بلدا هذا اجعل ربمن أهله وارزق آمنا

امن من الثمراتاليوم و بالله منهم

اآلخر

Clinical Implication of Serum Procalcitonin in Sepsis and

pneumonia

Lecturer of chest diseases, Assuit faculty of medicine

The most common cause of death in intensive care units

Mortality rate up to 50% depending on severity.

Early diagnosis and intervention markedly reduce the mortality

INFECTION SOURCE IN SEVERE SEPSIS

44.0%

17.3%9.1%

8.6%

6.6%

2.2%

8.0%

6.0%

10.8%Respiratory

Bacteremia

GU

Abdomen

Soft tissue

Device

CNS

Endocarditis

Other

Angus DC et al. Crit Care Med. 2001; 29:1303

20 to 50% of them will ultimately die

The major infection-related cause of death in

developed countries

10 to 20% admitted to the intensive

care unit

Fight as much as you can

Early diagnosis and intervention

Differentiate between infectious and non infectious case of systemic

inflammation

Early diagnosis is essential to :

Administer the correct treatment Avoid unnecessary antibiotic use Reducing the morbidity, mortality And decrease care-related costs.

Cantürk et al., Turk J Med Sci 2008; 38 (2): 139-144

• Delays treatment

• Increases hospital length-of-stay

• Increases costs

• Increased mortality

Delayed diagnosis

Delayed intervention can be fatal

Sebat CCM 2007; 35: 2568

It is very important to differentiate between infectious and non infectious case of systemic inflammation

Inability to differentiate between infectious and non infectious causes

Unplanned use of antibiotics

Antibiotic resistance

Chen et al, 2008 Chinese Medical Journal, 2008,

70% are infectious in

origin . 20–30% related to bacteria detected

by sputum culture

viruses are detected in >50% of exacerbations

Bacteria are isolated from the respiratory tract of only 50% of patients

Dauben et al., BMC Infect Dis. 2008; 8: 145.

Antibiotics were found to have been prescribed in 85% of patients

admitted for AE-COPD to 360 hospitals throughout the USA

Drug costs accounted for more than 70% of the total costs AE-

COPD

Chen et al, 2008 Chinese Medical Journal, 2008,

0%

20%

40%

60%

80%

100%

Antibiotic sensitivity for AECOPD in Upper Egypt

Agamy et al., Egyp.J. Ch.dises. And tub. 2011

0% 10% 20% 30% 40% 50% 60%

Lincomycin

Tetracyclines

1st&2ndcephalosporins.

Clindamycin

Aminoglycosides

Antibiotic sensitivity for CAP and HAP in Upper Egypt

Agamy et al., Egyp.J. Ch.dises. And tub. 2011

0% 20% 40% 60%

Amoxicillin-Clavulinic

Ampicilin-Sulbactam

1st&2ndcephalosporins.

Lincomycin

Tetracyclines

0% 20% 40% 60% 80% 100%

Amoxicillin-Clavulinic

Ampicilin-Sulbactam

1st&2ndcephalosporins.

Lincomycin

Tetracyclines

Erythromycin

Acute phase reactants

Capable of demonstrating the inflammation

differentiate between bacterial and nonbacterial inflammation

CRP and leukocyte count do not have sufficient specificity in differentiating between bacterial infections, non-infectious systemic inflammations or viral infections.

Cantürk et al., Turk J Med Sci 2008; 38 (2): 139-144

Because most microbiological test results are not available for 24 h, a sensitive and specific marker of systemic infection would be useful.

Hausfater et al, 2002. Clinical Infectious Diseases Volume 34, Issue 7Pp. 895-901

Reimer et al. Clinical Microbiol Rev 1997; 10:444-65.

We are in need for a simple and rapid laboratory method to:

Guide antibiotic use Predict the prognosis Predict mortality Differentiate between infectious and

non infectious causes of systemic inflammation

(PCT) levels appears to be useful in order to minimize this problem. The sensitivity and specificity of PCT in

bacterial infections were found to be 92.6% and 97.5%

Cantürk et al., Turk J Med Sci 2008; 38 (2): 139-144

Bacterial toxins and cytokines

Invasion by pathogenic

bacteria

Stimulate PCT production in all paraynchymal cells

Adapted from Christ-Crain et al. 2005

22

23

VALUES OF PROCALCITONIN IN INFECTION

24

1- PCT LEVEL INCREASE = INCREASED SIGNIFICANCE OF BACTERIAL INFECTION

Healthy Individuals

Local Infections

Systemic Infections (Sepsis)

Severe Sepsis

Septic Shock

0.05 ng/ml

0.5 ng/ml

2 ng/ml

25

2- Differentiates between bacterial contamination and real bacterial infection

PCT may help discriminate blood stream infections from blood culture contamination due to coagulase-negative staphylococci

Schuetz P. et al., Infection 2007;35 (5): 352-5

26

3- Predicts bacteremia

Muller et al. CHEST July 2010

PCT measurement demonstrated the potential to reduce the number of blood cultures

27

PneumoniaSepsis

4- PROCALCITONIN CORRELATES TO THE SEVERITY OF THE INFECTION

Harbarth S et al. Am J Respir Crit Care Med 2001, 164: 396-402Meisner M et al., Critical Care 1999, 3(1): 45-50 Krüger S. et al., Eur Respir J 2008; 31: 349–355

28

Mortality by PCT level

0%

2%

4%

6%

8%

10%

12%

0 5 10 15 20 25 30

Day

Mo

rta

lity

, %

≥ 0.1

< 0.1

Huang, et.al., Annals of Emergency Medicine, Vol 51, March 2008

• Low PCT levels identify patients presenting in the ED that have a low risk for mortality

5- Evaluates the prognosis

PCT

PCT

29

• Decreasing PCT levels indicate effective treatment of the underlying infection

• Persistently elevated PCT levels indicate a possible treatment failure

6- Evaluates patient response to antibiotics

Stueber, F. University of Bonn, Lecture at ISICEM, Brussels 2001

30

Nobre V. et alAM Resp Crit Care Med 2008: 177:498-505

• Effect of PCT-guided management in patients with sepsis on ICU length of stay

PCT GUIDANCE IN ANTIBIOTIC USAGE EFFECTS ON LENGTH OF STAY

31

• PCT levels do not increase in some of the disease entities that cause the FUO syndrome, e.g., Still's disease, systemic lupus erythematosus, and inflammatory bowel disease

7- Sort out the etiology of the fever in patients with the fever of unknown origin (FUO) syndrome

32

PCT levels are not affected by the patient's use of nonsteroidal anti-

inflammatory agents or glucocorticoids

PCT levels remain a valuable marker of the host inflammatory response even when

nonsteroidal anti-inflammatory drugs and corticosteroids are used

33Simon L. et al. Clin Infect Dis. 2004; 39:206-217.

• PCT levels accurately differentiate sepsis from noninfectious inflammation*• PCT has been demonstrated to be the best marker for differentiating patients with sepsis

from those with systemic inflammatory reaction not related to infectious cause

DIAGNOSTIC ACCURACY OF PCT COMPARED TO OTHER BIOMARKERS USED IN SEPSIS

34

False negative results

Low PCT levels in the presence of bacterial infection may occur:

• Early course of infection: Re-measure in 6-12hrs• Subacute Endocarditis• Localized infections

35

Cirrhosis Pancreatitis Mesenteric infarction (ischemic bowel) Cardiogenic shock, and hypotension during

surgery Burns Pulmonary edema and pulmonary

aspiration

False positive results

36

PCT is usefull to diffrentiate between bacterial and non bacterial infection

Differentiates between bacterial contamination and real bacterial infection

Predicts bacteremia

37

PCT level correlates with the severity of infection in sepsis and pneumonia

Evaluates the prognosis Evaluates patient response to

antibiotics Sort out the etiology of the fever in

patients with the fever of unknown origin (FUO) syndrome

38

Never ever forget to love those dearest to you