Procalcitonin and C-reactive protein: markers in the early diagnosis of anastomotic leak

OBJECTIVE

To determine the efficacy of serum procalcitonin (PCT) and C-reactive protein (CRP) in the early diagnosis of anastomotic leak (AL) in patients undergoing colorectal surgery.

METHOD

Diagnostic test in a tertiary care hospital. Patients who did not have preoperative measurements of PCT and CRP were excluded. Those with postoperative infection not related to AL were eliminated. The diagnostic efficacy measures were sensitivity (Sn), specificity (Sp), positive (PPV) and negative (NPV) predictive values, positive (LR+) and negative (LR-) likelihood ratios, and area under the receiver operating characteristic curve (AUROC).

RESULTS

Thirty-nine patients were analyzed; six had AL (15.4%). PCT and CRP increased on the second postoperative day, only in patients with AL. The cut-off points at the second postoperative day were 1.55 ng/mL for PCT and 11.25 mg/L for CRP. The most efficacious test was PCR at second postoperative day (AUROC: 1.00; Sn: 100%; Sp: 96.7%; PPV: 85.7%; NPV: 100%; LR+: 33.0).

CONCLUSIONS

CRP at second postoperative day was the most effective test in the early diagnosis of AL in patients undergoing colorectal surgery, with a cut-off point lower than that reported in the international literature.

Usefulness of the 5MPB-Toledo model to predict bacteremia in patients with urinary tract infections in the emergency department

OBJECTIVE

To analyze the usefulness of a new predictive model of bacteremia (5MPB-Toledo) in patients treated for urinary tract infection (UTI) in the emergency department (ED).

METHODS

Prospective and multicenter observational cohort study of the blood cultures (BC) ordered for patients with UTIs in 65 Spanish ED from November 1, 2019, to March 31, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The diagnostic performance was calculated with the chosen cut-off point for sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

A total of 1,499 blood cultures were evaluated. True cases of bacteremia were confirmed in 277 (18.5%). The remaining 1,222 cultures (81.5%) were negative. Ninety-four (6.3%) were considered contaminated. The model's area under the ROC curve was 0.937 (95% CI, 0.926-0.949). The prognostic performance with a model's cut-off value of ≥5 points achieved 97.47% (95% CI, 94.64-98.89) sensitivity, 76.68% (95% CI, 74.18-79.00) specificity, 48.65% (95% CI, 44.42-52.89) positive predictive value and 99.26% (95% CI, 98.41-99.67) negative predictive value.

CONCLUSION

The 5MPB-Toledo score is useful for predicting bacteremia in patients with UTIs who visit the ED.

Procalcitonina y proteína C reactiva séricas como biomarcadores predictivos de dehiscencia de anastomosis intestinal en cirugía colorrectal

BACKGROUND

There has been recent interest in the seric levels of procalcitonin (PCT) and C reactive protein (PCR) as a marker of intraabdominal infection after a colorrectal surgery, however, the actual literature remains inconclusive.

OBJECTIVE

To test if C-Reactive Protein (PCR) and procalcitonin (PCT) as predictive factors of anastomotic leak after colorectal surgery.

METHOD

Retrospective cohort, of patients with ileostomy or colostomy who had intestinal transit restitution by general surgeons in our center, from march 2018 to march 2020.

RESULTS

We registered 4 (36.4%) anastomotic leaks. We compared median PCR and PCT between group 1 (without anastomotic leak) and group 2 (with anastomotic leak). Median PCT3PO was 4.86 ng/ml in group 1 vs 13.7 ng/ml in group 2, and PCT5PO was 1.3071 ng/ml vs 6.74 ng/ml (DS: 5.04 vs. 11.53 and 0.779 vs. 10.44). Median PCR3PO and PCR5PO was 194.7 mg/l in group 1 vs 100.97 mg/l in group 2, and 159.8 mg/l vs 65.67 mg/l, (DS: 88.78 vs. 82.01 and 94.77 vs. 58.009).

CONCLUSIONS

Persistent higher levels of seric PCR and PCT at 3^rd and 5^th postoperative day could be an anastomotic leackage. This biomarkers might be added as additional criteria of discharge.

Validation of a predictive model for bacteraemia (MPB5-Toledo) in the patients seen in emergency departments due to infections

OBJECTIVE

To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections.

METHODS

Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0-2 points, intermediate risk by 3-5 points, and high risk by 6-8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70).

CONCLUSION

The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

Predicting bacteremia in patients attended for infections in an emergency department: the 5MPB-Toledo model

OBJECTIVES

To develop a simple risk score to predict bacteremia in patients in our hospital emergency department for infection.

MATERIAL AND METHODS

Retrospective observational cohort study of all blood cultures ordered in the emergency department for adults (aged 18 or older) from July 1, 2018, to March 31, 2019. We gathered data on 38 independent variables (demographic, comorbidity, functional status, and laboratory findings) that might predict bacteremia. Univariate and multiple logistic regression analyses were applied to the data and a risk scale was developed.

RESULTS

A total of 2181 blood samples were cultured. True cases of bacteremia were confirmed in 262 (12%). The remaining 1919 cultures (88%) were negative. No growth was observed in 1755 (80.5%) of the negative cultures, and 164 (7.5%) were judged to be contaminated. The 5MPB-Toledo model identified 5 predictors of bacteremia: temperature higher than 38.3°C (1 point), a Charlson comorbidity index of 3 or more (1 point), respiratory frequency of at least 22 breaths/min (1 point), leukocyte count greater than 12 000/mm3 (1 point), and procalcitonin concentration of 0.51 ng/mL or higher (4 points). Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.1%, 10.5%, and 77%, respectively. The model's area under the receiver operating characteristic curve was 0.946 (95% CI, 0.922-0.969).

CONCLUSION

The 5MPB-Toledo score could be useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

Validation of a predictive model for bacteraemia (MPB5-Toledo) in the patients seen in emergency departments due to infections

OBJECTIVE

To validate a simple risk score to predict bacteremia (MPB5-Toledo) in patients seen in the emergency departments (ED) due to infections.

METHODS

Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 74 Spanish ED for adults (aged 18 or older) seen from from October 1, 2019, to February 29, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

A total of 3.843 blood samples wered cultured. True cases of bacteremia were confirmed in 839 (21.83%). The remaining 3.004 cultures (78.17%) were negative. Among the negative, 172 (4.47%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.5%, 16.8%, and 81.6%, respectively. The model's area under the receiver operating characteristic curve was 0.930 (95% CI, 0.916-0.948). The prognostic performance with a model's cut-off value of ≥ 5 points achieved 94.76% (95% CI: 92.97-96.12) sensitivity, 81.56% (95% CI: 80.11-82.92) specificity, and negative predictive value of 98.24% (95% CI: 97.62-98.70).

CONCLUSION

The 5MPB-Toledo score is useful for predicting bacteremia in patients attended in hospital emergency departments for infection.

Evaluation of C-reactive protein, procalcitonin and the PCR/PCT index as indicators of mortality in abdominal sepsis

Background

Biomarker combinations can improve timely diagnosis and survival.

Objective

To determine the usefulness of serum procalcitonin concentration (PCT), C-reactive protein (PCR) and the PCR / PCT index as predictors of mortality.

Method

Retrospective study of patients diagnosed with abdominal sepsis during the period from April 2017 to February 2018.

Results

We included 182 cases. In the survivors, the mean PCR was 170 and procalcitonin (PCT) 10.5. In the deceased, the mean of C-reactive protein (CRP) was 328 and that of PCT was 17.6. When applying the student's t-test for independent samples, it was found that these differences were significant for PCR (p = 0.001); however, for PCT it was not significant (p = 0.460). Afterwards, the PCR/PCT index was studied, as a predictor of mortality, in the deceased cases a PCR/PCT score of 7534 (standard deviation [SD]: 19,303) and for survivors of 538 (SD:805) (p = 0.001) was obtained.

Conclusion

CRP is associated with mortality, serum PCT does not correlate with mortality. The PCR/PCT index seems to be a better indicator to predict mortality in patients with abdominal sepsis due to secondary peritonitis.

Predictive biomarkers for complicated acute appendicitis: A prospective Ecuadorian study

Aim

The aim of the study was to determine the usefulness of known biomarkers as pre-operative predictors of complicated acute appendicitis (CAA) and perforated appendicitis (PA).

Materials and methods

This was an observational, analytic, cross-sectional, and prospective study at Hospital Teodoro Maldonado Carbo (August 2016-December 2017). Evaluated biomarkers: white blood cells count, neutrophil percentage (N%), neutrophil-to-lymphocyte ratio, glucose, total bilirubin, C-reactive protein, and procalcitonin (PCT). The statistical analysis was performed by means of the area under the receiver operating characteristics (AUROC) curve estimation. Biomarkers' cutoff point was identified using Youden's index. Sensitivity, specificity, positive, and negative predictive value (NPV) (positive predictive value [PPV] and NPV) were estimated.

Results

One hundred and twenty-eight cases were included (median age 30 years, 44% female), 70 cases (54%) corresponded to CAA (PA 38/70). N% and PCT obtained an AUROC of 78% and 80% for CAA (PA 76% and 81%), respectively. A N% > 78.1% predicted CAA with a sensitivity, specificity, PPV, and NPV of 82%, 62%, 72%, and 72% (> 74.9%, PA: 94%, 53%, 46%, and 96%), respectively. PCT > 0.14 ng/dL predicted CAA with sensitivity, specificity, PPV, and NPV of 69%, 79%, 80%, and 68% (PA: 84%, 69%, 53%, and 91%).

Conclusion

The N% and PCT represent useful pre-operative biomarkers for discarding PA when an acute appendicitis is suspected.

Are reactive C protein and procalcitonin useful for early diagnosis of postoperative intraabdominal infection after pancreaticoduodenectomy for pancreatic cancer?

Objective

To evaluate the relationship between C reactive protein and procalcitonin levels and the appearance of post-operative intraabdominal infection, in patients with pancreaticoduodenectomy due to pancreatic cancer.

Method

A prospective observational study, including 35 patients, was made. Procalcitonin and C reactive protein were measured before surgery, as well as 24, 48 and 72 h after the surgical procedure. Patients were divided in two groups, with and without intraabdominal infection.

Results

Six patients (17.1%) presented post-operative intraabdominal infection. Both, procalcitonin and C reactive protein, increased in all patients after surgery, but there were no significant differences between the two groups. However, the ratio between the C reactive protein concentrations on post-operative day 3 and the concentrations on post-operative day 1 was significantly increased in the group of patients with intraabdominal infection. The predictive positive value and the predictive negative value for this ratio were 60% and 95%, respectively, for a cut-off point of 2.3.

Conclusions

The ratio between C reactive protein value on post-operative day 3 and the value on post-operative day 1 is a good predictor of post-operative intraabdominal infection after pancreaticoduodenectomy.

Presepsin versus other biomarkers to predict sepsis and septic shock in patients with infection defined by Sepsis-3 criteria: the PREDI study of diagnostic accuracy

OBJECTIVES

An accurate diagnosis of sepsis in the emergency department must be made before appropriate treatment can be started. Many biomarkers that are potentially useful have been studied. The main aim of this study was to compare the diagnostic accuracy of blood levels of presepsin, lactate, C-reactive protein (CRP), and procalcitonin (PCT) for predicting sepsis as defined by the Sepsis-3 criteria. The secondary aim was to evaluate the diagnostic accuracy of these biomarkers for predicting bacteremia whether or not sepsis or septic shock was present.

MATERIAL AND METHODS

Single-center, prospective, observational cohort study in the emergency department of a university hospital. Consecutive patients suspected of having infection were enrolled prospectively if they had at least 2 criteria for systemic inflammatory response syndrome. We measured presepsin, PCT, CRP, and lactate in blood extracted on admission.

RESULTS

Blood samples from 359 patients were analyzed; 228 (63.5%) met the criteria for sepsis and 20 (5.6%) met the criteria for septic shock. PCT and presepsin levels were the best predictors of sepsis and septic shock with areas under the receiver operating characteristic curve (AUC) of 0.711 (95% CI, 0.660-0.758) and 0.709 (95% CI, 0.658- 0.756), respectively (P <.001, both comparisons). The AUCs for CRP and lactate concentrations were, respectively, 0.63 (95% CI, 0.58-0.69) and 0.61 (95% CI, 0.56-0.66) (P <.05, both comparisons). On applying the diagnostic cut points of 0.25 ng/mL for PCT and 500 pg/mL for presepsin, the odds ratios were 2.51 (95% CI, 1.53-4.12) for PCT and 3.19 (95% CI, 1.91-5.31) for presepsin. The diagnostic accuracy of the combination of presepsin and PCT results (AUC, 0.71; 95% CI 0.66-0.76; P <.001) was no better than the accuracy of PCT alone. The most accurate predictor of bacteremia was PCT (AUC, 0.835; 95% CI, 0.79-0.87; P <.001).

CONCLUSION

Presepsin and PCT seem to be the best predictors of a diagnosis of sepsis or septic shock in emergency department patients.

Outcome prediction using the Mortality in Emergency Department Sepsis score combined with procalcitonin for influenza patients

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.

Ability of procalcitonin to differentiate true bacteraemia from contaminated blood cultures in an emergency department

OBJECTIVES

To analyse and compare the ability of procalcitonin (PCT), C-reactive protein (CRP) and leukocytes to differentiate true bacteraemia from contaminated blood cultures in patients seen in the emergency department (ED) for an episode of infectious disease.

METHODS

Observational, retrospective and descriptive analytical study of all blood cultures with positive growth extracted in an ED in adult patients (≥18 years) during 2016 and 2017. The follow-up was carried out over a 30-day period to calculate the predictive power and the prognostic performance for true bacteraemia.

RESULTS

A total of 266 blood cultures with positive growth were included in the study. Out of these, 154 (57.9%) were considered true bacteraemia and 112 (42.1%) were considered to be contaminated blood cultures. The area under the Receiver Operating Characteristic curve (AUC-ROC) for PCT to predict true bacteraemia was 0.983 (95% CI: 0.972-0.994; P<0.001) and, considering a cut-off value of≥0.43 ng/ml, PCT achieved 94% sensitivity, 91% specificity, positive predictive value of 94%, and negative predictive value of 92%. The AUC-ROC obtained for CRP was 0.639 (95% CI: 0.572-0.707, P<.001), for leukocytes of 0.693 (95% CI: 0.630-0.756, P<.001) and for immature leukocytes (>10% bands) of 0.614 (95% CI: 0.547-0.682, P<.001). The mean values for PCT were 3.44 (SD 6.30) ng/ml in true bacteraemia vs. 0.16 (SD 0.18) ng/ml in contaminated blood cultures (P<.001).

CONCLUSIONS

In blood cultures with positive growth extracted in an ED, PCT achieves the best prognostic performance of true bacteraemia vs. contaminated blood cultures, better than CRP and leukocytes.

[Valor predictivo de la procalcitonina para la necesidad de cirugía y la presencia de isquemia y necrosis en pacientes con obstrucción del intestino delgado]

Introduction

The purpose of this prospective cohort study was to evaluate whether serum procalcitonin (PCT) levels predict the need for surgery and the presence of ischemia and/or necrosis (I/N) in small bowel obstruction.

Method

Of 54 patients included, conservative management was performed in 31 (non-surgical group) and an exploratory laparotomy in 23 (surgical group). The reference value of the PCT was between 0.10 and 0.50 ng/mL.

Results

PCT levels were higher in the surgical group (7.05 ± 7.03 ng/mL) than in the non-surgical (0.37 ± 0.63 ng/mL), and in patients with I/N (10.06 ± 7.07 ng/mL) than without I/N (1.52 ± 1.45 ng/mL). In the ROC curve, the area under the curve was 0.91 for the need for surgery and 0.93 for I/N. PCT ≥ 0.80 ng/mL had the best sensitivity and specificity for surgery and ≥ 1.95 ng/mL for I/N. PCT was also an independent predictor for these events.

Conclusions

The levels of PCT can recognize the need for surgery and the presence of I/N in small bowel obstruction. Additional studies are needed to affirm or invalidate our findings.

[Comparación del índice de neutrófilos/linfocitos, la escala de SOFA y la concentración sérica de procalcitonina como indicadores de la gravedad de la apendicitis aguda]

Introducción

La apendicitis aguda (AA) es una de las principales causas de abdomen agudo. Un retraso en su diagnóstico y tratamiento elevan la morbimortalidad.

Objetivo

Evaluar el índice de neutrófilos/linfocitos (INL), la escala SOFA (Sequential Organ Failure Assessment), la procalcitonina (PCT) y la bilirrubina total (BT), y ver si existe relación como determinantes de la gravedad de la AA.

Método

Estudio retrospectivo, observacional, para comparar el INL contra biomarcadores (PCT, BT) y contra escalas de gravedad (APACHE II [Acute Physiology and Chronic Health Evaluation] y SOFA) y quirúrgica (Mannheim).

Resultados

82 casos de enero a mayo de 2017. El 80.8% de los casos con peritonitis generalizada presentaron un INL > 12 (p = 0.002). El 66% de los casos con perforación apendicular presentaban un INL > 12 (p = 0.024). El 70% de los casos graves por BT mostraron un INL > 12 (p = 0.004). El 75% de los casos graves por PCT presentaban un INL > 12 (p = 0.006). El 50% de los casos con SOFA > 6 mostraron un INL > 12 (U de Mann-Whitney, p = 0.023).

Conclusión

Existe una relación entre el INL tanto con SOFA, BT y PCT, lo cual indica que un INL > 12 puntos podría estar relacionado con peritonitis generalizada y apendicitis perforada.

Diagnostic value of procalcitonin in ventilator-associated pneumonia

BACKGROUND AND OBJECTIVE

Procalcitonin (PCT) can help the early diagnosis of bacterial infections and estimate the response obtained. The objective is to study the value of PCT for the diagnosis of ventilator-associated pneumonia (VAP).

PATIENTS AND METHOD

Prospective and observational study, carried out for 18 months, in a polyvalent Intensive Care Unit (ICU). Those included were over 18 years of age, with suspected pneumonia after 48h of mechanical ventilation (MV). Collected were demographic characteristics; admission pathology; reason for beginning MV; gravity scores (APACHE II, SAPS II and SOFA); C-reactive protein (CRP) and PCT. At the time of suspicion of VAP: early or late, radiological severity, presence of septic shock, SOFA, CRP, PCT and microbiology.

RESULTS

Ninety-one patients with suspected VAP were included. The mean age was 42 (17.76) and that of hospitalisation in the ICU was 18.59 (11.69) days. VAP was confirmed in 74 patients, of which 19 (25.7%) presented septic shock. The mortality was 28.4%. There were no significant differences of the PCT in the patients who presented VAP versus those who did not present VAP (P=.449). When patients without VAP, with VAP and VAP with shock, were compared, the PCT median was 0.38 (CI95%: 0.22-1.90), 0.56 (CI95%: 0.19-1.77) and 1.93 (CI95%: 0.38-10.07), respectively (P=.169).

CONCLUSIONS

In our study, PCT did not prove useful for the diagnosis of VAP.

Relationship between acute kidney injury and serum procalcitonin (PCT) concentration in critically ill patients with influenza infection

INTRODUCTION

Serum procalcitonin (PCT) concentration could be increased in patients with renal dysfunction in the absence of bacterial infection.

OBJECTIVE

To determine the interactions among serum renal biomarkers of acute kidney injury (AKI) and serum PCT concentration, in patients admitted to the intensive care unit (ICU) due to lung influenza infection.

DESIGN

Secondary analysis of a prospective multicentre observational study.

SETTING

148 Spanish ICUs.

PATIENTS

ICU patients admitted with influenza infection without bacterial co-infection. Clinical, laboratory and hemodynamic variables were recorded. AKI was classified as AKI I or II based on creatinine (Cr) concentrations (≥1.60-2.50mg/dL and Cr≥2.51-3.99mg/dL, respectively). Patients with chronic renal disease, receiving renal replacement treatment or with Cr>4mg/dL were excluded. Spearman's correlation, simple and multiple linear regression analysis were performed.

INTERVENTIONS

None.

RESULTS

Out of 663 patients included in the study, 52 (8.2%) and 10 (1.6%) developed AKI I and II, respectively. Patients with AKI were significantly older, had more comorbid conditions and were more severally ill. PCT concentrations were higher in patients with AKI (2.62 [0.60-10.0]ng/mL vs. 0.40 [0.13-1.20]ng/mL, p=0.002). Weak correlations between Cr/PCT (rho=0.18) and Urea (U)/PCT (rho=0.19) were identified. Simple linear regression showed poor interaction between Cr/U and PCT concentrations (Cr R²=0.03 and U R²=0.018). Similar results were observed during multiple linear regression analysis (Cr R²=0.046 and U R²=0.013).

CONCLUSIONS

Although PCT concentrations were slightly higher in patients with AKI, high PCT concentrations are not explained by AKI and could be warning sign of a potential bacterial infection.

Usefulness and prognostic value of biomarkers in patients with community-acquired pneumonia in the emergency department

Between all patients treated in the Emergency Department (ED), 1.35% are diagnosed with community-acquired pneumonia (CAP). CAP is the main cause of death due to infectious disease (10-14%) and the most frequent reason of sepsis-septic shock in the ED. In the last decade, the search for objective tools to help establishing an early diagnosis, bacterial aetiology, severity, suspicion of bacteremia and the prognosis of mortality has increased. Biomarkers have shown their usefulness in this matter. Procalcitonin (obtains the highest accuracy for CAP diagnosis, bacterial aetiology and the presence of bacteremia), lactate (biomarker of hypoxia and tissue hypoperfusion) and proadrenomedullin (which has the greatest accuracy to predict mortality which in combination with the prognostic severity scales obtains even better results). The aim of this review is to highlight recently published scientific evidence and to compare the utility and prognostic accuracy of the biomarkers in CAP patients treated in the ED.

[Construction of a diagnostic prediction model of severe bacterial infection in febrile infants under 3 months old]

INTRODUCTION

Fever is a common cause of paediatric admissions in emergency departments. An aetiological diagnosis is difficult to obtain in those less than 3 months of age, as they tend to have a higher rate of serious bacterial infection (SBI). The aim of this study is to find a predictor index of SBI in children under 3 months old with fever of unknown origin.

METHODS

A study was conducted on all children under 3 months of age with fever admitted to hospital, with additional tests being performed according to the clinical protocol. Rochester criteria for identifying febrile infants at low risk for SBI were also analysed. A predictive model for SBI and positive cultures was designed, including the following variables in the maximum model: C-reactive protein (CRP), procalcitonin (PCT), and meeting not less than four of the Rochester criteria.

RESULTS

A total of 702 subjects were included, of which 22.64% had an SBI and 20.65% had positive cultures. Children who had SBI and a positive culture showed higher values of white cells, total neutrophils, CRP and PCT. A statistical significance was observed with less than 4 Rochester criteria, CRP and PCT levels, an SBI (area under the curve [AUC] 0.877), or for positive cultures (AUC 0.888). Using regression analysis a predictive index was calculated for SBI or a positive culture, with a sensitivity of 87.7 and 91%, a specificity of 70.1 and 87.7%, an LR+ of 2.93 and 3.62, and a LR- of 0.17 and 0.10, respectively.

CONCLUSIONS

The predictive models are valid and slightly improve the validity of the Rochester criteria for positive culture in children less than 3 months admitted with fever.

Risk Factors for Mortality in 272 Patients With Lung Transplant: A Multicenter Analysis of 7 Intensive Care Units

BACKGROUND

One-year survival in lung transplant is around 85%, but this figure has not increased in recent years, in spite of technical improvements.

METHODS

Retrospective, multicenter cohort study. Data from 272 eligible adults with lung transplant were recorded at 7 intensive care units (ICU) in Spain in 2013. The objective was to identify variables that might help to guide future clinical interventions in order to reducethe risk of death in the postoperative period.

RESULTS

One patient (0.3%) died in the operating room and 27 (10%) within 90 days. Twenty (7.4%) died within 28 days, after a median of 14 ICU days. Grade 3 pulmonary graft dysfunction was documented in 108 patients, of whom 21 died, compared with 6 out of 163 without pulmonary graft dysfunction (P<.001). At ICU admission, non-survivors had significantly lower (P=.03) median PaO2/FiO2 (200mmHg vs 280mmHg), and the difference increased after 24hours (178 vs 297mmHg, P<.001). Thirteen required extracorporeal membrane oxygenation, and 7(53.8%) died. A logistic regression model identified pulmonary graft dysfunction (OR: 6.77), donor age>60yr (OR: 2.91) and SOFA>8 (OR: 2.53) as independent predictors of 90-day mortality. At ICU admission, higher median procalcitonin (1.6 vs 0.6) and lower median PaO2/FiO2 (200 vs 280mmHg) were significantly associated with mortality.

CONCLUSION

Graft dysfunction remains a significant problem in lung transplant. Early ICU interventions in patients with severe hypoxemia or high procalcitonin are crucial in order to lower mortality.

Usefulness of blood and cerebrospinal fluid laboratory testing to predict bacterial meningitis in the emergency department

INTRODUCTION

The classic clinical presentation of bacterial meningitis (BM) is observed in less than half of the cases in adults, and symptoms are less specific in children, the elderly or immunocompromised, and other chronic patients. The usual signs and symptoms do not provide optimal sensitivity and specificity for distinguishing possible BM from viral meningitis (VM), which may lead to a delay in the appropriate antimicrobial therapy. Society therefore stands to benefit from the development of effective, objective, and rapid tools able to predict and identify patients with BM. These tools include laboratory tests for blood and cerebrospinal fluid (CSF). The aim of this review is to summarise recently published scientific evidence in order to clarify existing controversies and compare the usefulness and diagnostic ability of the different parameters used to predict BM.

DEVELOPMENT

Systematic search of the main bibliographic databases and platforms to identify articles published between January 2000 and January 2016. We selected 59 articles that meet the objectives of this review.

CONCLUSIONS

CSF lactate, proportion of polymorphonuclear leukocytes, and CSF glucose, as well as serum procalcitonin (PCT), are the independent factors most predictive of bacterial aetiology. The model that combines serum PCT and CSF lactate achieves the highest predictive power for BM, with a sensitivity and specificity exceeding 99%. We should consider BM when CSF lactate >33 md/dL and/or PCT>0.25ng/mL.

Can procalcitonin be a diagnostic marker for catheter-related blood stream infection in children?

OBJECTIVE

The potential role of procalcitonin (PCT) in the diagnosis of catheter-related bloodstream infection (CRBSIs) is still unclear and requires further research. The diagnostic value of serum PCT for the diagnosis of CRBSI in children is evaluated here.

METHOD

This study was conducted between October 2013 and November 2014, and included patients with suspected CRBSI from 1 month to 18 years of age who were febrile, with no focus of infection, and had a central venous catheter. Levels of PCT and other serum markers were measured, and their utility as CRBSI markers was assessed. Additionally, the clinical performance of a new, automated, rapid, and quantitative assay for the detection of PCT was tested.

RESULTS

Among the 49 patients, 24 were diagnosed with CRBSI. The PCT-Kryptor and PCT-RTA values were significantly higher in proven CRBSI compared to those in unproven CRBSI (p=0.03 and p=0.03, respectively). There were no differences in white blood cell count and C-reactive protein (CRP) levels between proven CRBSI and unproven CRBSI. Among the 24 patients with CRBSI, CRP was significantly higher among those with Gram-negative bacterial infection than in those with Gram-positive bacterial infections. PCT-Kryptor was also significantly higher among patients with Gram-negative bacterial infection than in those with Gram-positive bacterial infections (p=0.01 and p=0.02, respectively).

CONCLUSIONS

The authors suggest that PCT could be a helpful rapid diagnostic marker in children with suspected CRBSIs.

Usefulness of analytical parameters in the management of paediatric patients with suspicion of acute pyelonephritis. Is procalcitonin reliable?

OBJECTIVE

To investigate the usefulness of procalcitonin (PCT) and other analytical parameters (white blood cell count [WBC], C-reactive protein [CRP]) as markers of acute renal damage in children after a first febrile or afebrile urinary tract infection (UTI).

METHODS

A retrospective study was conducted on children with a first episode of UTI admitted between January 2009 to December 2011, and in whom serum PCT, CRP and white blood cell count were measured, as well as assessing the acute renal damage with renal scintigraphy with ^99mTc-DMSA (DMSA) within the first 72h after referral. A descriptive study was performed and ROC curves were plotted, with optimal cut-off points calculated for each parameter.

RESULTS

The 101 enrolled patients were divided into two groups according to DMSA scintigraphy results, with 64 patients being classified with acute pyelonephritis (APN), and 37 with UTI. The mean WBC, CRP and PCT values were significantly higher in patients with APN with respect to normal acute DMSA. The area under the ROC curve was 0.862 for PCR, 0.774 for WBC, and 0.731 for PCT. The optimum statistical cut-off value for PCT was 0.285ng/ml (sensitivity 71.4% and specificity 75%).

CONCLUSION

Although the mean levels of fever, WBC, CRP, and PCT were significantly increased in patients with APN than in those who had UTI, the sensitivity and specificity of these analytical parameters are unable to predict the existence of acute renal damage, making the contribution by renal DMSA scintigraphy essential.

Review of Non-Bacterial Infections in Respiratory Medicine: Viral Pneumonia

Although bacteria are the main pathogens involved in community-acquired pneumonia, a significant number of community-acquired pneumonia are caused by viruses, either directly or as part of a co-infection. The clinical picture of these different pneumonias can be very similar, but viral infection is more common in the pediatric and geriatric populations, leukocytes are not generally elevated, fever is variable, and upper respiratory tract symptoms often occur; procalcitonin levels are not generally affected. For years, the diagnosis of viral pneumonia was based on cell culture and antigen detection, but since the introduction of polymerase chain reaction techniques in the clinical setting, identification of these pathogens has increased and new microorganisms such as human bocavirus have been discovered. In general, influenza virus type A and syncytial respiratory virus are still the main pathogens involved in this entity. However, in recent years, outbreaks of deadly coronavirus and zoonotic influenza virus have demonstrated the need for constant alert in the face of new emerging pathogens. Neuraminidase inhibitors for viral pneumonia have been shown to reduce transmission in cases of exposure and to improve the clinical progress of patients in intensive care; their use in common infections is not recommended. Ribavirin has been used in children with syncytial respiratory virus, and in immunosuppressed subjects. Apart from these drugs, no antiviral has been shown to be effective. Prevention with anti-influenza virus vaccination and with monoclonal antibodies, in the case of syncytial respiratory virus, may reduce the incidence of pneumonia.

Usefulness of procalcitonin and C-reactive protein for predicting bacteremia in urinary tract infections in the emergency department

INTRODUCTION

The aim of this study was to analyze and compare the capacity of procalcitonin (PCT), C-reactive protein (CRP), lactate and leukocytes to predict the presence of bacteremia in patients with urinary tract infections (UTIs).

METHODS

Observational, retro-prospective analytical study of adult patients (≥15 years) diagnosed with UTI in an emergency department from August 2012 to January 2013.

RESULTS

The study included 328 patients diagnosed with UTI, with a mean age of 52±22 years, 74% of whom were women. Of these, 43 (13.1%) had bacteremia. For predicting bacteremia, PCT achieved the largest area under the receiver operating characteristic curve (ROC-AUC) at .993 (95% CI .987-1; P<.001). A cutoff≥1.16ng/mL achieves a sensitivity of 100%, a specificity of 97%, a positive predictive value of 84% and a negative predictive value of 100%. Lactate achieved an ROC-AUC of .844, and CRP achieved only .534. The mean values when comparing PCT levels in patients with UTIs with and without bacteremia were 8.08±16.37 and .34±.37ng/mL, respectively (P<.001).

CONCLUSIONS

For patients with UTIs in the emergency department, PCT achieves considerable diagnostic performance for suspecting bacteremia, a performance greater than that of lactate, CRP and leukocytes.

[Predictive value of procalcitonin in children with suspected sepsis]

INTRODUCTION

The use of biomarkers could be a tool for diagnosis, prognosis and stratifying children with sepsis. Our main goal was to analyze the value of procalcitonin (PCT), C reactive protein (CRP) and lactate in predicting mortality, septic shock and the stratification in children with suspected sepsis

PATIENTS AND METHOD

Prospective study in 81 patients. Plasma levels of PCT, CRP and lactate were measured at admission in the pediatric intensive care unit. Patients were categorized into systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock.

RESULTS

Concentrations of PCT (ng/mL) increased significantly according to the severity of sepsis: 0.36 (0-1.2) for systemic inflammatory response syndrome; 1.96 (0.4-3.5) for sepsis; 7.5 (3.9-11.1) for severe sepsis; and 58.9 (35.1-82.7) for septic shock (P<.001). Compared to CRP and lactate, the area under the ROC curve revealed a good discriminative power of PCT to predict septic shock and mortality, 0.91 (95% CI: 0.83-0.97) and 0.80 (95% CI: 0.69-0.88), respectively.

CONCLUSIONS

In contrast to CRP and lactate, the determination of PCT in pediatric intensive care unit admission is a good predictor of mortality and septic shock and can stratify patients according to severity of sepsis.

Review of Non-Bacterial Infections in Respiratory Medicine: Viral Pneumonia

Although bacteria are the main pathogens involved in community-acquired pneumonia, a significant number of community-acquired pneumonia are caused by viruses, either directly or as part of a co-infection. The clinical picture of these different pneumonias can be very similar, but viral infection is more common in the pediatric and geriatric populations, leukocytes are not generally elevated, fever is variable, and upper respiratory tract symptoms often occur; procalcitonin levels are not generally affected. For years, the diagnosis of viral pneumonia was based on cell culture and antigen detection, but since the introduction of polymerase chain reaction techniques in the clinical setting, identification of these pathogens has increased and new microorganisms such as human bocavirus have been discovered. In general, influenza virus type A and syncytial respiratory virus are still the main pathogens involved in this entity. However, in recent years, outbreaks of deadly coronavirus and zoonotic influenza virus have demonstrated the need for constant alert in the face of new emerging pathogens. Neuraminidase inhibitors for viral pneumonia have been shown to reduce transmission in cases of exposure and to improve the clinical progress of patients in intensive care; their use in common infections is not recommended. Ribavirin has been used in children with syncytial respiratory virus, and in immunosuppressed subjects. Apart from these drugs, no antiviral has been shown to be effective. Prevention with anti-influenza virus vaccination and with monoclonal antibodies, in the case of syncytial respiratory virus, may reduce the incidence of pneumonia.

[Usefulness of procalcitonin for diagnosing infection in critically ill patients with liver cirrhosis]

OBJECTIVE

To evaluate the usefulness of procalcitonin (PCT) for diagnosing infection in patients with liver cirrhosis admitted to an Intensive Care Unit.

DESIGN

A retrospective study was carried out.

SCOPE

Intensive Care Unit. Versatile, twenty-four beds. Participants Patients with liver cirrhosis admitted to our Intensive Care Unit in the last four years with suspected infection and measurement of PCT.

RESULTS

Among the 255 patients with cirrhosis admitted to our unit, PCT was determined for the differential diagnosis of infection in 69 cases (27%). Three patients were excluded from analysis due to a lack of clinical data. The average stay was 10.6 ± 9.2 days, with a mortality rate of 65%. The origin of cirrhosis was mainly viral (57%) or alcoholic (37%). The Child-Pugh and MELD scores were 9.5 ± 2 and 23 ± 8, respectively. Infection was diagnosed in 54 patients (82%). The most common infection was pneumonia (72%), followed by intraabdominal infections (18%) and bacteremia (5%). In patients without infection, the median PCT concentration was 0.57 ng/ml (range 0.28 to 1.14) versus 2.99 (1.31 to 9.4) in those with infection (p<.001). Diagnostic capacity was maintained in patients with intraabdominal infections. The diagnostic cutoff point was set at 0.8 ng/ml (sensitivity 83%, specificity 75%, AUC 0.82 [0.702-0.93]).

CONCLUSIONS

In patients with liver cirrhosis, PCT is useful for identifying bacterial infections, including intraabdominal processes.

Validity of procalcitonin for the diagnosis of bacterial infection in elderly patients

INTRODUCTION

PCT has been consolidated as a key tool in the diagnosis of bacterial infections in general population. Few studies have been conducted to determine the applicability of this test in elderly patients.

METHODS

Study of validity of PCT on elderly patients. Two groups were formed; the first group was formed by patients aged 75 years or older, under bacterial infection criteria and PCT on the initial Lab test. The second group was formed by patients aged 75 years or older with any noninfectious disease; these patients were asked PCT in the initial Lab test. Sensitivity, specificity, positive and negative likelihood ratio were calculated.

RESULTS

161 patients were included, 95 with probable bacterial infection and 66 without infection. Patients with probable bacterial infection criteria, 72% of them had PCT >0.5 ng/mL. Patients without infection, 8% of the patients had PCT >0.5 ng/mL. Sensitivity and specificity of PCT to bacterial infection with the cutoff value of 0.5 ng/mL was 72% and 92%, respectively.

CONCLUSION

PCT can be used in elderly patients to diagnose bacterial infections because it has proved good sensitivity and high specificity.

Ability of procalcitonin to predict bacterial meningitis in the emergency department

INTRODUCTION

The aim of this study was to analyse and compare procalcitonin (PCT) and C-reactive protein (CRP) as tools for detecting bacterial meningitis and predicting bacteraemia.

METHODS

Prospective, observational, and descriptive analytical study of 98 consecutive patients aged ≥15 years and diagnosed with acute meningitis in an emergency department between August 2009 and July 2013.

RESULTS

We analysed 98 patients with AM (66 males [67%]); mean age was 44±21 years. The diagnosis was bacterial meningitis in 38 patients (20 with bacteraemia); viral meningitis in 33; probable viral meningitis in 15; and presumptively diagnosed partially treated acute meningitis in 12. PCT had the highest area under the ROC curve (AUC) (0.996; 95% CI, 0.987-1; p<0.001). With a cutoff of ≥ 0.74 ng/ml, PCT achieved 94.7% sensitivity, 100% specificity, negative predictive value (NPV) of 93.9%, and positive predictive value (PPV) of 100%. The mean levels for PCT were11.47±7.76 ng/ml in bacterial meningitis vs. 0.10±0.15 ng/ml in viral meningitis (p <0.001). The AUC for CRP was 0.916 and a cutoff of ≥ 90 mg/L achieved 67.5% sensitivity, 86.3% specificity, PPV of 89.2%, and NPV of 90.4%. As a predictor of bacteraemia in bacterial meningitis, only PCT delivered a significant difference (14.7±7.1 ng/mL vs. 4.68±3.54 ng/mL, p<0.001). A cutoff of ≥ 1.1 ng/mL achieved 94.6% sensitivity, 72.4% specificity, NPV of 95.4%, and PPV of 69.2%; the AUC was 0.965 (95% CI, 0.921-1; p<0.001).

CONCLUSIONS

PCT has a high diagnostic power for acute meningitis in emergency department patients. PCT outperforms CRP in the detection of bacterial aetiology and is a good predictor of bacteraemia in bacterial meningitis.

[Prognostic value of lipopolysaccharide binding protein and procalcitonin in patients with severe sepsis and septic shock admitted to intensive care]

AIMS

1) To assess the prognostic value of levels on admission and serial measurements of lipopolysaccharide binding protein (LBP) and procalcitonin (PCT) in relation to in-hospital mortality; and 2) to determine whether the addition of these parameters to severity scores (APACHE II and SOFA) is able to improve prognostic accuracy.

DESIGN

A single-center, prospective observational study was carried out.

SETTING

Intensive Care unit of a university hospital.

PATIENTS

One hundred severe sepsis and septic shock patients were included.

DATA COLLECTED

Demographic data, APACHE II and SOFA scores, PCT and LBP levels on admission and after 48 hours, and in-hospital mortality.

RESULTS

The best area under the curve for predicting in-hospital mortality corresponded to APACHE II on admission and SOFA after 48 h (AUC ROC: 0.75 for both). PCT and LBP levels on admission and LBP clearance were not statistically different between in-hospital survivors and non-survivors. Only PCT clearance was higher among in-hospital survivors than in non-survivors (AUC ROC: 0.66). The combination of severity scores and PCT clearance did not result in superior areas under the curve.

CONCLUSIONS

LBP and PCT levels on admission and LBP clearance showed no prognostic value in severe sepsis and septic shock patients. Only PCT clearance was predictive of in-hospital mortality. The prognostic accuracy was significantly better for APACHE on admission and SOFA after 48 h than for any of the analyzed biomarkers, and the addition of PCT clearance did not improve their prognostic value.

[Procalcitonin and C-reactive protein as early indicators of postoperative intra-abdominal infection after surgery for gastrointestinal cancer]

AIM

to evaluate the association between serum levels of procalcitonin and C-reactive protein, on the first 3 postoperative days, and the appearance of postoperative intra-abdominal infection.

METHOD

Prospective observational study including 67 patients operated on for colo-rectal, gastric and pancreatic cancer. Serum levels of procalcitonin and C-reactive protein were analyzed before surgery and daily until the third postoperative day. Values of procalcitonin (PCT) and C-reactive protein (CRP) were recorded as well as their accuracy for detection of postoperative intra-abdominal infection (PIAI).

RESULTS

The incidence of postoperative intra-abdominal infection was 13.4%. CRP serum levels at 72h, PCT serum levels at 24, 48 and 72h and the ratio between serum levels of CRP at 72hours and serum levels of CRP at 48hours (CRP D3/CRP D2) were significantly associated with the appearance of postoperative intra-abdominal infection. The highest sensitivity corresponded to PCT at 72hours (88.9%); the highest specificity and positive predictive value corresponded to the ratio CRP D3/CRP D2 (96.49% and 71.4%, respectively); the highest negative predictive value to procalcitonin at 72h and 24h.

CONCLUSIONS

Serum levels of PCT are significantly associated with the appearance of postoperative intra-abdominal infection. Sensitivity and predictive positive values are low, but negative predictive value is high, even at 24h after surgery.

[Diagnostic and prognostic power of biomarkers to improve the management of community acquired pneumonia in the emergency department]

OBJECTIVES

To analyse the usefulness and performance of several biomarkers [C-reactive protein (CRP), mid-regional pro-adrenomedullin (MR-proADM), procalcitonin (PCT)] and lactate in predicting short- and medium-term mortality compared with the prognostic severity scales (PSS) usually employed for community-acquired pneumonia (CAP) and in assessing the aetiological suspicion of infection by Streptococcus pneumoniae and bacteraemia.

METHODS

Observational, prospective and analytical study was conducted on patients who were diagnosed with CAP in our emergency department (ED). The data collected included socio-demographic and comorbidity variables, Charlson index, priority level according to the Spanish Triage System (STS), stage in the Pneumonia Severity Index (PSI) and in the CURB-65 (confusion, urea, respiratory rate, blood pressure and age ≥65years), criteria of severe CAP, microbiological studies, and biomarkers determinations. The patients were followed-up for 180days to calculate the prognostic power and the diagnostic performance for bacteraemia and aetiology.

RESULTS

A total of 127patients were finally enrolled in the study. The 30-day mortality was 10.3% (13), and 22.6% (28) at 180 days. Blood cultures were positive in 29 patients (23%) and S.pneumoniae was identified as the responsible pathogen in 28 cases (22.2%). The area under the ROC curve (AUC-ROC) for lactate and MR-proADM to predict 30-day mortality was 0.898 (95%CI: 0.824-0.973; P<.0001) and 0.892 (95%CI: 0.811-0.974; P<.0001), respectively, and for MR-proADM at 180 days it was 0.921 (95%CI: 0.874-0.968; P<.0001). The AUC-ROC for PCT to predict bacteraemia was 0.952 (95%CI: 0.898-1.000; P<.0001) and, considering a cut-off value ≥0.95ng/ml, the negative predictive value (NPV) and the likelihood ratio (LR+) were 97.8% and 9.03, respectively. Using a PCT cut-off value >0.85ng/ml, the NPV and the LR+ were 96.6% and 5.89%, respectively, to predict a S.pneumoniae infection.

CONCLUSIONS

MR-proADM and lactate showed a similar or even better performance for 30-day intra-hospital mortality than PSI, CURB-65, STS and CAP severity criteria in patients diagnosed with CAP (P>.05). Furthermore, the MR-proADM capacity to predict 180-day mortality was higher than PSS and the rest of biomarkers (P>.05), and its AUC-ROC increased if it was used in combination with PSI, CURB65 and STS. The determination of PCT has a remarkable diagnostic performance to rule out bacteraemia and to orientate the aetiology towards a S.pneumoniae infection.

[Role of plasma procalcitonin in the diagnosis of ventilator-associated pneumonia: systematic review and metaanalysis]

OBJECTIVE

To determine the role of plasma procalcitonin (PCT) levels in diagnosing ventilator-associated pneumonia.

DESIGN

A systematic review of publications prospectively assessing the diagnostic role of PCT in ventilator-associated pneumonia was carried out. The search was performed using Medline, Embase, the Cochrane Collaboration and MEDION, with reviewing of the references of retrieved articles. We extracted data that allowed the calculation of sensitivity, specificity, likelihood ratios and diagnostic odds ratio. Intervention Metaregression was performed to determine whether exposure to previous antibiotic treatment, the time to occurrence of ventilator-associated pneumonia and the type of patients had an impact upon the diagnostic performance of procalcitonin.

RESULTS

Seven studies were considered (373 patients, 434 episodes). We found no publication bias or threshold effect. High plasma PCT levels were associated to an increased risk of suffering ventilator-associated pneumonia (OR: 8.39; 95% CI: 5.4-12.6). The pooled data on sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio found were 76% (69-82), 79% (74-84), 4.35 (2.48-7.62), 0.26 (0.15-0.46) and 17.9 (10.1-31.7), respectively. Diagnostic yield was modified by prior exposure to antibiotics (rDOR 0.11, 0.02-0.069), but not by the type of critically ill patient or the time to occurrence of ventilator-associated pneumonia.

CONCLUSIONS

Our results suggest that PCT provides additional information on the risk of VAP. Inclusion of PCT in diagnostic algorithms could improve their effectiveness.