Advertisement

Early procalcitonin determination in the emergency department and clinical outcome of community-acquired pneumonia in old and oldest old patients

      Highlights

      • The utility of a PCT guided management for respiratory tract infections in ED is still uncertain.
      • In general CAP patients the impact of an early PCT determination in ED was limited.
      • Patients with bloodstream infection could have reduced hospital stay if PCT is obtained in ED
      • Patients ≥ 85 years are more likely to have benefit from PCT determination.
      • PCT might be associated with reduced mortality in patients with severe CAP or high comorbidity

      Abstract

      We evaluated patients admitted through our ED for community-acquired pneumonia (CAP) to assess the relevance of an early procalcitonin (PCT) determination on patient's outcomes.

      Methods

      We reviewed all patients admitted for CAP in a 10 years period (2008-2017). Patients were stratified according to age groups: (18-65 years; 65–84 years; and ≥85 years), CURB-65 score, need for ventilation, Sepsis-3 criteria at admission, enrollment period, blood culture in ED. In-hospital mortality rate and length of hospital stay (LOS) were compared between patients that had an early PCT determination in ED vs. patients admitted without.

      Results

      Our study cohort consisted of 4056 CAP patients, age 76 [IQ range 64-84] years. We enrolled 1039 patients <65 years old, 2015 aged 65-84 years, and 1002 aged ≥85 years. Overall, the early PCT determination in ED was not associated to a reduced LOS (p=0.630), nor to a reduced mortality rate (p=0.134). However, in patients ≥ 85 years, the PCT determination in ED was associated with lower mortality in those with CURB-65 ≥ 2, and Charlson's score ≥ 2 (p=0.033 and p=0.002, respectively).

      Conclusions

      Although an early PCT assessment in ED was not associated with better outcomes in term of LOS and mortality in patients with CAP, our findings suggest that it might be associated with reduced mortality in patients ≥ 85 years with severe CAP or high comorbidity.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Rodrigo C
        • Mckeever TM
        • Woodhead M
        • Welham S
        • Lim WS
        • Society British Thoracic
        Admission via the emergency department in relation to mortality of adults hospitalized with community-acquired pneumonia: an analysis of the British Thoracic Society national community-acquired pneumonia audit.
        Emerg Med J. 2015; 32 (Jan): 55-59
        • Macfarlane JT
        • Colville A
        • Guion A
        • Macfarlane RM
        • Rose DH
        Prospective study of aetiology and outcome of adult lower-respiratory-tract infections in the community.
        Lancet. 1993; 341: 511-514
        • Woodhead MA
        • Macfarlane JT
        • McCracken JS
        • Rose DH
        • Finch RG
        Prospective study of the aetiology and outcome of pneumonia in the community.
        Lancet. 1987; 1: 671-674
        • Guest JF
        • pneumonia Morris A.Community-acquired
        the annual cost to the National Health Service in the UK.
        Eur Respir J. 1997; 10: 1530-1534
      1. Increase in the share of the population aged 65 years or over between 2008 and 2018. Population Structure and ageing. source: Eurostat (online data code: demo pjanind) data extracted in July 2019.

        • Clegg A
        • Young J
        • Iliffe S
        • Rikkert MO
        • Rockwood K
        Frailty in elderly people.
        Lancet. 2013; 381: 752-762
        • Torres A
        • Peetermans WE
        • Viegi G
        • Blasi F
        Risk factors for community-acquired pneumonia in adults in Europe: a literature review.
        Thorax. 2013; 68: 1057-1065
        • Covino M
        • Petruzziello C
        • Onder G
        • Migneco A
        • Simeoni B
        • Franceschi F
        • Ojetti V
        A 12-year retrospective analysis of differences between elderly and oldest old patients referred to the emergency department of a large tertiary hospital.
        Maturitas. 2019; 120 (Feb): 7-11
        • Schuetz P
        • Wirz Y
        • Sager R
        • Christ-Crain M
        • Stolz D
        • Tamm M
        • Bouadma L
        • Luyt CE
        • Wolff M
        • Chastre J
        • Tubach F
        • Kristoffersen KB
        • Burkhardt O
        • Welte T
        • Schroeder S
        • Nobre V
        • Wei L
        • Bucher HC
        • Annane D
        • Reinhart K
        • Falsey AR
        • Branche A
        • Damas P
        • Nijsten M
        • de Lange DW
        • Deliberato RO
        • Oliveira CF
        • Maravić-Stojković V
        • Verduri A
        • Beghé B
        • Cao B
        • Shehabi Y
        • Jensen JS
        • Corti C
        • van Oers JAH
        • Beishuizen A
        • Girbes ARJ
        • de Jong E
        • Briel M
        • Mueller B
        Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis.
        Lancet Infect Dis. 2018; 18 (Jan): 95-107
        • Huang DT
        • Yealy DM
        • Filbin MR
        • Brown AM
        • Chang CH
        • Doi Y
        • Donnino MW
        • Fine J
        • Fine MJ
        • Fischer MA
        • Holst JM
        • Hou PC
        • Kellum JA
        • Khan F
        • Kurz MC
        • Lotfipour S
        • LoVecchio F
        • Peck-Palmer OM
        • Pike F
        • Prunty H
        • Sherwin RL
        • Southerland L
        • Terndrup T
        • Weissfeld LA
        • Yabes J
        • Angus DC
        ProACT Investigators. Procalcitonin-guided use of antibiotics for lower respiratory tract infection.
        N Engl J Med. 2018; 379 (Jul 19): 236-249
        • Covino M
        • Manno A
        • Merra G
        • Simeoni B
        • Piccioni A
        • Carbone L
        • Forte E
        • Ojetti V
        • Franceschi F
        • Murri R
        Reduced utility of early procalcitonin and blood culture determination in patients with febrile urinary tract infections in the emergency department.
        Intern Emerg Med. 2020; 15 (Jan): 119-125
        • Van der Does Y
        • Limper M
        • Jie KE
        • Schuit SCE
        • Jansen H
        • Pernot N
        • van Rosmalen J
        • Poley MJ
        • Ramakers C
        • Patka P
        • van Gorp ECM
        • Rood PPM
        Procalcitonin-guided antibiotic therapy in patients with fever in a general emergency department population: a multicentre non-inferiority randomized clinical trial (HiTEMP study).
        Clin Microbiol Infect. 2018; 24 (Dec): 1282-1289
        • Montassier E
        • Javaudin F
        • Moustafa F
        • Nandjou D
        • Maignan M
        • Hardouin JB
        • Annoot C
        • Ogielska M
        • Orer PL
        • Schotté T
        • Bouget J
        • Agha Babaei S
        • Raynal PA
        • Eche A
        • Duc AT
        • Cojocaru RA
        • Benaouicha N
        • Potel G
        • Batard E
        • Talan DA
        Guideline-based clinical assessment versus procalcitonin-guided antibiotic use in pneumonia: a pragmatic randomized trial.
        Ann Emerg Med. 2019; (Apr 11. pii: S0196-0644(19)30147-7. doi: 10.1016/j.annemergmed.2019.02.025. [Epub ahead of print])
        • Stucker F
        • Herrmann F
        • Graf JD
        • Michel JP
        • Krause KH
        • Gavazzi G
        Procalcitonin and infection in elderly patients.
        J Am Geriatr Soc. 2005; 53: 1392-1395
        • Dwolatzky T
        • Olshtain-Pops K
        • Yinnon AM
        • Raveh D
        • Rogowski O
        • Shapira I
        • Rotstein R
        • Berliner S
        • Rudensky B
        Procalcitonin in the elderly: normal plasma concentrations and response to bacterial infections.
        Eur J Clin Microbiol Infect Dis. 2005; 24: 763-765
        • Caterino JM
        • Scheatzle MD
        • Forbes ML
        • D'Antonio JA
        Bacteremic elder emergency department patients: procalcitonin and white count.
        Acad Emerg Med. 2004; 11: 393-396
        • Steichen O
        • Bouvard E
        • Grateau G
        • Bailleul S
        • Capeau J
        • Lefèvre G
        Diagnostic value of procalcitonin in acutely hospitalized elderly patients.
        Eur J Clin Microbiol Infect Dis. 2009; 28 (Dec): 1471-1476
        • Seymour CW
        • Liu VX
        • Iwashyna TJ
        • Brunkhorst FM
        • Rea TD
        • Scherag A
        • Rubenfeld G
        • Kahn JM
        • Shankar-Hari M
        • Singer M
        • Deutschman CS
        • Escobar GJ
        • Angus DC
        Assessment of clinical criteria for sepsis: for the third international consensus definitions for sepsis and septic shock (sepsis-3).
        JAMA. 2016; 315 (Feb 23): 762-774
        • Myint PK.
        • Kamath AV.
        • Vowler SL.
        • Maisey DN.
        • Harrison BD.
        The CURB (confusion, urea, respiratory rate and blood pressure) criteria in community-acquired pneumonia (CAP) in hospitalised elderly patients aged 65 years and over: a prospective observational cohort study.
        Age Ageing. 2005; 34: 75-77
        • British Thoracic Society
        BTS guidelines for the management of community acquired pneumonia in adults., in Thorax.
        Dic. 2001; 56: IV1-I64
        • Aujesky D.
        • Auble TE.
        • Yealy DM.
        • Stone RA.
        • Obrosky DS.
        • Meehan TP.
        • Graff LG.
        • Fine JM.
        • Fine MJ.
        Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia.
        Am J Med. 2005; 118: 384-392
        • Charlson M
        • Szatrowski TP
        • Peterson J
        • Gold J
        Validation of a combined comorbidity index.
        J Clin Epidemiol. 1994; 47 (Nov): 1245-1251
        • Welte T
        • Torres A
        • Nathwani D
        Clinical and economic burden of community-acquired pneumonia among adults in Europe.
        Thorax. 2012; 67: 71-79
        • Torres A
        • Peetermans WE
        • Viegi G
        • Blasi F
        Risk factors for community-acquired pneumonia in adults in Europe: a literature review.
        Thorax. 2013; 68: 1057-1065
        • Trotter CL
        • Stuart JM
        • George R
        • Miller E
        Increasing hospital admissions for pneumonia, England.
        Emerg Infect Dis. 2008; 14: 727-733
      2. US Food and Drug Administration. FDA press release. FDA clears test to help manage antibiotic treatment for lower respiratory tract infections and sepsis. Feb 23, 2017.

        • 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
        • Schuetz P
        • Christ-Crain M
        • Muller B
        Procalcitonin and other biomarkers to improve assessment and antibiotic stewardship in infections—hope for hype?.
        Swiss Med Wkly. 2009; 139: 318-326
        • 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
        • de Jong E
        • van Oers JA
        • Beishuizen A
        • Vos P
        • Vermeijden WJ
        • Haas LE
        • Loef BG
        • Dormans T
        • van Melsen GC
        • Kluiters YC
        • Kemperman H
        • van den Elsen MJ
        • Schouten JA
        • Streefkerk JO
        • Krabbe HG
        • Kieft H
        • Kluge GH
        • van Dam VC
        • van Pelt J
        • Bormans L
        • Otten MB
        • Reidinga AC
        • Endeman H
        • Twisk JW
        • van de Garde EMW
        • de Smet AMGA
        • Kesecioglu J
        • Girbes AR
        • Nijsten MW
        • de Lange DW
        Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial.
        Lancet Infect Dis. 2016; 16: 819-827
        • Schuetz P
        • Chiappa V
        • Briel M
        • Greenwald JL
        Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms.
        Arch Intern Med. 2011; 171: 1322-1331
        • Schuetz P
        • Wirz Y
        • Sager R
        • Christ-Crain M
        • Stolz D
        • Tamm M
        • Bouadma L
        • Luyt CE
        • Wolff M
        • Chastre J
        • Tubach F
        • Kristoffersen KB
        • Burkhardt O
        • Welte T
        • Schroeder S
        • Nobre V
        • Wei L
        • Bucher HC
        • Annane D
        • Reinhart K
        • Falsey AR
        • Branche A
        • Damas P
        • Nijsten M
        • de Lange DW
        • Deliberato RO
        • Oliveira CF
        • Maravić-Stojković V
        • Verduri A
        • Beghé B
        • Cao B
        • Shehabi Y
        • Jensen JS
        • Corti C
        • van Oers JAH
        • Beishuizen A
        • Girbes ARJ
        • de Jong E
        • Briel M
        • Mueller B
        Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis.
        Lancet Infect Dis. 2018; 18: 95-107
        • Huang DT
        • Yealy DM
        • Filbin MR
        • Brown AM
        • Chang CH
        • Doi Y
        • Donnino MW
        • Fine J
        • Fine MJ
        • Fischer MA
        • Holst JM
        • Hou PC
        • Kellum JA
        • Khan F
        • Kurz MC
        • Lotfipour S
        • LoVecchio F
        • Peck-Palmer OM
        • Pike F
        • Prunty H
        • Sherwin RL
        • Southerland L
        • Terndrup T
        • Weissfeld LA
        • Yabes J
        • Angus DC
        • Investigators ProACT
        Procalcitonin-guided use of antibiotics for lower respiratory tract infection.
        N Engl J Med. 2018; 379 (Jul 19): 236-249
        • Van der Does Y
        • Limper M
        • Jie KE
        • Schuit SCE
        • Jansen H
        • Pernot N
        • van Rosmalen J
        • Poley MJ
        • Ramakers C
        • Patka P
        • van Gorp ECM
        • Rood PPM
        Procalcitonin-guided antibiotic therapy in patients with fever in a general emergency department population: a multicentre non-inferiority randomized clinical trial (HiTEMP study).
        Clin Microbiol Infect. 2018; 24: 1282-1289
        • Makam AN
        • Auerbach AD
        • Steinman MA
        Blood culture use in the emergency department in patients hospitalized for community-acquired pneumonia.
        JAMA Intern Med. 2014; 174: 803-806
        • Washio Y
        • Ito A
        • Kumagai S
        • Ishida T
        • Yamazaki A
        A model for predicting bacteremia in patients with community-acquired pneumococcal pneumonia: a retrospective observational study.
        BMC Pulm Med. 2018; 18: 24
        • Hoeboer SH
        • van der Geest PJ
        • Nieboer D
        • Groeneveld AB
        The diagnostic accuracy of procalcitonin for bacteraemia: a systematic review and meta-analysis.
        Clin Microbiol Infect. 2015; 21 (May): 474-481
        • Long B
        • Koyfman A
        Best clinical practice: blood culture utility in the emergency department.
        J Emerg Med. 2016; 51 (Nov): 529-539
        • Salinas M
        • López-Garrigós M
        • Flores E
        • Uris J
        Leiva-Salinas C; pilot group of the appropriate utilization of laboratory tests (REDCONLAB) working group. Procalcitonin in the emergency department: a potential expensive over-request that can be modulated through institutional protocols.
        Am J Emerg Med. 2018; 36: 158-160