Procalcitonin and C-reactive protein in hospitalized adult patients with community-acquired pneumonia or exacerbation of asthma or COPD

Mona Bafadhel, Tristan W Clark, Carlene Reid, Marie-Jo Medina, Sally Batham, Michael R Barer, Karl G Nicholson, Christopher E Brightling, Mona Bafadhel, Tristan W Clark, Carlene Reid, Marie-Jo Medina, Sally Batham, Michael R Barer, Karl G Nicholson, Christopher E Brightling

Abstract

Background: Antibiotic overuse in respiratory illness is common and is associated with drug resistance and hospital-acquired infection. Biomarkers that can identify bacterial infections may reduce antibiotic prescription. We aimed to compare the usefulness of the biomarkers procalcitonin and C-reactive protein (CRP) in patients with pneumonia or exacerbations of asthma or COPD.

Methods: Patients with a diagnosis of community-acquired pneumonia or exacerbation of asthma or COPD were recruited during the winter months of 2006 to 2008. Demographics, clinical data, and blood samples were collected. Procalcitonin and CRP concentrations were measured from available sera.

Results: Sixty-two patients with pneumonia, 96 with asthma, and 161 with COPD were studied. Serum procalcitonin and CRP concentrations were strongly correlated (Spearman rank correlation coefficient [rs] = 0.56, P < .001). Patients with pneumonia had increased procalcitonin and CRP levels (median [interquartile range] 1.27 ng/mL [2.36], 191 mg/L [159]) compared with those with asthma (0.03 ng/mL [0.04], 9 mg/L [21]) and COPD (0.05 ng/mL [0.06], 16 mg/L [34]). The area under the receiver operating characteristic curve (95% CI) for distinguishing between patients with pneumonia (antibiotics required) and exacerbations of asthma (antibiotics not required), for procalcitonin and CRP was 0.93 (0.88-0.98) and 0.96 (0.93-1.00). A CRP value > 48 mg/L had a sensitivity of 91% (95% CI, 80%-97%) and specificity of 93% (95% CI, 86%-98%) for identifying patients with pneumonia.

Conclusions: Procalcitonin and CRP levels can both independently distinguish pneumonia from exacerbations of asthma. CRP levels could be used to guide antibiotic therapy and reduce antibiotic overuse in hospitalized patients with acute respiratory illness.

Figures

Figure 1.
Figure 1.
Trial profile for patients enrolled in the study. CXR = chest radiograph.
Figure 2.
Figure 2.
Box and whisker plots for patients admitted with exacerbation of asthma, COPD, and pneumonia for the biomarkers procalcitonin and C-reactive protein. The horizontal bar represents the median; the box length represents the interquartile range. Outliers are identified by ○ (1.5 × the interquartile range) and * (3 × the interquartile range).
Figure 3.
Figure 3.
Receiver operator characteristic curve distinguishing between patients with pneumonia (antibiotics required) and exacerbations of asthma (antibiotics not required) for peripheral neutrophils, temperature, and modified early warning score. AUC = area under the receiver operator characteristic curve.
Figure 4.
Figure 4.
Receiver operator characteristic curve for distinguishing between patients with pneumonia (antibiotics required) and exacerbations of asthma (antibiotics not required) for PCT.CRP, PCT, and CRP. CRP = C-reactive protein; PCT = procalcitonin; PCT.CRP = procalcitonin C-reactive protein product. See Figure 3 for expansion of the other abbrevation.

References

    1. Bauer MP, van Dissel JT, Kuijper EJ. Clostridium difficile: controversies and approaches to management. Curr Opin Infect Dis. 2009;22(6):517–524.
    1. Hawkey PM, Jones AM. The changing epidemiology of resistance. J Antimicrob Chemother. 2009;64(suppl 1):i3–i10.
    1. Dubberke ER, Wertheimer AI. Review of current literature on the economic burden of Clostridium difficile infection. Infect Control Hosp Epidemiol. 2009;30(1):57–66.
    1. Steinman MA, Gonzales R, Linder JA, Landefeld CS. Changing use of antibiotics in community-based outpatient practice, 1991-1999. Ann Intern Med. 2003;138(7):525–533.
    1. Frank MO, Batteiger BE, Sorensen SJ, et al. Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program. Clin Perform Qual Health Care. 1997;5(4):180–188.
    1. Braman SS. The global burden of asthma. Chest. 2006;130(1) suppl:4S–12S.
    1. Rabe KF, Hurd S, Anzueto A, et al. Global Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532–555.
    1. Lim WS, Baudouin SV, George RC, et al. Pneumonia Guidelines Committee of the BTS Standards of Care Committee BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009;64(suppl 3):iii1–iii55.
    1. Roumie CL, Halasa NB, Grijalva CG, et al. Trends in antibiotic prescribing for adults in the United States—1995 to 2002. J Gen Intern Med. 2005;20(8):697–702.
    1. Lim WS, Macfarlane JT, Boswell TC, et al. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax. 2001;56(4):296–301.
    1. Sykes A, Johnston SL. Etiology of asthma exacerbations. J Allergy Clin Immunol. 2008;122(4):685–688.
    1. Papi A, Bellettato CM, Braccioni F, et al. Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations. Am J Respir Crit Care Med. 2006;173(10):1114–1121.
    1. British Thoracic Society Scottish Intercollegiate Guidelines Network British Guideline on the Management of Asthma. Thorax. 2008;63(suppl 4):iv1–iv121.
    1. Graham VA, Milton AF, Knowles GK, Davies RJ. Routine antibiotics in hospital management of acute asthma. Lancet. 1982;1(8269):418–420.
    1. Glauber JH, Fuhlbrigge AL, Finkelstein JA, Homer CJ, Weiss ST. Relationship between asthma medication and antibiotic use. Chest. 2001;120(5):1485–1492.
    1. Sethi S. Bacteria in exacerbations of chronic obstructive pulmonary disease: phenomenon or epiphenomenon? Proc Am Thorac Soc. 2004;1(2):109–114.
    1. Puhan MA, Vollenweider D, Latshang T, Steurer J, Steurer-Stey C. Exacerbations of chronic obstructive pulmonary disease: when are antibiotics indicated? A systematic review. Respir Res. 2007;8:30–41.
    1. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, Garcia-Aymerich J, Barnes NC. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(2):CD004403.
    1. Rothberg MB, Pekow PS, Lahti M, Brody O, Skiest DJ, Lindenauer PK. Antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. JAMA. 2010;303(20):2035–2042.
    1. Christ-Crain M, Jaccard-Stolz D, Bingisser R, et al. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet. 2004;363(9409):600–607.
    1. Schuetz P, Christ-Crain M, Thomann R, et al. ProHOSP Study Group Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302(10):1059–1066.
    1. Stolz D, Christ-Crain M, Bingisser R, et al. Antibiotic treatment of exacerbations of COPD: a randomized, controlled trial comparing procalcitonin-guidance with standard therapy. Chest. 2007;131(1):9–19.
    1. Christ-Crain M, Stolz D, Bingisser R, et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med. 2006;174(1):84–93.
    1. Almirall J, Bolíbar I, Toran P, et al. Community-Acquired Pneumonia Maresme Study Group Contribution of C-reactive protein to the diagnosis and assessment of severity of community-acquired pneumonia. Chest. 2004;125(4):1335–1342.
    1. Menéndez R, Martinez R, Reyes S, et al. Stability in community-acquired pneumonia: one step forward with markers? Thorax. 2009;64(11):987–992.
    1. Menéndez R, Martínez R, Reyes S, et al. Biomarkers improve mortality prediction by prognostic scales in community-acquired pneumonia. Thorax. 2009;64(7):587–591.
    1. Smith RP, Lipworth BJ, Cree IA, Spiers EM, Winter JH. C-reactive protein. A clinical marker in community-acquired pneumonia. Chest. 1995;108(5):1288–1291.
    1. Coelho L, Póvoa P, Almeida E, et al. Usefulness of C-reactive protein in monitoring the severe community-acquired pneumonia clinical course. Crit Care. 2007;11(4):R92–R100.
    1. Hansson LO, Hedlund JU, Ortqvist AB. Sequential changes of inflammatory and nutritional markers in patients with community-acquired pneumonia. Scand J Clin Lab Invest. 1997;57(2):111–118.
    1. van der Meer V, Neven AK, van den Broek PJ, Assendelft WJ. Diagnostic value of C reactive protein in infections of the lower respiratory tract: systematic review. BMJ. 2005;331(7507):26–31.
    1. Brämer GR. International statistical classification of diseases and related health problems. Tenth revision. World Health Stat Q. 1988;41(1):32–36.
    1. Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. QJM. 2001;94(10):521–526.
    1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377–382.
    1. Health Protection Agency . London, England: Department for Evaluations, Standards and Training, Health Protection Agency; 2009. Investigation of Bronchoalveolar Lavage, Sputum and Associated Specimens. National Standard Method BSOP 57. Issue 2.3.
    1. Akobeng AK. Understanding diagnostic tests 3: Receiver operating characteristic curves. Acta Paediatr. 2007;96(5):644–647.
    1. Müller F, Christ-Crain M, Bregenzer T, Krause M, Zimmerli W, Mueller B, et al. Procalcitonin levels predict bacteremia in patients with community-acquired pneumonia: a prospective cohort trial. Chest. 2010;138(1):121–129.
    1. Joffe E, Justo D, Mashav N, et al. C-reactive protein to distinguish pneumonia from acute decompensated heart failure. Clin Biochem. 2009;42(16-17):1628–1634.
    1. Justo D, Lachmi S, Saar N, et al. C-reactive protein velocity following antibiotics in patients with chronic obstructive pulmonary disease exacerbation and community acquired pneumonia. Eur J Intern Med. 2009;20(5):518–521.
    1. Cals JW, Butler CC, Hopstaken RM, Hood K, Dinant GJ. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ. 2009;338:1112–1116.
    1. Póvoa P, Coelho L, Almeida E, et al. C-reactive protein as a marker of infection in critically ill patients. Clin Microbiol Infect. 2005;11(2):101–108.
    1. Chan YL, Tseng CP, Tsay PK, Chang SS, Chiu TF, Chen JC. Procalcitonin as a marker of bacterial infection in the emergency department: an observational study. Crit Care. 2004;8(1):R12–R20.
    1. Holm A, Nexoe J, Bistrup LA, et al. Aetiology and prediction of pneumonia in lower respiratory tract infection in primary care. Br J Gen Pract. 2007;57(540):547–554.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner