Download Dr Yaser Gad

‫رب اجعل هذا بلدا آمنا وارزق‬
‫أهله من الثمرات من امن منهم‬
‫باهلل و اليوم اآلخر‬
Clinical Implication of Serum
Procalcitonin in Sepsis and
pneumonia
Lecturer of chest diseases, Assuit
faculty of medicine
 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
INFECTION SOURCE IN SEVERE SEPSIS
10.8%
6.0%
8.0%
44.0%
2.2%
6.6%
8.6%
9.1%
Respiratory
Bacteremia
GU
Abdomen
Soft tissue
Device
CNS
Endocarditis
Other
17.3%
Angus DC et al. Crit Care Med. 2001; 29:1303
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
Fight as much as you can
Early diagnosis and intervention
Differentiate between infectious and
non infectious case of systemic
inflammation
Early diagnosis is essential to :
 Administer the correct treatment
 Avoid unnecessary antibiotic use
 Reducing the morbidity, mortality
 And decrease care-related costs.
Cantürk et al., Turk J Med Sci 2008; 38 (2):
139-144
Delayed diagnosis
•
•
•
•
Delays treatment
Increases hospital length-of-stay
Increases costs
Increased mortality
Delayed intervention can be fatal
Sebat CCM 2007; 35: 2568
It is very important to differentiate
between infectious and non
infectious case of systemic
inflammation
Inability to differentiate between
infectious and non infectious causes
Unplanned use of antibiotics
Antibiotic resistance
70% are
infectious in
origin .
20–30% related to
bacteria detected
by sputum culture
viruses are
detected in >50%
of exacerbations
Bacteria are isolated from the respiratory
tract of only 50% of patients
Dauben et al., BMC Infect Dis. 2008; 8: 145.
Chen et al, 2008 Chinese Medical
Journal, 2008,
 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 AECOPD
Chen et al, 2008 Chinese Medical
Journal, 2008,
100%
80%
60%
40%
20%
0%
Aminoglycosides
Clindamycin
1st&2nd
cephalosporins.
Ca
vu
lin
at
e
e
im
Lincomycin
0%
10% 20% 30% 40% 50% 60%
Am
ox
ici
llin
Ce
fip
es
id
Ma
cr
ol
ac
in
lox
Le
vo
f
Mo
xif
l
ox
ac
in
Tetracyclines
Antibiotic sensitivity for AECOPD in Upper
Egypt
Agamy et al., Egyp.J. Ch.dises. And tub. 2011
Erythromycin
Tetracyclines
Tetracyclines
Lincomycin
Lincomycin
1st&2nd
cephalosporins.
1st&2nd
cephalosporins.
Ampicilin-Sulbactam
Ampicilin-Sulbactam
AmoxicillinClavulinic
AmoxicillinClavulinic
0%
20%
40%
60%
0%
20%
40%
60%
80%
100%
Antibiotic sensitivity for CAP and HAP in
Upper Egypt
Agamy et al., Egyp.J. Ch.dises. And tub. 2011
Acute phase reactants
Capable of demonstrating the
inflammation
differentiate between bacterial and
nonbacterial inflammation
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
 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; 10:444-65.
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
(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
Invasion by pathogenic
bacteria
Bacterial toxins and cytokines
Stimulate PCT production in all
paraynchymal cells
Adapted from Christ-Crain et al. 2005
22
VALUES OF PROCALCITONIN IN
INFECTION
23
1- PCT LEVEL INCREASE = INCREASED SIGNIFICANCE
OF BACTERIAL INFECTION
2 ng/ml
0.5 ng/ml
0.05 ng/ml
Healthy
Individuals
Local
Infections
Systemic
Infections
(Sepsis)
Severe
Sepsis
Septic
Shock
24
Differentiates
between
bacterial
contamination and real bacterial infection
2-
PCT may help discriminate blood stream
infections from blood culture contamination
due to coagulase-negative staphylococci
Schuetz P. et al., Infection 2007;35 (5): 352-5
25
3- Predicts bacteremia
PCT measurement demonstrated the potential
to reduce the number of blood cultures
Muller et al. CHEST July 2010
26
4- PROCALCITONIN CORRELATES TO THE SEVERITY OF
THE INFECTION
Sepsis
Pneumonia
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: 349–355
27
5- Evaluates the prognosis
Mortality by PCT level
12%
PCT
10%
≥ 0.1
Mortality, %
8%
6%
4%
< 0.1
2%
0%
0
5
10
15
20
25
30
Day
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
28
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
29
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: 177:498-505
30
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
31
 PCT levels are not affected by the
patient's use of nonsteroidal antiinflammatory
agents
or
glucocorticoids
PCT levels remain a valuable marker of the
host inflammatory response even when
nonsteroidal anti-inflammatory drugs and
corticosteroids are used
32
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; 39:206-217.
33
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
34
False positive results
 Cirrhosis
 Pancreatitis
 Mesenteric infarction (ischemic bowel)
 Cardiogenic shock, and hypotension during
surgery
 Burns
 Pulmonary
edema
and
pulmonary
aspiration
35
 PCT is usefull to diffrentiate between bacterial
and non bacterial infection
 Differentiates between bacterial contamination
and real bacterial infection
 Predicts bacteremia
36
 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
37
Never ever forget to love those
dearest
to
you
38