Microbial diagnostics in patients with presumed severe infection in the emergency department

  • S. Hettwer
  • J. Wilhelm
  • M. Schürmann
  • H. Ebelt
  • D. Hammer
  • M. Amoury
  • F. Hofmann
  • A. Oehme
  • D. Wilhelms
  • A.S. Kekulé
  • T. Klöss
  • K. Werdan
Originalarbeit

Abstract

Introduction

Sepsis in the early stage is a common disease in emergency medicine, and rapid diagnosis is essential. Our aim was to compare pathogen diagnosis using blood cultures (BC) and the multiplex polymerase chain reaction (PCR) test.

Methods

At total of 211 patients admitted to the multidisciplinary emergency department of our university hospital between 2006 and 2009 with suspected severe infection from any origin were studied. Blood samples for BC (aerobic and anaerobic) and multiplex PCR were taken for identification of infectious microorganisms immediately after hospital admission. Results of the BC and PCR correlated with procalcitonin concentration (PCT) and clinical diagnosis of sepsis (≥2 positive SIRS criteria) as well as with severity of disease at admission and with clinical outcome measures.

Results

Results of the BC were available in 200 patients (94.8%) and PCR were available in 119 patients (56.3%), respectively. In total, 87 BC (43.5%) were positive and identified 94 pathogens. In 45 positive PCRs, 47 pathogens (37.8%) were found. Identical results were obtained in 81.4%. In addition, BC identified 9 Gram-positive and 3 Gram-negative bacteria, while PCR added 5 Gram-negative pathogens. Coagulase-negative staphylococci were detected in blood cultures only (n=20, 21.3%), whereas PCR identified significantly more Gram-negative bacteria than BC. In patients with positive PCR results, the PCT level was significantly higher than in patients with negative PCR (15.0±23.3 vs. 8.8±32.8 ng/ml, p<0.001). This difference was not observed for BC (10.6±25.7 vs. 11.6±44.9 ng/ml, p=0.075). The APACHE II score correlated with PCR (19.2±9.1 vs. 15.8±8.9, p<0.05) and was also higher in positive BC (18.7±8.7 vs. 14.4±8.0, p<0.01). Positive PCR and BC were correlated with negative clinical outcomes (e.g., transfer to ICU, mechanical ventilation, renal replacement therapy, death).

Conclusion

In patients admitted with suspected severe infection, a high percentage of positive BC and PCR were observed. Positive findings in the PCR correlate with elevated levels of PCT and high APACHE II scores.

Keywords

Sepsis Polymerase chain reaction Blood culture Emergency service, hospital Procalcitonin 

Mikrobiologische Diagnostik bei Patienten mit schweren Infektionen in der Notaufnahme

Zusammenfassung

Einleitung

Die Sepsis im frühen Stadium ist eine häufige Erkrankung in der Notaufnahme, eine rasche Diagnosestellung ist essenziell. Ziel dieser Studie war der Vergleich der Erregerdiagnostik mittels Blutkultur (BC) und Polymerasekettenreaktion (PCR).

Methoden

Wir untersuchten 211 Patienten, die zwischen 2006 und 2009 mit Verdacht auf eine schwere Infektion in die Notaufnahme unseres Klinikums eingewiesen wurden. Blutproben für BC und Multiplex-PCR zur Identifikation infektiöser Mikroorgansimen wurden unmittelbar nach Aufnahme entnommen. Ferner wurden Procalcitonin (PCT) bestimmt, die klinische Diagnose einer Sepsis, die Schwere der Infektion und das klinische Outcome erhoben.

Ergebnisse

Ergebnisse der BC waren bei 200 (94,8%) und der PCR bei 119 (56,3%) Patienten verfügbar. Insgesamt waren 87 der BC (43,5%) positiv und identifizierten 94 Erreger. In 45 positiven PCRs (37,8%) wurden 47 Erreger gefunden. Identische Ergebnisse wurden in 81,4% erzielt. Durch die BC wurden 9 zusätzliche grampositive und 3 gramnegative Bakterien identifiziert. Die PCR fand 5 zusätzliche gramnegative Bakterien. Koagulasenegative Staphylokokken wurden nur in Blutkulturen gefunden (n=20, 21,3%); die PCR identifizierte signifikant mehr gramnegative Bakterien als die BC.

Bei Patienten mit positiver PCR war der PCT-Spiegel signifikant höher als bei Patienten mit negativer PCR (15,0±23,3 vs. 8,8±32,8 ng/ml, p<0,001). Diese Differenz konnte nicht für die BC beobachtet werden (10,6±25,7 vs. 11,6±44,9 ng/ml, p=0,075). Der APACHE-II-Score war bei positiver PCR (19,2±9,1 vs. 15,8±8,9, p<0,05) und positiver BC (18,7±8,7 vs. 14,4±8,0, p<0,01) erhöht. Positive PCR und BC korrelierten mit schlechtem klinischem Outcome (z. B. Verlegung auf ITS, mechanische Beatmung, Nierenersatztherapie oder Tod).

Schlussfolgerung

Bei Patienten mit Verdacht auf eine schwere Infektion kann ein hoher Prozentsatz positiver BC und PCR gefunden werden. Positive Ergebnisse in der PCR korrelieren mit erhöhten PCT-Spiegeln und hohen APACHE-II-Scores.

Schlüsselwörter

Sepsis Polymerasekettenreaktion Blutkultur Notaufnahme Procalcitonin 

References

  1. 1.
    Majuran M, Clancy M (2008) Determination of the size of the different sepsis categories presenting to a UK teaching hospital emergency department. Emerg Med J 25:11–14PubMedCrossRefGoogle Scholar
  2. 2.
    Rezende E, Silva JM Jr, Isola AM et al (2008) Epidemiology of severe sepsis in the emergency department and difficulties in the initial assistance. Clinics (Sao Paulo) 63:457–464Google Scholar
  3. 3.
    Wang HE, Shapiro NI, Angus DC, Yealy DM (2007) National estimates of severe sepsis in United States emergency departments. Crit Care Med 35:1928–1936PubMedCrossRefGoogle Scholar
  4. 4.
    Puskarich MA, Marchick MR, Kline JA et al (2009) One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care 13:R167PubMedCrossRefGoogle Scholar
  5. 5.
    Ibrahim EH, Sherman G, Ward S et al (2000) The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 118:146–155PubMedCrossRefGoogle Scholar
  6. 6.
    Catenacci MH, King K (2008) Severe sepsis and septic shock: improving outcomes in the emergency department. Emerg Med Clin North Am 26:603–623PubMedCrossRefGoogle Scholar
  7. 7.
    Stefani S (2009) Diagnostic techniques in bloodstream infections: where are we going? Int J Antimicrob Agents 34(Suppl 4):S9–12PubMedCrossRefGoogle Scholar
  8. 8.
    Struelens MJ, Mendonca R de (2001) The emerging power of molecular diagnostics: towards improved management of life-threatening infection. Intensive Care Med 27:1696–1698PubMedCrossRefGoogle Scholar
  9. 9.
    Westh H, Lisby G, Breysse F et al (2009) Multiplex real-time PCR and blood culture for identification of bloodstream pathogens in patients with suspected sepsis. Clin Microbiol Infect 15:544–551PubMedCrossRefGoogle Scholar
  10. 10.
    Reinhart K, Brunkhorst FM, Bone HG et al (2010) Prevention, diagnosis, treatment, and follow-up care of sepsis. First revision of the S2 k Guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI). Anaesthesist 59:347–370PubMedCrossRefGoogle Scholar
  11. 11.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829PubMedCrossRefGoogle Scholar
  12. 12.
    Vincent JL, Moreno R, Takala J et al (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710PubMedCrossRefGoogle Scholar
  13. 13.
    Werdan K, Pilz G, Bujdoso O et al (2007) Score-based immunoglobulin G therapy of patients with sepsis: the SBITS study. Crit Care Med 35:2693–2701PubMedCrossRefGoogle Scholar
  14. 14.
    Tsalik EL, Jones D, Nicholson B et al (2010) Multiplex PCR to diagnose bloodstream infections in patients admitted from the emergency department with sepsis. J Clin Microbiol 48:26–33PubMedCrossRefGoogle Scholar
  15. 15.
    Lodes U, Meyer F, Konig B, Lippert H (2009) Microbiological sepsis screening in surgical ICU patients with the “lightCycler” Septifast test – a pilot study. Zentralbl Chir 134:249–253PubMedCrossRefGoogle Scholar
  16. 16.
    Mylotte JM, Tayara A (2000) Blood cultures: clinical aspects and controversies. Eur J Clin Microbiol Infect Dis 19:157–163PubMedCrossRefGoogle Scholar
  17. 17.
    Peters RP, Agtmael MA van, Danner SA et al (2004) New developments in the diagnosis of bloodstream infections. Lancet Infect Dis 4:751–760PubMedCrossRefGoogle Scholar
  18. 18.
    Casalta JP, Gouriet F, Roux V et al (2009) Evaluation of the LightCycler SeptiFast test in the rapid etiologic diagnostic of infectious endocarditis. Eur J Clin Microbiol Infect Dis 28:569–573PubMedCrossRefGoogle Scholar
  19. 19.
    Brunkhorst FM, Wegscheider K, Forycki ZF, Brunkhorst R (2000) Procalcitonin for early diagnosis and differentiation of SIRS, sepsis, severe sepsis, and septic shock. Intensive Care Med 26(Suppl 2):S148–152PubMedGoogle Scholar
  20. 20.
    James MT, Quan H, Tonelli M et al (2009) CKD and risk of hospitalization and death with pneumonia. Am J Kidney Dis 54:24–32PubMedCrossRefGoogle Scholar
  21. 21.
    Amour J, Birenbaum A, Langeron O et al (2008) Influence of renal dysfunction on the accuracy of procalcitonin for the diagnosis of postoperative infection after vascular surgery. Crit Care Med 36:1147–1154PubMedCrossRefGoogle Scholar
  22. 22.
    Montagnana M, Lippi G, Tessitore N et al (2009) Procalcitonin values after dialysis is closely related to type of dialysis membrane. Scand J Clin Lab Invest 69:703–707PubMedCrossRefGoogle Scholar
  23. 23.
    Klouche M, Schroder U (2008) Rapid methods for diagnosis of bloodstream infections. Clin Chem Lab Med 46:888–908PubMedGoogle Scholar
  24. 24.
    Abe T, Tokuda Y, Ishimatsu S, Birrer RB (2009) Usefulness of initial blood cultures in patients admitted with pneumonia from an emergency department in Japan. J Infect Chemother 15:180–186PubMedCrossRefGoogle Scholar
  25. 25.
    Weinstein MP (2003) Blood culture contamination: persisting problems and partial progress. J Clin Microbiol 41:2275–2278PubMedCrossRefGoogle Scholar
  26. 26.
    Smith MD, Sheppard CL, Hogan A et al (2009) Diagnosis of Streptococcus pneumoniae infections in adults with bacteremia and community-acquired pneumonia: clinical comparison of pneumococcal PCR and urinary antigen detection. J Clin Microbiol 47:1046–1049PubMedCrossRefGoogle Scholar
  27. 27.
    Molina JM, Cordoba J, Ramirez P, Gobernado M (2008) Automatic detection of bacterial and fungal infections in blood. Enferm Infecc Microbiol Clin 26(Suppl 9):75–80PubMedCrossRefGoogle Scholar
  28. 28.
    Bloos F, Hinder F, Becker K et al (2010) A multicenter trial to compare blood culture with polymerase chain reaction in severe human sepsis. Intensive Care Med 36:241–247PubMedCrossRefGoogle Scholar
  29. 29.
    Vince A, Lepej SZ, Barsic B et al (2008) LightCycler SeptiFast assay as a tool for the rapid diagnosis of sepsis in patients during antimicrobial therapy. J Med Microbiol 57:1306–1307PubMedCrossRefGoogle Scholar
  30. 30.
    Dierkes C, Ehrenstein B, Siebig S et al (2009) Clinical impact of a commercially available multiplex PCR system for rapid detection of pathogens in patients with presumed sepsis. BMC Infect Dis 9:126PubMedCrossRefGoogle Scholar
  31. 31.
    Jongwutiwes U, Suitharak K, Tiengrim S, Thamlikitkul V (2009) Serum procalcitonin in diagnosis of bacteremia. J Med Assoc Thai 92(Suppl 2):S79–87PubMedGoogle Scholar
  32. 32.
    Charles PE, Ladoire S, Snauwaert A et al (2008) Impact of previous sepsis on the accuracy of procalcitonin for the early diagnosis of blood stream infection in critically ill patients. BMC Infect Dis 8:163PubMedCrossRefGoogle Scholar
  33. 33.
    Phua J, Koay ES, Lee KH (2008) Lactate, procalcitonin, and amino-terminal pro-B-type natriuretic peptide versus cytokine measurements and clinical severity scores for prognostication in septic shock. Shock 29:328–333PubMedCrossRefGoogle Scholar
  34. 34.
    Kushimoto S, Shibata Y, Koido Y et al (2007) The clinical usefulness of procalcitonin measurement for assessing the severity of bacterial infection in critically ill patients requiring corticosteroid therapy. J Nippon Med Sch 74:236–240PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • S. Hettwer
    • 1
  • J. Wilhelm
    • 1
  • M. Schürmann
    • 1
  • H. Ebelt
    • 1
  • D. Hammer
    • 1
  • M. Amoury
    • 2
  • F. Hofmann
    • 3
  • A. Oehme
    • 3
  • D. Wilhelms
    • 3
  • A.S. Kekulé
    • 3
  • T. Klöss
    • 2
  • K. Werdan
    • 1
  1. 1.Department of Medicine III (Cardiology, Angiology and Medical Intensive Care Medicine)University Clinics HalleHalle (Saale)Deutschland
  2. 2.Department of Emergency MedicineUniversity Clinics Halle (Saale)Halle (Saale)Deutschland
  3. 3.Institute of Medical MicrobiologyHalle (Saale)Deutschland

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