Procalcitonin and procalcitonin kinetics for diagnosis and prognosis of intravascular catheter-related bloodstream infections in selected critically ill patients: a prospective observational study
Tóm tắt
Procalcitonin (PCT) has emerged as a valuable marker of sepsis. The potential role of PCT in diagnosis and therapy monitoring of intravascular catheter-related bloodstream infections (CRBSI) in intensive care unit (ICU) is still unclear and was evaluated. Forty-six patients were included in the study, provided they were free of infection upon admission and presented the first episode of suspected CRBSI during their ICU stay. Patients who had developed any other infection were excluded. PCT was measured daily during the ICU hospitalization. Primary endpoint was proven CRBSI. Therapy monitoring as according to infection control was also evaluated. Among the 46 patients, 26 were diagnosed with CRBSI. Median PCT on the day of infection suspicion (D0) was 7.70 and 0.10 ng/ml for patients with and without proven CRBSI, respectively (p < 0.001). The area under the curve (AUC) for PCT was 0.990 (95% CI; 0.972 – 1.000), whereas a cut-off value of 0.70 ng/ml provided sensitivity and specificity of 92.3 and 100% respectively. In contrast, the AUC for white blood cells (WBC) was 0.539 (95% CI; 0.369 – 0.709), and for C-reactive protein (CRP), 0.603 (95% CI; 0.438 – 0.768). PCT was the best predictor of proven infection. Moreover, an increase >0.20 ng/ml of PCT between the D0 and any of the 4 preceding days was associated with a positive predictive value exceeding 96%. PCT concentrations from the D2 to D6 after suspected infection tended to decrease in controlled patients, whereas remained stable in non-controlled subjects. A PCT concentration exceeding 1.5 ng/ml during D3 was associated with lack of responsiveness to therapy (p = 0.028). We suggest that PCT could be a helpful diagnostic and prognostic marker of CRBSI in critically ill patients. Both absolute values and variations should be considered.
Tài liệu tham khảo
Safdar N, Maki DG: The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med. 2004, 30: 62-67. 10.1007/s00134-003-2045-z.
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Coeschel C: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006, 355: 2725-2732. 10.1056/NEJMoa061115.
O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph AG, Rupp ME, Saint S, Healthcare Infection Control Practices Advisory Committee (HICPAC): Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011, 52: e162-e193. 10.1093/cid/cir257.
Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K, EPIC II Group of Investigators: International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009, 302: 2323-2329. 10.1001/jama.2009.1754.
Raad I, Hanna H, Maki D: Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis. 2007, 7: 645-657. 10.1016/S1473-3099(07)70235-9.
Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP, Raad II, Rijnders BJ, Sherertz RJ, Warren DK: Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009, 49: 1-45. 10.1086/599376.
Safdar N, Maki DG: Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med. 2002, 30: 2632-2635. 10.1097/00003246-200212000-00003.
Bouza E, Alvarado N, Alcalá L, Pérez MJ, Rincón C, Muñoz P: A randomized and prospective study of 3 procedures for the diagnosis of catheter-related bloodstream infection without catheter withdrawal. Clin Infect Dis. 2007, 44: 820-826. 10.1086/511865.
Khatib R, Riederer K, Saeed S, Johnson LB, Fakih MG, Sharma M, Tabriz MS, Khosrovaneh A: Time to positivity in Staphylococcus aureus bacteremia: possible correlation with the source and outcome of infection. Clin Infect Dis. 2005, 41: 594-598. 10.1086/432472.
Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti S, Taiberg L, Gurka D, Kumar A, Cheang M: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006, 34: 1589-1596. 10.1097/01.CCM.0000217961.75225.E9.
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008, 36: 296-327. 10.1097/01.CCM.0000298158.12101.41.
Schuetz P, Mueller B, Trampuz A: Procalcitonin and other biomarkers for the assessment of disease severity and guidance of treatment in bacterial infections. Adv Sepsis. 2008, 6: 82-89.
Assicot M, Gendrel D, Carsin H, Raymond J, Guilbaud J, Bohuon C: High serum procalcitonin concentrations in patients with sepsis and infection. Lancet. 1993, 341: 515-518. 10.1016/0140-6736(93)90277-N.
Charles PE, Kus E, Aho S, Prin S, Doise JM, Olsson NO, Blettery B, Quenot JP: Serum procalcitonin for the early recognition of nosocomial infection in the critically ill patients: a preliminary report. BMC Infect Dis. 2009, 9: 49-10.1186/1471-2334-9-49.
Tsangaris I, Plachouras D, Kavatha D, Gourgoulis GM, Tsantes A, Kopterides P, Tsaknis G, Dimopoulou I, Orfanos S, Giamarellos-Bourboulis E, Giamarellou H, Armaganidis A: Diagnostic and prognostic value of procalcitonin among febrile critically ill patients with prolonged ICU stay. BMC Infect Dis. 2009, 9: 213-10.1186/1471-2334-9-213.
Nobre V, Stephan Harbarth S, Graf J, Rohner P, Pugin J: Use of procalcitonin to shorten antibiotic treatment duration in septic patients. Am J Respir Crit Care Med. 2007, 177: 498-505. 10.1164/rccm.200708-1238OC.
Bouadma L, Luyt CE, Tubach F, Cracco C, Alvarez A, Schwebel C, Schortgen F, Lasocki S, Veber B, Dehoux M, Bernard M, Pasquet B, Régnier B, Brun-Buisson C, Chastre J, Wolff M, PRORATA trial group: Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet. 2010, 375: 463-474. 10.1016/S0140-6736(09)61879-1.
Uzzan B, Cohen R, Nicholas P, Cucherat M, Perret GY: 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. 2006, 34: 1996-2003. 10.1097/01.CCM.0000226413.54364.36.
Tang B, Eslick G, Craig J, McLean A: Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis. 2007, 7: 210-217. 10.1016/S1473-3099(07)70052-X.
Schuetz P, Albrich W, Mueller B: Procalcitonin for diagnosis of infection and guide to antibiotic decisions: past, present and future. BMC Med. 2011, 9: 107-10.1186/1741-7015-9-107.
Chen J, Wang Y, Shen Z, Zhu Z, Song Y, Han R: Early diagnostic value of plasma PCT and BG assay for CRBSI after OLT. Transplant Proc. 2011, 43: 1777-1779. 10.1016/j.transproceed.2010.11.026.
Schuetz P, Mueller B, Trampuz A: Serum procalcitonin for discrimination of blood contamination from bloodstream infection due to coagulase-negative staphylococci. Infection. 2007, 35: 352-355. 10.1007/s15010-007-7065-0.
Calandra T, Cohen J, International Sepsis Forum Definition of Infection in the ICU Consensus Conference: The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med. 2005, 33: 1538-1548. 10.1097/01.CCM.0000168253.91200.83.
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, SCCM/ESICM/ACCP/ATS/SIS: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003, 31: 1250-1256. 10.1097/01.CCM.0000050454.01978.3B.
Estenssoro E, Reina R, Canales HS, Saenz MG, Gonzalez FE, Aprea MM, Laffaire , Gola V, Dubin A: The distinct clinical profile of chronically critically ill patients: a cohort study. Crit Care. 2006, 10 (3): R8-10.1186/cc4834.
Charles PE, Ladoire S, Aho S, Quenot J-P, Doise J-M, Prin S, Olsson N-O, Blettery Β: Serum procalcitonin elevation in critically ill patients at the onset of bacteremia caused by either gram negative or gram positive bacteria. BMC Infect Dis. 2008, 8: 38-10.1186/1471-2334-8-38.
Charles PE, Ladoire S, Snauwaert A, Prin S, Aho S, Pechinot A, Olsson NO, Blettery B, Doise JM, Quenot JP: Impact of previous sepsis on the accuracy of procalcitonin for the early diagnosis of blood stream infection in critically ill patients. BMC Infect Dis. 2008, 8: 163-10.1186/1471-2334-8-163.
van Nieuwkoop C, Bonten TN, van’t Wout JW, Kuijper EJ, Groeneveld GH, Becker MJ, Koster T, Wattel-Louis GH, Delfos NM, Ablij HC, Leyten EM, van Dissel JT: Procalcitonin reflects bacteremia and bacterial load in urosepsis syndrome: a prospective observational study. Crit Care. 2010, 14: R206-10.1186/cc9328.
Charles PE, Tinel C, Barbar S, Aho S, Prin S, Doise JM, Olsson NO, Blettery B, Quenot JP: Procalcitonin kinetics within the first days of sepsis: relationship with the appropriateness of antibiotic therapy and the outcome. Crit Care. 2009, 13: R38-10.1186/cc7751.
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/12/247/prepub