PROCALCITONIN: Contributing to IMPROVED CLINICAL DECISION MAKING

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Clinical Implication of Serum Procalcitonin in
Sepsis and pneumonia
Dr. Yaser Gad
Lecturer of chest diseases, Assuit faculty of
medicine
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Sepsis

• The most common cause of death in intensive care
  units
• Mortality rate up to 50 depending on severity.
• Early diagnosis and intervention markedly reduce
  the mortality

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Infection Source in Severe Sepsis
Angus DC et al. Crit Care Med. 2001 291303
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Pneumonia
The major infection-related cause of death in
developed countries
10 to 20 admitted to the intensive care unit
20 to 50 of them will ultimately die
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Fight as much as you can

• Early diagnosis and intervention
• Differentiate between infectious and non
  infectious case of systemic inflammation

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• Early diagnosis is essential to
• Administer the correct treatment
• Avoid unnecessary antibiotic use
• Reducing the morbidity, mortality
• And decrease care-related costs.

(1)
Cantürk et al., Turk J Med Sci 2008 38 (2)
139-144
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Delayed diagnosis

• Delays treatment
• Increases hospital length-of-stay
• Increases costs
• Increased mortality

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Delayed intervention can be fatal
Sebat CCM 2007 35 2568
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It is very important to differentiate between
infectious and non infectious case of systemic
inflammation
(2)
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Inability to differentiate between infectious and
non infectious causes
Unplanned use of antibiotics
Antibiotic resistance
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Acute exacerbations
70 are infectious in origin .
2030 related to bacteria detected by sputum
culture
viruses are detected in gt50 of exacerbations
Bacteria are isolated from the respiratory tract
of only 50 of patients
Chen et al, 2008 Chinese Medical Journal, 2008,
Dauben et al., BMC Infect Dis. 2008 8 145.
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• Antibiotics were found to have been prescribed in
  85 of patients admitted for AE-COPD to 360
  hospitals throughout the USA
• Drug costs accounted for more than 70 of the
  total costs AE-COPD

Chen et al, 2008 Chinese Medical Journal, 2008,
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Antibiotic sensitivity for AECOPD in Upper Egypt
Agamy et al., Egyp.J. Ch.dises. And tub. 2011
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Antibiotic sensitivity for CAP and HAP in Upper
Egypt
Agamy et al., Egyp.J. Ch.dises. And tub. 2011
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Acute phase reactants
Capable of demonstrating the inflammation
But can not
differentiate between bacterial and nonbacterial
inflammation
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CRP and leukocyte count do not have sufficient
specificity in differentiating between bacterial
infections, non-infectious systemic inflammations
or viral infections.
Cantürk et al., Turk J Med Sci 2008 38 (2)
139-144
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• Because most microbiological test results are not
  available for 24 h, a sensitive and specific
  marker of systemic infection would be useful.

Hausfater et al, 2002. Clinical Infectious
Diseases Volume 34, Issue 7Pp. 895-901 Reimer et
al. Clinical Microbiol Rev 1997 10444-65.
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• We are in need for a simple and rapid laboratory
  method to
• Guide antibiotic use
• Predict the prognosis
• Predict mortality
• Differentiate between infectious and non
  infectious causes of systemic inflammation

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Recently,
(PCT) levels appears to be useful in order to
minimize this problem. The sensitivity and
specificity of PCT in bacterial infections were
found to be 92.6 and 97.5
Cantürk et al., Turk J Med Sci 2008 38 (2)
139-144
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Invasion by pathogenic bacteria
Bacterial toxins and cytokines
Stimulate PCT production in all paraynchymal cells
Adapted from Christ-Crain et al. 2005
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IFN-g
Viral infection
Decreases PCT production
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VALUES OF PROCALCITONIN IN INFECTION
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1- PCT LEVEL INCREASE INCREASED SIGNIFICANCE OF
BACTERIAL INFECTION
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2- Differentiates between bacterial contamination
and real bacterial infection

• PCT may help discriminate blood stream infections
  from blood culture contamination due to
  coagulase-negative staphylococci

Schuetz P. et al., Infection 200735 (5) 352-5
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3- Predicts bacteremia

• PCT measurement demonstrated the potential to
  reduce the number of blood cultures

Muller et al. CHEST July 2010
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4- PROCALCITONIN CORRELATES TO THE SEVERITY OF
THE INFECTION
Pneumonia
Sepsis
Harbarth S et al. Am J Respir Crit Care Med 2001,
164 396-402 Meisner M et al., Critical Care
1999, 3(1) 45-50 Krüger S. et al., Eur Respir J
2008 31 349355
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5- Evaluates the prognosis
PCT
PCT

• Low PCT levels identify patients presenting in
  the ED that have a low risk for mortality

Huang, et.al., Annals of Emergency Medicine, Vol
51, March 2008
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6- Evaluates patient response to antibiotics

• Decreasing PCT levels indicate effective
  treatment of the underlying infection
• Persistently elevated PCT levels indicate a
  possible treatment failure

Stueber, F. University of Bonn, Lecture at
ISICEM, Brussels 2001
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PCT guidance in antibiotic usage Effects on
length of stay

• Effect of PCT-guided management in patients with
  sepsis on ICU length of stay

Nobre V. et alAM Resp Crit Care Med 2008
177498-505
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7- Sort out the etiology of the fever in patients
with the fever of unknown origin (FUO) syndrome

• PCT levels do not increase in some of the disease
  entities that cause the FUO syndrome, e.g.,
  Still's disease, systemic lupus erythematosus,
  and inflammatory bowel disease

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• PCT levels are not affected by the patient's use
  of nonsteroidal anti-inflammatory agents or
  glucocorticoids

If so,

• PCT levels remain a valuable marker of the host
  inflammatory response even when nonsteroidal
  anti-inflammatory drugs and corticosteroids are
  used

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Diagnostic accuracy of PCT compared to other
biomarkers used in sepsis

• PCT levels accurately differentiate sepsis from
  noninfectious inflammation
• PCT has been demonstrated to be the best marker
  for differentiating patients with sepsis from
  those with systemic inflammatory reaction not
  related to infectious cause

Simon L. et al. Clin Infect Dis. 2004
39206-217.
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False negative results

• Low PCT levels in the presence of bacterial
  infection may occur
• Early course of infection Re-measure in 6-12hrs
• Subacute Endocarditis
• Localized infections

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False positive results

• Cirrhosis
• Pancreatitis
• Mesenteric infarction (ischemic bowel)
• Cardiogenic shock, and hypotension during surgery
• Burns
• Pulmonary edema and pulmonary aspiration

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In conclusion

• PCT is usefull to diffrentiate between bacterial
  and non bacterial infection
• Differentiates between bacterial contamination
  and real bacterial infection
• Predicts bacteremia

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• PCT level correlates with the severity of
  infection in sepsis and pneumonia
• Evaluates the prognosis
• Evaluates patient response to antibiotics
• Sort out the etiology of the fever in patients
  with the fever of unknown origin (FUO) syndrome

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Thank you