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Prognostic value of procalcitonin in Legionella pneumonia

  • J. Haeuptle
  • R. Zaborsky
  • R. Fiumefreddo
  • A. Trampuz
  • I. Steffen
  • R. Frei
  • M. Christ-Crain
  • B. MüllerEmail author
  • P. Schuetz
Article

Abstract

The diagnostic reliability and prognostic implications of procalcitonin (PCT) (ng/ml) on admission in patients with community-acquired pneumonia (CAP) due to Legionella pneumophila are unknown. We retrospectively analysed PCT values in 29 patients with microbiologically proven Legionella-CAP admitted to the University Hospital Basel, Switzerland, between 2002 and 2007 and compared them to other markers of infection, namely, C-reactive protein (CRP) (mg/l) and leukocyte count (109/l), and two prognostic severity assessment scores (PSI and CURB65). Laboratory analysis demonstrated that PCT values on admission were >0.1 in over 93%, >0.25 in over 86%, and >0.5 in over 82% of patients with Legionella-CAP. Patients with adverse medical outcomes (59%, n = 17) including need for ICU admission (55%, n = 16) and/or inhospital mortality (14%, n = 4) had significantly higher median PCT values on admission (4.27 [IQR 2.46–9.48] vs 0.97 [IQR 0.29–2.44], p = 0.01), while the PSI (124 [IQR 81–147] vs 94 [IQR 75–116], p = 0.19), the CURB65 (2 [IQR 1–2] vs 1 [1–3], p = 0.47), CRP values (282 [IQR 218–343], p = 0.28 vs 201 [IQR 147–279], p = 0.28), and leukocyte counts (12 [IQR 10–21] vs 12 [IQR 9–15], p = 0.58) were similar. In receiver operating curves, PCT concentrations on admission had a higher prognostic accuracy to predict adverse outcomes (AUC 0.78 [95%CI 0.61–96]) as compared to the PSI (0.64 [95%CI 0.43–0.86], p = 0.23), the CURB65 (0.58 [95%CI 0.36–0.79], p = 0.21), CRP (0.61 [95%CI 0.39–0.84], p = 0.19), and leukocyte count (0.57 [95%CI 0.35–0.78], p = 0.12). Kaplan-Meier curves demonstrated that patients with initial PCT values above the optimal cut-off of 1.5 had a significantly higher risk of death and/or ICU admission (log rank p = 0.003) during the hospital stay. In patients with CAP due to Legionella, PCT levels on admission might be an interesting predictor for adverse medical outcomes.

Keywords

Pneumonia Severity Index Diagnostic Reliability Urine Antigen Testing Receiver Operating Curf CURB65 Score 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Competing interests

Authors PS, MCC and BM received support from BRAHMS to attend meetings and fulfilled speaking engagements. BM has served as a consultant and received research support to attend meetings and for travel expenses. All other co-authors declare that they have no competing interests.

Authors’ contributions

Authors PS, JH, RZ, RF, MCC, and BM had the idea for the study and directed the study design, data collection, and analysis and writing of the report. Authors RF, IS, and AT each had substantial contributions in planning of the study, data collection, interpretation of data, and/or writing of the manuscript.

References

  1. 1.
    Muller B, Harbarth S, Stolz D, Bingisser R, Mueller C, Leuppi J et al (2007) Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia. BMC Infect Dis 7:10. doi: 10.1186/1471-2334-7-10 PubMedCrossRefGoogle Scholar
  2. 2.
    Simon L, Gauvin F, Amre DK, Saint-Louis P, Lacroix J (2004) Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis 39(2):206–217. doi: 10.1086/421997 PubMedCrossRefGoogle Scholar
  3. 3.
    Christ-Crain M, Jaccard-Stolz D, Bingisser R, Gencay MM, Huber PR, Tamm M et al (2004) Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet 363(9409):600–607. doi: 10.1016/S0140-6736(04)15591-8 PubMedCrossRefGoogle Scholar
  4. 4.
    Briel M, Christ-Crain M, Young J, Schuetz P, Huber P, Periat P et al (2005) Procalcitonin-guided antibiotic use versus a standard approach for acute respiratory tract infections in primary care: study protocol for a randomised controlled trial and baseline characteristics of participating general practitioners. BMC Fam Pract 6:34. doi: 10.1186/1471-2296-6-34 PubMedCrossRefGoogle Scholar
  5. 5.
    Christ-Crain M, Stolz D, Bingisser R, Muller C, Miedinger D, Huber PR et al (2006) Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med 174(1):84–93. doi: 10.1164/rccm.200512-1922OC PubMedCrossRefGoogle Scholar
  6. 6.
    Stolz D, Christ-Crain M, Bingisser R, Leuppi J, Miedinger D, Muller C et al (2007) Antibiotic treatment of exacerbations of COPD: a randomized, controlled trial comparing procalcitonin-guidance with standard therapy. Chest 131(1):9–19. doi: 10.1378/chest.06-1500 PubMedCrossRefGoogle Scholar
  7. 7.
    Jensen JU, Heslet L, Jensen TH, Espersen K, Steffensen P, Tvede M (2006) Procalcitonin increase in early identification of critically ill patients at high risk of mortality. Crit Care Med 34(10):2596–2602. doi: 10.1097/01.CCM.0000239116.01855.61 PubMedCrossRefGoogle Scholar
  8. 8.
    Harbarth S, Holeckova K, Froidevaux C, Pittet D, Ricou B, Grau GE et al (2001) Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis. Am J Respir Crit Care Med 164(3):396–402PubMedGoogle Scholar
  9. 9.
    Masia M, Gutierrez F, Padilla S, Soldan B, Mirete C, Shum C et al (2007) Clinical characterisation of pneumonia caused by atypical pathogens combining classic and novel predictors. Clin Microbiol Infect 13(2):153–161. doi: 10.1111/j.1469-0691.2006.01629.x PubMedCrossRefGoogle Scholar
  10. 10.
    Korppi M, Remes S, Heiskanen-Kosma T (2003) Serum procalcitonin concentrations in bacterial pneumonia in children: a negative result in primary healthcare settings. Pediatr Pulmonol 35(1):56–61. doi: 10.1002/ppul.10201 PubMedCrossRefGoogle Scholar
  11. 11.
    Franzin L, Cabodi D (2005) Legionella pneumonia and serum procalcitonin. Curr Microbiol 50(1):43–46. doi: 10.1007/s00284-004-4360-1 PubMedCrossRefGoogle Scholar
  12. 12.
    Prat C, Dominguez J, Andreo F, Blanco S, Pallares A, Cuchillo F et al (2006) Procalcitonin and neopterin correlation with aetiology and severity of pneumonia. J Infect 52(3):169–177. doi: 10.1016/j.jinf.2005.05.019 PubMedCrossRefGoogle Scholar
  13. 13.
    Stout JE, Yu VL (1997) Legionellosis. N Engl J Med 337(10):682–687. doi: 10.1056/NEJM199709043371006 PubMedCrossRefGoogle Scholar
  14. 14.
    Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI et al (2003) Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58(5):377–382. doi: 10.1136/thorax.58.5.377 PubMedCrossRefGoogle Scholar
  15. 15.
    Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE et al (1997) A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 336(4):243–250. doi: 10.1056/NEJM199701233360402 PubMedCrossRefGoogle Scholar
  16. 16.
    Neill AM, Martin IR, Weir R, Anderson R, Chereshsky A, Epton MJ et al (1996) Community acquired pneumonia: aetiology and usefulness of severity criteria on admission. Thorax 51(10):1010–1016PubMedCrossRefGoogle Scholar
  17. 17.
    Woodhead M, Blasi F, Ewig S, Huchon G, Leven M, Ortqvist A et al (2005) Guidelines for the management of adult lower respiratory tract infections. Eur Respir J 26(6):1138–1180. doi: 10.1183/09031936.05.00055705 PubMedCrossRefGoogle Scholar
  18. 18.
    Dominguez JA, Gali N, Pedroso P, Fargas A, Padilla E, Manterola JM et al (1998) Comparison of the Binax Legionella urinary antigen enzyme immunoassay (EIA) with the Biotest Legionella Urin antigen EIA for detection of Legionella antigen in both concentrated and nonconcentrated urine samples. J Clin Microbiol 36(9):2718–2722PubMedGoogle Scholar
  19. 19.
    Lee TC, Vickers RM, Yu VL, Wagener MM (1993) Growth of 28 Legionella species on selective culture media: a comparative study. J Clin Microbiol 31(10):2764–2768PubMedGoogle Scholar
  20. 20.
    Schuetz P, Christ-Crain M, Wolbers M, Schild U, Thomann R, Falconnier C et al (2007) Procalcitonin guided antibiotic therapy and hospitalization in patients with lower respiratory tract infections: a prospective, multicenter, randomized controlled trial. BMC Health Serv Res 7:102. doi: 10.1186/1472-6963-7-102 PubMedCrossRefGoogle Scholar
  21. 21.
    Schuetz P, Christ-Crain M, Muller B (2007) Biomarkers to improve diagnostic and prognostic accuracy in systemic infections. Curr Opin Crit Care 13(5):578–585. doi: 10.1097/MCC.0b013e3282c9ac2a PubMedCrossRefGoogle Scholar
  22. 22.
    Nylen ES, Muller B, Becker KL, Snyder RH (2003) The future diagnostic role of procalcitonin levels: the need for improved sensitivity. Clin Infect Dis 36:823–824. doi: 10.1086/368088 PubMedCrossRefGoogle Scholar
  23. 23.
    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(3):210–217. doi: 10.1016/S1473-3099(07)70052-X PubMedCrossRefGoogle Scholar
  24. 24.
    Muller B, Christ-Crain M, Schuetz P (2007) Meta-analysis of procalcitonin for sepsis detection. Lancet Infect Dis 7(8):498–499, author reply 502–3. doi: 10.1016/S1473-3099(07)70163-9 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • J. Haeuptle
    • 1
  • R. Zaborsky
    • 1
  • R. Fiumefreddo
    • 1
  • A. Trampuz
    • 2
  • I. Steffen
    • 3
  • R. Frei
    • 5
  • M. Christ-Crain
    • 1
  • B. Müller
    • 1
    • 4
    Email author
  • P. Schuetz
    • 1
  1. 1.Department of Internal MedicineUniversity Hospital BaselBaselSwitzerland
  2. 2.Division of Infectious DiseasesUniversity Hospital BaselBaselSwitzerland
  3. 3.Institute of Medical MicrobiologyUniversity of BaselBaselSwitzerland
  4. 4.Department of Internal MedicineKantonsspital AarauAarauSwitzerland
  5. 5.Microbiology LaboratoryUniversity Hospital BaselBaselSwitzerland

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