Markers of treatment failure in hospitalised community acquired pneumonia

Abstract

Background: Lack of response to treatment in community acquired pneumonia (CAP) worsens outcome. We evaluated the systemic cytokine profile (tumour necrosis factor a, interleukin (IL)1, IL6, IL8 and IL10), C reactive protein (CRP) and procalcitonin (PCT) in patients with CAP who had treatment failure. Methods: A prospective study was performed in hospitalised patients with CAP. Cytokines, PCT and CRP measurements were obtained on day 1 and after 72 h of treatment. Treatment failure was the endpoint evaluated, with separation of those with early ((72 h) or late failure. Results: 453 patients were included: 84 (18%) had treatment failure, of whom 38 (8%) were early failures. Median levels of IL6, PCT and CRP on days 1 and 3 and median levels of IL8 on day 1 were significantly higher in patients with any treatment failure. Logistic regression analysis demonstrated that values above the cut-off points for IL6 (>169 pg/ml), IL8 (>14 pg/ml) and CRP (>21.9 mg/dl) on day 1 had independent predictive value for any treatment failure after adjustment for initial severity; relative risks (OR) found were 1.9, 2.2 and 2.6, respectively. Increased levels for CRP and PCT on day 1 were also independent predictors for early failure. Increased levels for IL6 and CRP were the best predictors of late failure. Conclusions: Serum levels of CRP, IL6 and PCT on days 1 and 3 were independently associated with a higher risk of any treatment failure. Low levels of PCT and CRP on day 1 had a high negative predictive value for early failure.

Clinical Approach to Nonresponsive Pneumonia in Adults Diagnosed by a Primary Care Clinician: A Retrospective Study

“…16 Additionally, others have defined NRP in hospitalized CAP patients as those with lack of response after 3 to 4 days of appropriate antibiotic treatment, often with clinical deterioration. 7,8,9,17 The second portion of our definition of NRP, 10 days of antibiotic therapy without improvement, is consistent with the observation that 90% of pneumonia-related hospitalizations in a cohort of 944 CAP patients who were treated as outpatients occurred within 10 days of treatment. 22 These same authors concluded that "the incidence of hospitalization within 10 days of beginning outpatient treatment for CAP is a reasonable screening tool for unsatisfactory quality of care in this illness."…”

“…15 This same group prospectively studied 453 patients with CAP admitted to two Spanish hospitals and observed treatment failure in 18%. 17 Roson et al performed an observational study of 1,383 CAP patients hospitalized in Barcelona. 9 Early failure, defined as lack of response or worsening of clinical or radiologic status at 48-72 hours requiring changes in antibiotic therapy or invasive procedures, was experienced by 6% of these patients, predominantly due to progressive pneumonia.…”

“…A number of biomarkers have been considered useful adjuncts for the determination of bacterial pneumonia diagnosis, severity and treatment response in some, but not all, studies. 7,17,26,[39][40][41] Further investigations are certainly needed to confirm the utility of these tests in the patient with CAP who is evaluated as an outpatient. Similarly, the role of rapid diagnostic tests for specific respiratory pathogens in the outpatient setting is still being defined.…”

“…[7][8][9][10][11] Recent studies of NRP have all involved hospitalized patients. [7][8][9][10][12][13][14][15][16][17] Thus, little is known about NRP in patients initially seen in a primary care ambulatory clinic.…”

Spielen CRP-Spiegel neben IL-6 und PCT noch eine Rolle für Patienten auf Intensivstationen?/Are circulating levels of CRP compared to IL-6 and PCT still relevant in intensive care unit patients?

“…Andererseits hatten niedrige CRP-bzw. PCT-Werte am Tag 1 einen hohen negativen pr ä diktiven Wert f ü r fr ü hes Therapieversagen [119] .…”