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Usefulness of Serum Procalcitonin Levels for the Early Diagnosis of Stroke-Associated Respiratory Tract Infections

Abstract

Background

Patients with extensive brain infarcts are at increased risk for stroke-associated respiratory tract infections (SARTI), which cause worse outcome. The benefit of general antibiotic prophylaxis is controversial. Early diagnosis of SARTI may improve patient selection for antimicrobial therapy. Procalcitonin (PCT) is widely recognized as serum marker for bacterial infections. Its diagnostic value with respect to SARTI has not been assessed systematically.

Methods

Serum PCT levels were analyzed in ischemic stroke patients (n = 50) at day 1 (d1) and day 4 (d4) after stroke onset. PCT test performance was assessed by receiver operator characteristics (ROC) curve analysis. Multivariable logistic regression analysis was applied to identify early predictors for SARTI.

Results

Higher d4 serum PCT levels were associated with SARTI; ROC curve analysis revealed an area under the curve (AUC) of 0.79 (95%-confidence interval (CI) 0.61–0.96). A 0.25-ng/ml cutoff resulted in a test sensitivity and specificity of 42 and 96%, respectively. Positive (LR+) and negative (LR−) likelihood ratios were 10.8 and 0.6, respectively. In predicting SARTI, multivariable logistic regression analysis controlling for infarct volume ruled out an independent explanatory effect of serum PCT. Greater infarct volume (odds ratio (OR) 1.06, 95%-CI 1.02–1.1) prevailed as independent SARTI-predictor.

Conclusions

In the absence of clinical signs, post-stroke screening for SARTI using serum PCT levels is not useful since test sensitivity is low. If the clinical suspicion for SARTI is strong, serum PCT-testing (>0.25 ng/ml) may improve diagnostic accuracy by improving specificity.

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Abbreviations

AUC:

Area under the curve

BAL:

Bronchoalveolar lavage

CI:

Confidence interval

CNS:

Central nervous system

CRP:

C-reactive protein

CT:

Computed tomography

d1:

Day 1 post-stroke

d4:

Day 4 post-stroke

GCS:

Glasgow coma scale

h:

Hours

HLA-DR:

Human leukocyte antigen-DR

IQR:

Interquartile range

LR−:

Negative likelihood ratio

LR+:

Positive likelihood ratio

LRTI:

Lower respiratory tract infection

ml:

Milliliter

MRI:

Magnetic resonance imaging

n:

Number

n.s.:

Non-significant

ng:

Nanogram

NIHSSS:

National Institute of Health Stroke Scale Score

nl:

Nanoliter

OR:

Odds ratio

PCT:

Procalcitonin

ROC:

Receiver operator characteristics

SAI:

Stroke-associated infection

SARTI:

Stroke-associated respiratory tract infection

SID:

Stroke-induced immune depression

VAP:

Ventilator-associated pneumonia

WBC:

White blood cell count

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Acknowledgments

This study was supported by a grant from the Else Kröner Fresenius Stiftung to R.V. R.V. is supported by an Else Kröner Memorial scholarship.

Authorship responsibility and contributions

Andreas Hug conceived and designed the research, enrolled patients, acquired/analyzed clinical data/blood specimens, performed statistical analysis and drafted the manuscript.

Bettina Mürle performed brain MRIs/volumetric analysis of brain infarcts and made critical revisions of the manuscript for important intellectual content.

Alexander Dalpke analyzed clinical data/blood specimens and made critical revisions of the manuscript for important intellectual content.

Markus Zorn analyzed blood specimens and made critical revisions of the manuscript for important intellectual content.

Arthur Liesz analyzed clinical data and made critical revisions of the manuscript for important intellectual content.

Roland Veltkamp designed the research, handled funding and supervision and made critical revisions of the manuscript for important intellectual content.

Author information

Correspondence to Andreas Hug.

Additional information

The study was performed at the University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany.

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Hug, A., Mürle, B., Dalpke, A. et al. Usefulness of Serum Procalcitonin Levels for the Early Diagnosis of Stroke-Associated Respiratory Tract Infections. Neurocrit Care 14, 416–422 (2011) doi:10.1007/s12028-009-9325-6

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Keywords

  • Acute ischemic stroke
  • Respiratory tract infection
  • Procalcitonin