Ability of procalcitonin to distinguish between bacterial and nonbacterial infection in severe acute exacerbation of chronic obstructive pulmonary syndrome in the ICU

Abstract

Background To assess the ability of procalcitonin (PCT) to distinguish between bacterial and nonbacterial causes of patients with severe acute exacerbation of COPD (AECOPD) admitted to the ICU, we conducted a retrospective analysis of two prospective studies including 375 patients with severe AECOPD with suspected lower respiratory tract infections. PCT levels were sequentially assessed at the time of inclusion, 6 h after and at day 1, using a sensitive immunoassay. The patients were classified according to the presence of a documented bacterial infection (including bacterial and viral coinfection) (BAC + group), or the absence of a documented bacterial infection (i.e., a documented viral infection alone or absence of a documented pathogen) (BAC- group). The accuracy of PCT levels in predicting bacterial infection (BAC + group) vs no bacterial infection (BAC- group) at different time points was evaluated by receiver operating characteristic (ROC) analysis. Results Regarding the entire cohort (n = 375), at any time, the PCT levels significantly differed between groups (Kruskal–Wallis test, p < 0.001). A pairwise comparison showed that PCT levels were significantly higher in patients with bacterial infection (n = 94) than in patients without documented pathogens (n = 218) (p < 0.001). No significant difference was observed between patients with bacterial and viral infection (n = 63). For example, the median PCT-H0 levels were 0.64 ng/ml [0.22–0.87] in the bacterial group vs 0.24 ng/ml [0.15–0.37] in the viral group and 0.16 ng/mL [0.11–0.22] in the group without documented pathogens. With a c-index of 0.64 (95% CI; 0.58–0.71) at H0, 0.64 [95% CI 0.57–0.70] at H6 and 0.63 (95% CI; 0.56–0.69) at H24, PCT had a low accuracy for predicting bacterial infection (BAC + group). Conclusion Despite higher PCT levels in severe AECOPD caused by bacterial infection, PCT had a poor accuracy to distinguish between bacterial and nonbacterial infection. Procalcitonin might not be sufficient as a standalone marker for initiating antibiotic treatment in this setting.

Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the ICU: An Observational Study From the OUTCOMEREA Database, 1997–2018

“…Nowadays, the place of NIV is well defined in the recommendations for the treatment of AECOPD, with a demonstration of efficiency in survival and a reduction in intubation (12, 30, 31). The proportion of patients treated with NIV in our study (58.87%) and the increase in the use of NIV is in line with the current literature (20, 26, 32, 33). NIV failure rates (19.2%) were also similar to those reported in the literature (3, 26, 34), the gradual reduction in NIV failure probably reflecting the learning curve and a better selection of patients.…”

“…However, the systematic prescription of antibiotics remains controversial, as stated in the latest GOLD recommendations (1). For the ICU population, there is no clear recommendation for antibiotic use (19), and no validated biomarkers have been established to guide prescription (20, 21). Again, previous studies have frequently excluded patients in the ICU (22, 23).…”

IL-6 and IL-10 Are Associated With Gram-Negative and Gram-Positive Bacteria Infection in Lymphoma

“…Commonly used clinical infection markers, such as PCT and CRP, have certain limitations in the diagnosis of infection. The study showed that PCT has poor accuracy in distinguishing bacterial from nonbacterial infections, and PCT may not be an independent marker for the initiation of antibiotic therapy (16). CRP is often elevated in rheumatic connective tissue diseases.…”

Early antibiotic therapy is associated with a lower probability of successful liberation from mechanical ventilation in patients with severe acute exacerbation of chronic obstructive pulmonary disease

“…New tools such as multiplex polymerase chain reaction assay panel (mPCR) can provide bacterial or viral documentation with acceptable sensitivity and specificity in less than six hours [ 33 ], and could help eABT decision-making. However, the impact of PCT in the specific setting of ICU patients with AECOPD remains unclear when opposed to short-course antibiotic therapy with immediate cessation in case of negative bacterial samples [ 17 ]. In the absence of evident bacterial infection, early antibiotic treatment may prove potentially futile or even deleterious, in relation with treatment adverse events or MDR pathogen selection, which may in turn, be associated with prolonged ICU and hospital stays and worse clinical outcome [ 34 ].…”

“…In an era of antibiotic sparing, the relevance of systematic antibiotic therapy may be questioned [11,12], especially since it may promote bacterial colonization and multidrug resistant pathogens selection [13]. The use of biomarker-based strategies has been proposed [14][15][16], but a recent randomized controlled trial failed to demonstrate non-inferiority of a procalcitonin (PCT)-based algorithm to guide initial antibiotic therapy in ICU patients with AECOPD [17]. Hence, national and international guidelines still recommend systematic antibiotic use as soon as mechanical ventilation is required in ICU patients with AECOPD [1,18].…”