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The Shapiro–Procalcitonin algorithm (SPA) as a decision tool for blood culture sampling: validation in a prospective cohort study

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Abstract

Purpose

Blood cultures (BC) are the gold standard for bacteremia detection despite a relatively low diagnostic yield and high costs. A retrospective study reported high predictive values for BC positivity when combining the clinical Shapiro score with procalcitonin (PCT).

Methods

Single-center, prospective cohort study between 01/2016 and 02/2017 to validate SPA algorithm, including a modified Shapiro score ≥ 3 points (S) PLUS admission PCT > 0.25 µg/l (P), or presence of overruling safety criteria (A) in patients with systemic inflammatory response syndrome. The diagnostic yield of SPA compared to non-standardized clinical judgment in predicting BC positivity was calculated and results presented as odds ratios (OR) with 95% confidence intervals.

Results

Of 1438 patients with BC sampling, 215 (15%) had positive BC which increased to 31% (173/555) in patients fulfilling SP criteria (OR for BC positivity 9.07 [6.34–12.97]). When adding 194 patients with overruling safety criteria (i.e., SPA), OR increased to 11.12 (6.99–17.69), although BC positivity slightly decreased to 26%. With an area under the receiver operating curve of 0.742, SPA indicated better diagnostic performance than its individual components. Positive BC in 689 patients not fulfilling SPA (sampling according to non-standardized clinical judgment) were rare (3%; OR for BC positivity 0.09 [0.06–0.14]). Eight out of 21 missed pathogens were still identified by sampling the primary infection focus.

Conclusions

This study validates the high predictive value of SPA for bacteremia, increasing true BC positivity from 15 to 26%. Restricting BC sampling to SPA would have reduced BC sampling by 48%, while still detecting 194/215 organisms (90%), which makes SPA a valuable diagnostic stewardship tool.

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Acknowledgements

We thank the nurses in the emergency department responsible for BC and biomarker sampling throughout the study period, the study nurses involved in data collection, and the laboratory and microbiology teams who performed all blood tests and microbiological analyses needed. In addition, we thank all the patients who participated in this study.

Funding

This work was supported by the Research Fund of the Kantonsspital Aarau, Switzerland. The sponsor had no role in the study design, data collection or interpretation, and writing and submitting the report.

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Author notes

  1. Géraldine Wyss and Silvia Berger have contributed equally to this work.

Authors and Affiliations

  1. Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland

    Géraldine Wyss, Silvia Berger, Sebastian Haubitz, Beat Mueller, Philipp Schuetz & Christoph A. Fux

  2. Department of Infectious Diseases and Hospital Hygiene, Kantonsspital Aarau, Aarau, Switzerland

    Sebastian Haubitz, Christoph A. Fux & Anna Conen

  3. Department of Clinical Microbiology, Institute of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland

    Hans Fankhauser

  4. Department of Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland

    Ulrich Buergi

  5. Department of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, Aarau, Switzerland

    Beat Mueller

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  1. Géraldine Wyss
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  2. Silvia Berger
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Correspondence to Anna Conen.

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Wyss, G., Berger, S., Haubitz, S. et al. The Shapiro–Procalcitonin algorithm (SPA) as a decision tool for blood culture sampling: validation in a prospective cohort study. Infection 48, 523–533 (2020). https://doi.org/10.1007/s15010-020-01423-6

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  • DOI: https://doi.org/10.1007/s15010-020-01423-6

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