رب اجعل هذا بلدا آمنا وارزق أهله من الثمرات من امن منهم بالله و اليوم الآخر

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

I NFECTION S OURCE IN S EVERE S EPSIS 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):

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,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,Chinese Medical Journal, 2008,

Antibiotic sensitivity for AECOPD in Upper Egypt Agamy et al., Egyp.J. Ch.dises. And tub. 2011

Antibiotic sensitivity for CAP and HAP in Upper Egypt Agamy et al., Egyp.J. Ch.dises. And tub. 2011

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):

 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, Clinical Infectious Diseases Volume 34, Issue 7Pp Clinical Infectious DiseasesVolume 34, Issue 7 Reimer et al. Clinical Microbiol Rev 1997; 10:

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):

Bacterial toxins and cytokines Invasion by pathogenic bacteria Stimulate PCT production in all paraynchymal cells Adapted from Christ-Crain et al. 2005

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23 VALUES OF PROCALCITONIN IN INFECTION

24 1- PCT LEVEL INCREASE = INCREASED SIGNIFICANCE OF BACTERIAL INFECTION

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: Meisner M et al., Critical Care 1999, 3(1): Krüger S. et al., Eur Respir J 2008; 31: 349–355

28 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

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: Effect of PCT-guided management in patients with sepsis on ICU length of stay PCT GUIDANCE IN ANTIBIOTIC USAGE E FFECTS 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

33 Simon L. et al. Clin Infect Dis. 2004; 39: 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 D IAGNOSTIC 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