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

Mikrobiologische Diagnostik bei Patienten mit schweren Infektionen in der Notaufnahme

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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.

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.

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References

  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 25:11–14

    Article  PubMed  CAS  Google Scholar 

  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) 63:457–464

    Google Scholar 

  3. Wang HE, Shapiro NI, Angus DC, Yealy DM (2007) National estimates of severe sepsis in United States emergency departments. Crit Care Med 35:1928–1936

    Article  PubMed  Google Scholar 

  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:R167

    Article  PubMed  Google Scholar 

  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 118:146–155

    Article  PubMed  CAS  Google Scholar 

  6. Catenacci MH, King K (2008) Severe sepsis and septic shock: improving outcomes in the emergency department. Emerg Med Clin North Am 26:603–623

    Article  PubMed  Google Scholar 

  7. Stefani S (2009) Diagnostic techniques in bloodstream infections: where are we going? Int J Antimicrob Agents 34(Suppl 4):S9–12

    Article  PubMed  CAS  Google Scholar 

  8. Struelens MJ, Mendonca R de (2001) The emerging power of molecular diagnostics: towards improved management of life-threatening infection. Intensive Care Med 27:1696–1698

    Article  PubMed  CAS  Google Scholar 

  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 15:544–551

    Article  PubMed  CAS  Google Scholar 

  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 59:347–370

    Article  PubMed  CAS  Google Scholar 

  11. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829

    Article  PubMed  CAS  Google Scholar 

  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 22:707–710

    Article  PubMed  CAS  Google Scholar 

  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 35:2693–2701

    Article  PubMed  CAS  Google Scholar 

  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 48:26–33

    Article  PubMed  CAS  Google Scholar 

  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 134:249–253

    Article  PubMed  CAS  Google Scholar 

  16. Mylotte JM, Tayara A (2000) Blood cultures: clinical aspects and controversies. Eur J Clin Microbiol Infect Dis 19:157–163

    Article  PubMed  CAS  Google Scholar 

  17. Peters RP, Agtmael MA van, Danner SA et al (2004) New developments in the diagnosis of bloodstream infections. Lancet Infect Dis 4:751–760

    Article  PubMed  CAS  Google Scholar 

  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 28:569–573

    Article  PubMed  CAS  Google Scholar 

  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):S148–152

    PubMed  Google Scholar 

  20. James MT, Quan H, Tonelli M et al (2009) CKD and risk of hospitalization and death with pneumonia. Am J Kidney Dis 54:24–32

    Article  PubMed  Google Scholar 

  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 36:1147–1154

    Article  PubMed  CAS  Google Scholar 

  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 69:703–707

    Article  PubMed  CAS  Google Scholar 

  23. Klouche M, Schroder U (2008) Rapid methods for diagnosis of bloodstream infections. Clin Chem Lab Med 46:888–908

    PubMed  CAS  Google Scholar 

  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 15:180–186

    Article  PubMed  Google Scholar 

  25. Weinstein MP (2003) Blood culture contamination: persisting problems and partial progress. J Clin Microbiol 41:2275–2278

    Article  PubMed  Google Scholar 

  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 47:1046–1049

    Article  PubMed  CAS  Google Scholar 

  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):75–80

    Article  PubMed  Google Scholar 

  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 36:241–247

    Article  PubMed  CAS  Google Scholar 

  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 57:1306–1307

    Article  PubMed  Google Scholar 

  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 9:126

    Article  PubMed  Google Scholar 

  31. Jongwutiwes U, Suitharak K, Tiengrim S, Thamlikitkul V (2009) Serum procalcitonin in diagnosis of bacteremia. J Med Assoc Thai 92(Suppl 2):S79–87

    PubMed  Google Scholar 

  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 8:163

    Article  PubMed  Google Scholar 

  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 29:328–333

    Article  PubMed  CAS  Google Scholar 

  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 74:236–240

    Article  PubMed  Google Scholar 

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Conflict of interest

This work was supported by Roche Diagnostics by supplying SeptiFast kits. KW received speaker’s honoraria and an unrestricted research grant from Roche Diagnostics. ASK received speaker’s honoraria from Roche Diagnostics. All other authors declare that there are no conflicts of interest.

Acknowledgment

We acknowledge Roche Diagnostics, Mannheim, Germany for providing SeptiFast PCR test kits free of charge. Furthermore, we acknowledge Dr. Heider for measurement of biochemical markers. We also thank the staff of our emergency department and the Institute of Medical Microbiology for their contribution to this study.

SH, JW, MS, and DH performed the study, gathered all the data and performed the statistical analyses. MA supported the screening and inclusion of patients in the emergency department. FH, AO, DW, and ASK performed the microbial diagnostics. HE and TK corrected the manuscript. KW supervised the conduct of the study and writing of the paper. All authors read and approved the final manuscript.

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Authors and Affiliations

  1. Department of Medicine III (Cardiology, Angiology and Medical Intensive Care Medicine), University Clinics Halle, Ernst-Grube-Str. 40, 06097, Halle (Saale), Deutschland

    S. Hettwer MD, J. Wilhelm, M. Schürmann, H. Ebelt, D. Hammer & K. Werdan

  2. Department of Emergency Medicine, University Clinics Halle (Saale), Halle (Saale), Deutschland

    M. Amoury & T. Klöss

  3. Institute of Medical Microbiology, Halle (Saale), Deutschland

    F. Hofmann, A. Oehme, D. Wilhelms & A.S. Kekulé

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  1. S. Hettwer MD
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  2. J. Wilhelm
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Correspondence to S. Hettwer MD.

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Hettwer, S., Wilhelm, J., Schürmann, M. et al. Microbial diagnostics in patients with presumed severe infection in the emergency department. Med Klin Intensivmed Notfmed 107, 53–62 (2012). https://doi.org/10.1007/s00063-011-0051-4

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  • DOI: https://doi.org/10.1007/s00063-011-0051-4

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