut-off ranges, day seven levels or changes from baseline to day seven. High baseline levels of CRP (>100 mg/dL, regression coefficient 1.6, 95 % CI 0.5 to 2.6, sociodemographic-adjusted model) as well as PCT (>0.5ug/L regression coefficient 2.0, 95 % CI 0.0 to 4.0, sociodemographic-adjusted model) were significantly associated with larger number of days with restricted activities. There were no associations of either biomarker with persistence of discomfort at day 14. CONCLUSIONS CRP and PCT levels do not well correlate, but both have moderate prognostic accuracy in primary care patients with ARI to predict clinical outcomes. The low correlation between the two biomarkers calls for interventional research comparing these markers head to head in regard to their ability to guide antibiotic decisions. TRIAL REGISTRATION Current Controlled Trials, ISRCTN73182671.
Collapse
Affiliation(s)
- Marc Meili
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse 5001, Aarau, Switzerland
| | - Alexander Kutz
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse 5001, Aarau, Switzerland
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Beat Mueller
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse 5001, Aarau, Switzerland
| | - Philipp Schuetz
- University Department of Medicine, Kantonsspital Aarau, Tellstrasse 5001, Aarau, Switzerland.
| |
Collapse
|