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Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia

Charles-Edouard Luyt| Alain Combes| Catherine Reynaud| Guillaume Hekimian| Ania Nieszkowska| Marc Tonnellier| Alexandra Aubry| Jean-Louis Trouillet| Maguy Bernard| Jean Chastre
Original
Volume 34, Issue 8 / August , 2008

Pages 1434 - 1440

Abstract

Objective

To assess the predictive capacity for the diagnosis of ventilator-associated pneumonia (VAP) of serum procalcitonin levels before and on the day it is suspected.

Design and setting

Single-center observational study in the intensive care unit of a teaching hospital.

Patients and participants

Consecutive patients whose serum procalcitonin levels were available on the day that VAP was clinically suspected (day 1) and at some time within the preceding 5 days (“before”).

Measurements and results

Serum procalcitonin levels were determined on day 1 and “before”. Among the 73 suspected episodes VAP was confirmed by quantitative bronchoalveolar lavage cultures in 32 and refuted in 41. Respective median “before” procalcitonin levels were 1.89 ng/ml (interquartile range 0.18–6.01) and 2.14 (0.76–5.75) in patients with and without VAP, but their respective median day-1 procalcitonin levels did not differ: 1.07 ng/ml (0.39–6.57) vs. 1.40 (0.67–3.39). On day 1 a 0.5 ng/ml procalcitonin threshold had 72% sensitivity but only 24% specificity for diagnosing VAP. Between “before” and day 1, procalcitonin increased in 41% and 15% of patients with and without VAP, respectively. Thus a procalcitonin rise on day 1, compared to its “before” level, had 41% sensitivity and 85% specificity for diagnosing VAP, with respective positive and negative predictive values of 68% and 65%.

Conclusions

Crude values and procalcitonin rise had poor diagnostic value for VAP in this particular setting and thus should not be used to initiate antibiotics when VAP is clinically suspected.

Keywords

References

  1. Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903
    • View reference on PubMed
  2. Canadian Critical Care Trials Groups (2006) A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 355:2619–2630
    • View reference on publisher's website
  3. Heyland DK, Cook DJ, Marshall J, Heule M, Guslits B, Lang J, Jaeschke R (1999) The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Canadian Critical Care Trials Group. Chest 115:1076–1084
    • View reference on PubMed
    • View reference on publisher's website
  4. Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stephan F, Similowski T, Mercat A, Diehl JL, Sollet JP, Tenaillon A (2000) Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial. Ann Intern Med 132:621–630
    • View reference on PubMed
  5. American Thoracic Society, Infectious Diseases Society of America (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416
    • View reference on publisher's website
  6. Muller B, White JC, Nylen ES, Snider RH, Becker KL, Habener JF (2001) Ubiquitous expression of the calcitonin-i gene in multiple tissues in response to sepsis. J Clin Endocrinol Metab 86:396–404
    • View reference on PubMed
    • View reference on publisher's website
  7. Uzzan B, Cohen R, Nicolas P, Cucherat M, Perret GY (2006) Procalcitonin as a diagnostic test for sepsis in critically ill adults and after surgery or trauma: a systematic review and meta-analysis. Crit Care Med 34:1996–2003
    • View reference on PubMed
    • View reference on publisher's website
  8. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med 29:530–538
    • View reference on PubMed
  9. Duflo F, Debon R, Monneret G, Bienvenu J, Chassard D, Allaouchiche B (2002) Alveolar and serum procalcitonin: diagnostic and prognostic value in ventilator-associated pneumonia. Anesthesiology 96:74–79
    • View reference on PubMed
    • View reference on publisher's website
  10. Gibot S, Cravoisy A, Levy B, Bene MC, Faure G, Bollaert PE (2004) Soluble triggering receptor expressed on myeloid cells and the diagnosis of pneumonia. N Engl J Med 350:451–758
    • View reference on PubMed
    • View reference on publisher's website
  11. Luyt CE, Guerin V, Combes A, Trouillet JL, Ayed SB, Bernard M, Gibert C, Chastre J (2005) Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia. Am J Respir Crit Care Med 171:48–53
    • View reference on PubMed
    • View reference on publisher's website
  12. Seligman R, Meisner M, Lisboa TC, Hertz FT, Filippin TB, Fachel JM, Teixeira PJ (2006) Decreases in procalcitonin and C-reactive protein are strong predictors of survival in ventilator-associated pneumonia. Crit Care 10:R125
    • View reference on PubMed
    • View reference on publisher's website
  13. Suprin E, Camus C, Gacouin A, Le Tulzo Y, Lavoue S, Feuillu A, Thomas R (2000) Procalcitonin: a valuable indicator of infection in a medical ICU? Intensive Care Med 26:1232–1238
  14. Chastre J, Fagon JY, Bornet-Lecso M, Calvat S, Dombret MC, al Khani R, Basset F, Gibert C (1995) Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 152:231–240
    • View reference on PubMed
  15. Luyt CE, Combes A, Nieszkowska A, Reynaud C, Tonnellier M, Trouillet JL, Chastre J (2007) Does invasive diagnosis of nosocomial pneumonia during off-hours delay treatment? Intensive Care Med 33:734–737
  16. McCabe WR, Jackson GG (1982) Gram-negative bacteremia. Arch Intern Med 110:2957–2963
  17. Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963
    • View reference on PubMed
    • View reference on publisher's website
  18. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710
  19. Weinberg PF, Matthay MA, Webster RO, Roskos KV, Goldstein IM, Murray JF (1984) Biologically active products of complement and acute lung injury in patients with the sepsis syndrome. Am Rev Respir Dis 130:791–796
    • View reference on PubMed
  20. Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL (2000) Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. Am J Respir Crit Care Med 162:505–511
    • View reference on PubMed
  21. Fartoukh M, Maitre B, Honore S, Cerf C, Zahar JR, Brun-Buisson C (2003) Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med 168:173–179
    • View reference on PubMed
    • View reference on publisher's website
  22. Luyt CE, Chastre J, Fagon JY (2004) Value of the clinical pulmonary infection score for the identification and management of ventilator-associated pneumonia. Intensive Care Med 30:844–852
  23. Oppert M, Reinicke A, Muller C, Barckow D, Frei U, Eckardt KU (2002) Elevations in procalcitonin but not C-reactive protein are associated with pneumonia after cardiopulmonary resuscitation. Resuscitation 53:167–170
    • View reference on PubMed
    • View reference on publisher's website
  24. Ramirez P, Garcia MA, Ferrer M, Aznar J, Valencia M, Sauquillo JM, Menendez R, Asenjo MA, Torres A (2008) Sequential measurements of procalcitonin in diagnosing ventilator-associated pneumonia. Eur Respir J 31:356–362
    • View reference on PubMed
    • View reference on publisher's website
  25. Hausfater P, Garric S, Ayed SB, Rosenheim M, Bernard M, Riou B (2002) Usefulness of procalcitonin as a marker of systemic infection in emergency department patients: a prospective study. Clin Infect Dis 34:895–901
    • View reference on PubMed
    • View reference on publisher's website
  26. Christ-Crain M, Stolz D, Bingisser R, Muller C, Miedinger D, Huber PR, Zimmerli W, Harbarth S, Tamm M, Muller B (2006) Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med 174:84–93
    • View reference on PubMed
    • View reference on publisher's website
  27. Tang BM, Eslick GD, Craig JC, McLean AS (2007) Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis 7:210–227
    • View reference on PubMed
    • View reference on publisher's website
  28. Boutten A, Dehoux MS, Seta N, Ostinelli J, Venembre P, Crestani B, Dombret MC, Durand G, Aubier M (1996) Compartmentalized IL-8 and elastase release within the human lung in unilateral pneumonia. Am J Respir Crit Care Med 153:336–342
    • View reference on PubMed
  29. Dehoux MS, Boutten A, Ostinelli J, Seta N, Dombret MC, Crestani B, Deschenes M, Trouillet JL, Aubier M (1994) Compartmentalized cytokine production within the human lung in unilateral pneumonia. Am J Respir Crit Care Med 150:710–716
    • View reference on PubMed
  30. Brunkhorst FM, Al-Nawas B, Krummenauer F, Forycki ZF, Shah PM (2002) Procalcitonin, C-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia. Clin Microbiol Infect 8:93–100
    • View reference on PubMed
    • View reference on publisher's website
  31. Meisner M (1999) Procalcitonin: experience with a new diagnostic tool for bacterial infection and systemic inflammation (in German). J Lab Med 23:263–272
  32. Stolz D, Christ-Crain M, Bingisser R, Leuppi J, Miedinger D, Muller C, Huber P, Muller B, Tamm M (2007) Antibiotic treatment of exacerbations of COPD: a randomized, controlled trial comparing procalcitonin-guidance with standard therapy. Chest 131:9–19
    • View reference on PubMed
    • View reference on publisher's website

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