Procalcitonin Increase Is Associated with the Development of Critical Care-Acquired Infections in COVID-19 ARDS

Abstract

Secondary bacterial infection in COVID-19 patients is associated with increased mortality and disproportionately affects critically ill patients. This single-centre retrospective observational study investigates the comparative efficacy of change in procalcitonin (PCT) and other commonly available biomarkers in revealing or predicting microbiologically proven secondary infection in critical COVID-19 patients. Adult patients admitted to an intensive care unit (ICU) with confirmed SARS-CoV-2 infection between 9 March 2020 and 5 June 2020 were recruited to the study. For daily biomarker and secondary infection, laboratory-confirmed bloodstream infection (LCBI) and ventilator-associated pneumonia/tracheobronchitis (VAP/VAT) data were collected. We observed a PCT rise in 53 (81.5%) of the patients, a C-reactive protein (CRP) rise in 55 (84.6%) and a white blood cell count (WBC) rise in 61 (93.8%). Secondary infection was confirmed in 33 (50.8%) of the patients. A PCT rise was present in 97.0% of patients with at least one confirmed VAP/VAT and/or LCBI event. CRP and WBC rises occurred in 93.9% and 97.0% of patients with confirmed VAP/VAT and/or LCBI, respectively. Logistic regression analysis found that, when including all biomarkers in the same model, there was a significant association between PCT rise and the occurrence of LCBI and/or VAP/VAT (OR = 14.86 95%CI: 2.20, 342.53; p = 0.021). Conversely, no statistically significant relationship was found between either a CRP rise (p = 0.167) or a WBC rise (p = 0.855) and the occurrence of VAP/VAT and/or LCBI. These findings provide a promising insight into the usefulness of PCT measurement in predicting the emergence of secondary bacterial infection in ICU.

Ceftazidime/Avibactam in Ventilator-Associated Pneumonia Due to Difficult-to-Treat Non-Fermenter Gram-Negative Bacteria in COVID-19 Patients: A Case Series and Review of the Literature

“…However, the clinical benefits of CZA-based treatment were demonstrated by the reduction and stabilization of infection markers and improved clinical status. Unfortunately, among critically ill COVID-19 patients, immunomodulatory treatment with dexamethasone and tocilizumab considerably reduces the value of biomarkers so their predictive role in defining significant clinical improvement is very limited [ 74 ].…”

Procalcitonin as a Tool to Antimicrobial Stewardship in COVID-19 Patients with Superimposed Bacterial Infections: A Systematic Review

“… Atallah et al 2 2 cut-off levels were used: 0.25 0.5 Procalcitonin (>0.25) is an indicator of bacterial coinfection in COVID-19 patients. Richards et al 3 None Procalcitonin (>50% of baseline) is an indicator of bacterial coinfection in COVID-19 patients. Basnet et al 12 None Procalcitonin is an indicator of bacterial coinfection in COVID-19 patients.…”

“…During inflammation, procalcitonin increases proportionately to the severity of infection in response to pro-inflammatory cytokines such as tumor necrosis factor (TNF)alpha, interleukin-1, interleukin-6, and endotoxins which are associated with bacterial infections; and it is inhibited by interferon (IFN)-gamma which is associated with viral infections. [1][2][3][4] These properties favored the utilization of procalcitonin as a tool to distinguish between bacterial and nonbacterial superimposed infections in COVID-19 patients.…”

“…There are studies which reported that COVID-19 patients with procalcitonin higher than normal cutoff values had significantly more frequent superimposed infections, they were more likely to develop bacteremia, their ICU stay was more likely to be longer, and their risk of mortality was higher compared to COVID-19 patients with lower procalcitonin levels. [1][2][3][4][5] One of the arguments against using procalcitonin as a biomarker for bacterial co-infection in COVID-19 patients is that despite its great sensitivity, it is less specific for bacterial infections as it can also be elevated in other syndromes such as acute renal failure. For that reason, it has been proposed to use procalcitonin in combination with other inflammatory markers namely C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) for a more accurate diagnosis.…”

Antimicrobial Stewardship Using Biomarkers: Accumulating Evidence for the Critically Ill

“…A recent meta-analysis of 10 cohort studies including a total of 7716 patients estimated a pooled risk of 1.77 (95% CI, 1.38 to 2.29) for severe and critical COVID-19 by elevated PCT levels at admission, although results are highly heterogenous (I 2 :85.6%) [94]. Similarly, rise in PCT is associated with secondary bacterial infections, such as VAP and bacteremia [91,[95][96][97]. PCT levels less than 0.25 ng/mL have been suggested as an optimal cut-off to rule out bacterial co-infection (negative predictive value 81%) and levels more than 1 ng/mL as optimal cutoff to rule in bacterial co-infection (positive predictive value 93%) [95].…”