Intensive Care Medicine

, Volume 34, Issue 8, pp 1434–1440 | Cite as

Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia

  • Charles-Edouard Luyt
  • Alain Combes
  • Catherine Reynaud
  • Guillaume Hekimian
  • Ania Nieszkowska
  • Marc Tonnellier
  • Alexandra Aubry
  • Jean-Louis Trouillet
  • Maguy Bernard
  • Jean Chastre
Original

Abstract

Objective

To assess the predictive capacity for the diagnosis of ventilator-associated pneumonia (VAP) of serum procalcitonin levels before and on the day it is suspected.

Design and setting

Single-center observational study in the intensive care unit of a teaching hospital.

Patients and participants

Consecutive patients whose serum procalcitonin levels were available on the day that VAP was clinically suspected (day 1) and at some time within the preceding 5 days (“before”).

Measurements and results

Serum procalcitonin levels were determined on day 1 and “before”. Among the 73 suspected episodes VAP was confirmed by quantitative bronchoalveolar lavage cultures in 32 and refuted in 41. Respective median “before” procalcitonin levels were 1.89 ng/ml (interquartile range 0.18–6.01) and 2.14 (0.76–5.75) in patients with and without VAP, but their respective median day-1 procalcitonin levels did not differ: 1.07 ng/ml (0.39–6.57) vs. 1.40 (0.67–3.39). On day 1 a 0.5 ng/ml procalcitonin threshold had 72% sensitivity but only 24% specificity for diagnosing VAP. Between “before” and day 1, procalcitonin increased in 41% and 15% of patients with and without VAP, respectively. Thus a procalcitonin rise on day 1, compared to its “before” level, had 41% sensitivity and 85% specificity for diagnosing VAP, with respective positive and negative predictive values of 68% and 65%.

Conclusions

Crude values and procalcitonin rise had poor diagnostic value for VAP in this particular setting and thus should not be used to initiate antibiotics when VAP is clinically suspected.

Keywords

Ventilator-associated pneumonia Procalcitonin Diagnosis Clinical pulmonary infection score 

Supplementary material

134_2008_1112_MOESM1_ESM.doc (28 kb)
Electronic Supplementary Material (DOC 28K)

References

  1. 1.
    Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903PubMedGoogle Scholar
  2. 2.
    Canadian Critical Care Trials Groups (2006) A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 355:2619–2630CrossRefGoogle Scholar
  3. 3.
    Heyland DK, Cook DJ, Marshall J, Heule M, Guslits B, Lang J, Jaeschke R (1999) The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Canadian Critical Care Trials Group. Chest 115:1076–1084PubMedCrossRefGoogle Scholar
  4. 4.
    Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stephan F, Similowski T, Mercat A, Diehl JL, Sollet JP, Tenaillon A (2000) Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial. Ann Intern Med 132:621–630PubMedGoogle Scholar
  5. 5.
    American Thoracic Society, Infectious Diseases Society of America (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416CrossRefGoogle Scholar
  6. 6.
    Muller B, White JC, Nylen ES, Snider RH, Becker KL, Habener JF (2001) Ubiquitous expression of the calcitonin-i gene in multiple tissues in response to sepsis. J Clin Endocrinol Metab 86:396–404PubMedCrossRefGoogle Scholar
  7. 7.
    Uzzan B, Cohen R, Nicolas P, Cucherat M, Perret GY (2006) Procalcitonin as a diagnostic test for sepsis in critically ill adults and after surgery or trauma: a systematic review and meta-analysis. Crit Care Med 34:1996–2003PubMedCrossRefGoogle Scholar
  8. 8.
    Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med 29:530–538PubMedGoogle Scholar
  9. 9.
    Duflo F, Debon R, Monneret G, Bienvenu J, Chassard D, Allaouchiche B (2002) Alveolar and serum procalcitonin: diagnostic and prognostic value in ventilator-associated pneumonia. Anesthesiology 96:74–79PubMedCrossRefGoogle Scholar
  10. 10.
    Gibot S, Cravoisy A, Levy B, Bene MC, Faure G, Bollaert PE (2004) Soluble triggering receptor expressed on myeloid cells and the diagnosis of pneumonia. N Engl J Med 350:451–758PubMedCrossRefGoogle Scholar
  11. 11.
    Luyt CE, Guerin V, Combes A, Trouillet JL, Ayed SB, Bernard M, Gibert C, Chastre J (2005) Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia. Am J Respir Crit Care Med 171:48–53PubMedCrossRefGoogle Scholar
  12. 12.
    Seligman R, Meisner M, Lisboa TC, Hertz FT, Filippin TB, Fachel JM, Teixeira PJ (2006) Decreases in procalcitonin and C-reactive protein are strong predictors of survival in ventilator-associated pneumonia. Crit Care 10:R125PubMedCrossRefGoogle Scholar
  13. 13.
    Suprin E, Camus C, Gacouin A, Le Tulzo Y, Lavoue S, Feuillu A, Thomas R (2000) Procalcitonin: a valuable indicator of infection in a medical ICU? Intensive Care Med 26:1232–1238PubMedCrossRefGoogle Scholar
  14. 14.
    Chastre J, Fagon JY, Bornet-Lecso M, Calvat S, Dombret MC, al Khani R, Basset F, Gibert C (1995) Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 152:231–240PubMedGoogle Scholar
  15. 15.
    Luyt CE, Combes A, Nieszkowska A, Reynaud C, Tonnellier M, Trouillet JL, Chastre J (2007) Does invasive diagnosis of nosocomial pneumonia during off-hours delay treatment? Intensive Care Med 33:734–737PubMedCrossRefGoogle Scholar
  16. 16.
    McCabe WR, Jackson GG (1982) Gram-negative bacteremia. Arch Intern Med 110:2957–2963Google Scholar
  17. 17.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963PubMedCrossRefGoogle Scholar
  18. 18.
    Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H (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
  19. 19.
    Weinberg PF, Matthay MA, Webster RO, Roskos KV, Goldstein IM, Murray JF (1984) Biologically active products of complement and acute lung injury in patients with the sepsis syndrome. Am Rev Respir Dis 130:791–796PubMedGoogle Scholar
  20. 20.
    Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL (2000) Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. Am J Respir Crit Care Med 162:505–511PubMedGoogle Scholar
  21. 21.
    Fartoukh M, Maitre B, Honore S, Cerf C, Zahar JR, Brun-Buisson C (2003) Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med 168:173–179PubMedCrossRefGoogle Scholar
  22. 22.
    Luyt CE, Chastre J, Fagon JY (2004) Value of the clinical pulmonary infection score for the identification and management of ventilator-associated pneumonia. Intensive Care Med 30:844–852PubMedCrossRefGoogle Scholar
  23. 23.
    Oppert M, Reinicke A, Muller C, Barckow D, Frei U, Eckardt KU (2002) Elevations in procalcitonin but not C-reactive protein are associated with pneumonia after cardiopulmonary resuscitation. Resuscitation 53:167–170PubMedCrossRefGoogle Scholar
  24. 24.
    Ramirez P, Garcia MA, Ferrer M, Aznar J, Valencia M, Sauquillo JM, Menendez R, Asenjo MA, Torres A (2008) Sequential measurements of procalcitonin in diagnosing ventilator-associated pneumonia. Eur Respir J 31:356–362PubMedCrossRefGoogle Scholar
  25. 25.
    Hausfater P, Garric S, Ayed SB, Rosenheim M, Bernard M, Riou B (2002) Usefulness of procalcitonin as a marker of systemic infection in emergency department patients: a prospective study. Clin Infect Dis 34:895–901PubMedCrossRefGoogle Scholar
  26. 26.
    Christ-Crain M, Stolz D, Bingisser R, Muller C, Miedinger D, Huber PR, Zimmerli W, Harbarth S, Tamm M, Muller B (2006) Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med 174:84–93PubMedCrossRefGoogle Scholar
  27. 27.
    Tang BM, Eslick GD, Craig JC, McLean AS (2007) Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis 7:210–227PubMedCrossRefGoogle Scholar
  28. 28.
    Boutten A, Dehoux MS, Seta N, Ostinelli J, Venembre P, Crestani B, Dombret MC, Durand G, Aubier M (1996) Compartmentalized IL-8 and elastase release within the human lung in unilateral pneumonia. Am J Respir Crit Care Med 153:336–342PubMedGoogle Scholar
  29. 29.
    Dehoux MS, Boutten A, Ostinelli J, Seta N, Dombret MC, Crestani B, Deschenes M, Trouillet JL, Aubier M (1994) Compartmentalized cytokine production within the human lung in unilateral pneumonia. Am J Respir Crit Care Med 150:710–716PubMedGoogle Scholar
  30. 30.
    Brunkhorst FM, Al-Nawas B, Krummenauer F, Forycki ZF, Shah PM (2002) Procalcitonin, C-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia. Clin Microbiol Infect 8:93–100PubMedCrossRefGoogle Scholar
  31. 31.
    Meisner M (1999) Procalcitonin: experience with a new diagnostic tool for bacterial infection and systemic inflammation (in German). J Lab Med 23:263–272Google Scholar
  32. 32.
    Stolz D, Christ-Crain M, Bingisser R, Leuppi J, Miedinger D, Muller C, Huber P, Muller B, Tamm M (2007) Antibiotic treatment of exacerbations of COPD: a randomized, controlled trial comparing procalcitonin-guidance with standard therapy. Chest 131:9–19PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Charles-Edouard Luyt
    • 1
  • Alain Combes
    • 1
  • Catherine Reynaud
    • 1
  • Guillaume Hekimian
    • 1
  • Ania Nieszkowska
    • 1
  • Marc Tonnellier
    • 1
  • Alexandra Aubry
    • 2
  • Jean-Louis Trouillet
    • 1
  • Maguy Bernard
    • 3
  • Jean Chastre
    • 1
  1. 1.Service de Réanimation Médicale, Groupe Hospitalier Pitié Salpêtrière, AP-HPUniversité Paris 6, Pierre-et-Marie-CurieParis Cedex 13France
  2. 2.Service de Bactériologie, Groupe Hospitalier Pitié Salpêtrière, AP-HPUniversité Paris 6, Pierre-et-Marie-CurieParis Cedex 13France
  3. 3.Service de Biochimie, Groupe Hospitalier Pitié Salpêtrière, AP-HPUniversité Paris 6, Pierre-et-Marie-CurieParis Cedex 13France

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