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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

Medizinische Klinik - Intensivmedizin und Notfallmedizin volume 107, pages 53–62 (2012)Cite this article

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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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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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

Authors
  1. S. Hettwer MD
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  2. J. Wilhelm
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  3. M. Schürmann
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  4. H. Ebelt
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  5. D. Hammer
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  6. M. Amoury
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  7. F. Hofmann
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  8. A. Oehme
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  9. D. Wilhelms
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  10. A.S. Kekulé
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  11. T. Klöss
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  12. K. Werdan
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Corresponding author

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

Keywords

  • Sepsis
  • Polymerase chain reaction
  • Blood culture
  • Emergency service, hospital
  • Procalcitonin

Schlüsselwörter

  • Sepsis
  • Polymerasekettenreaktion
  • Blutkultur
  • Notaufnahme
  • Procalcitonin