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PROCALCITONIN AS A GUIDE FOR ANTIBIOTIC THERAPY IN PATIENTS ADMITTED WITH ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

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ARTICLE INFO ABSTRACT Chronic obstructive pulmonary disease (COPD) is a preventable and treatable, but progressive disease and hospital admissions of patients with COPD are frequently due to acute exacerbations. Recently, measurement of procalcitonin (PCT) levels appears to be useful in order to minimize this problem as acute phase reactants does not difference between bacterial and non-bacterial causes of inflammation. Aim; The aim of this study was to investigate whether the measurement of Procalcitonin can be used in the differentiation of bacterial and non-bacterial infectious causes of COPD exacerbation, thus helping in planning the treatment, reduce overuse of antibiotics in patients admitted with acute exacerbation of COPD thus reducing economic burden and decrease drug resistance. 86 patients with known COPD and admitted in emergency department with symptoms of acute exacerbation of COPD were included in this study after obtaining written informed consent. At presentation before putting antibiotics blood samples were taken for procalcitonin level, routine blood tests including sputum and blood culture. Patients were allocated in to three groups based on procalcitonin value. Group A; procalcitonin value below < 0.25 ng/ml. (normal) (n=57) Group B; procalcitonin value between 0.25-0.5 ng/ml (local bacterial infection) (n=8) Group C; procalcitonin value between 0.5-2 ng/ml (systemic bacterial infection) (n=21) Results ; In our study a correlation was seen between procalcitonin value in each group and WBC count, fever, ESR, CRP, Vaccination, Chest X ray, smoking and microbiology i.e. blood and sputum culture. A significant correlation was seen between serum procalcitonin value and WBCCount, fever, chest x ray, CRP, blood and sputum culture. (P valve ≤ 0.0001) but no significant correlation was seen between serum procalcitonin level in each group with ESR which is one of acute phase reactant p valve 0.043 Conclusions: This study demonstrates that procalcitonin is a good marker for differentiation between bacterial and nonbacterial acute exacerbation of COPD and could be used to guide initiation and assessing response to antibiotic therapy in patients. Procalcitonin-guided antibiotic therapy has the potential to decrease unnecessary antibiotic use in nonbacterial COPD exacerbations, thereby decreasing the spread of antibiotic-resistant bacteria and reducing antibiotic-related adverse reactions.
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*Corresponding author: Irfan Gul
Medicine Government Medical College Srinagar Jammu and Kashmir India
ISSN: 0976-3031
Research Article
PROCALCITONIN AS A GUIDE FOR ANTIBIOTIC THERAPY IN PATIENTS ADMITTED
WITH ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Mohammadd Ashraf Khan1., Irfan Gul2*., Abid Rasool3., Rafi Ahmad Jan4
and Shujat Gul5
1,3Medicine SKIMS Soura, Jammu and Kashmir India
2Medicine Government Medical College Srinagar Jammu and Kashmir India
4Pulmonary and Internal Medicine SKIMS Soura, Jammu and Kashmir India
5Government Medical College Srinagar Jammu and Kashmir India
DOI: http://dx.doi.org/10.24327/ijrsr.2017.0807.0578
ARTICLE INFO ABSTRACT
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable, but progressive
disease and hospital admissions of patients with COPD are frequently due to acute exacerbations.
Recently, measurement of procalcitonin (PCT) levels appears to be useful in order to minimize this
problem as acute phase reactants does not difference between bacterial and non-bacterial causes of
inflammation. Aim; The aim of this study was to investigate whether the measurement of
Procalcitonin can be used in the differentiation of bacterial and non-bacterial infectious causes of
COPD exacerbation, thus helping in planning the treatment, reduce overuse of antibiotics in
patients admitted with acute exacerbation of COPD thus reducing economic burden and
decrease drug resistance. 86 patients with known COPD and admitted in emergency department
with symptoms of acute exacerbation of COPD were included in this study after obtaining written
informed consent. At presentation before putting antibiotics blood samples were taken for
procalcitonin level, routine blood tests including sputum and blood culture. Patients were allocated
in to three groups based on procalcitonin value.
Group A; procalcitonin value below < 0.25 ng/ml. (normal) (n=57)
Group B; procalcitonin value between 0.25- 0.5 ng/ml (local bacterial infection) (n=8)
Group C; procalcitonin value between 0.5-2 ng/ml (systemic bacterial infection) (n=21)
Results ; In our study a correlation was seen between procalcitonin value in each group and WBC
count, fever, ESR, CRP, Vaccination, Chest X ray, smoking and microbiology i.e. blood and sputum
culture. A significant correlation was seen between serum procalcitonin value and WBCCount,
fever, chest x ray, CRP, blood and sputum culture. (P valve ≤ 0.0001) but no significant correlation
was seen between serum procalcitonin level in each group with ESR which is one of acute phase
reactant p valve 0.043
Conclusions: This study demonstrates that procalcitonin is a good marker for differentiation
between bacterial and nonbacterial acute exacerbation of COPD and could be used to guide
initiation and assessing response to antibiotic therapy in patients. Procalcitonin- guided antibiotic
therapy has the potential to decrease unnecessary antibiotic use in nonbacterial COPD
exacerbations, thereby decreasing the spread of antibiotic-resistant bacteria and reducing antibiotic-
related adverse reactions.
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is a
preventable as well as treatable disease that might also have
extra-pulmonary manifestations. It is characterized by an
abnormal inflammatory response of the lungs against harmful
particles or gases (1) COPD constitutes a major health problem
[2]. Acute exacerbations of COPD (AECOPD) have
considerable impact on morbidity, mortality and quality of life
[3] An exacerbation of COPD is an event in the natural course
of COPD characterised by an acute change in the patient’s
Available Online at http://www.recentscientific.com
International Journal of
Recent Scientific
Research
International Journal of Recent Scientific Research
Vol. 8, Issue, 7, pp. 18839-18843, July, 2017
Copyright © Mohammadd Ashraf Khan et al, 2017, this is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the
original work is properly cited.
Article History:
Received 06th April, 2017
Received in revised form 14th
May, 2017
Accepted 23rd June, 2017
Published online 28th July, 2017
DOI: 10.24327/IJRSR
CODEN: IJRSFP (USA)
Key Words:
Chronic obstructive pulmonary disease
(COPD), procalcitonin (PCT), Antibiotic ,
Acute Exacerbation
Mohammadd Ashraf Khan et al., Procalcitonin as a Guide for Antibiotic Therapy in Patients Admitted
With acute Exacerbation of Chronic obstructive Pulmonary Disease
18840 | P a g e
baseline dyspnoea or breathing difficulty, cough and/or sputum
production beyond day-to-day variability sufficient to warrant a
change in management (Gold definition) [4] . It is essential to
determine the cause of worsening of symptoms for appropriate
clinical management. The available evidence suggests that at
least 80% of the COPD exacerbations are infectious in origin.
Of these infections, 40% to 50% are caused by bacteria,
30% by viruses, and 5% to 10% by atypical bacteria [5-15]
The role of bacteria in exacerbations has not been established
with reasonable certainty since bacterial species are present in
the airways of 25%–50% patients with COPD even in stable
conditions [16-19] While there is well- established evidence for
the use of steroids and bronchodilators in acute exacerbation of
COPD, the debate continues over the appropriate use of
antibiotics in the treatment of acute exacerbations. There are
multiple potential factors leading to acute exacerbation of
COPD, including viruses, bacteria, and common pollutants; as
such, antibiotic treatment may not be indicated for all patients
presenting with exacerbations. Further, the risks of antibiotic
treatment-including adverse drug events, selection for drug-
resistant bacteria, and associated costs-are not insignificant.
Classical diagnostic parameters including CRP and leukocyte
count do not have sufficient specificity in differentiating
between bacterial infections, non-infectious systemic
inflammations or viral infections. Therefore, more specific and
reliable markers that might be helpful in deciding the treatment
are needed in these patients [20]. Serum procalcitonin levels
are suggested to be one of the biomarkers for predicting a
bacterial infection [21]. Procalcitonin (PCT) is a protein having
a molecular weight of 13 kDa and it consists of 116 amino acid
residues. The exact regions of its secretion are not yet clear
[22].
Some literature suggests that PCT is secreted from
neuroendocrine cells of the liver, small intestine and thyroid
cells. In healthy humans, its normal serum level is 0.1 ng/mL.
In a previous study, administration of bacterial endotoxin to
healthy Individuals resulted in an increase in PCT levels
starting two hours after administration, with a peak value
reached in 12 h [23]. Consequently, the serum level remains
constant for another12 h and decreases back to normal level in
20–24 h.PCT gives rapid response to bacterial infections [24].
Studies performed in patients with pneumonia revealed that
serum PCT levels have high sensitivity and specificity in
showing the inflammatory response caused by pneumonia [25].
It has also been suggested in some studies that serum PCT
levels might have a relatively higher sensitivity and specificity
in differentiating pneumonias of bacterial origin from those of
viralorigin [26].
Aim
The aim of this study was to investigate whether the
measurement of PCT can be used in the differentiation of
bacterial and non-bacterial infection causes of COPD
exacerbation, thus helping in planning the treatment.
MATERIAL AND METHODS
Between November 2012 and April 2014 86 patients (47 males
and 39 females) with known copd and admitted in emergency
department with symptoms of acute exacerbation of COPD
(worsenening of cough, increased sputum production,
increased breathlessness) were included in this prospective
study after taking written informed consent.
Inclusion Criteria were patients of age 18 who were already
diagnostic cases of COPD [Gold criteria, PFT documented] and
have not received antibiotics in last 2 weeks nor have been
hospitalized in last 2 weeks. Exclusion Criteria were Age< 18
years, Pregnant women, Patients with absolute neutropenia and
Immunocomprised patients.
Definition
The diagnosis of COPD was based on clinical history, physical
examination findings, and spirometric criteria according to the
Global Initiative for Chronic Obstructive Lung Disease
(GOLD) guidelines [14]. An exacerbation of COPD was
defined as ‘‘a sustained worsening of the patient’s condition,
from the stable state and beyond normal day-to-day variations,
that is acute in onset and necessitates a change in regular
medication in a patient with underlying COPD[15].
METHODS
Complete medical history.
General and local chest examination.
Chest radiography.
Routine blood tests (including CBC, ESR and CRP).
Blood cultures, sputum culture (Sputum was induced with
hypertonic saline if subjects were unable to expectorate an
adequate sputum sample spontaneously).
Procalcitonin level by ELISA method
OBSERVATIONS AND RESULTS
Characteristics of subjects with acute exacerbation of COPD
stratified by procalcitonin value above and below threshold i.e
0.25 ng/ml are summarized in table I
In our study we observed potential correlation of Procalcitonin
value in each group with clinical parameters like WBC count,
fever, ESR, CRP, Vaccination, Chest X ray and
microbiological parameter blood and sputum culture.
A significant correlation was seen between procalcitonin value
and WBC count as showing in table 1 with p value ≤ 0.001
between various groups. There is also significant corelation
noted between procalcitonin valve and chest x ray as described
in table 1 with p value ≤ 0.001. A significant correlation was
also noted between patients who were smokers and
procalcitonin level with p value 0.0019. When procalcitonin
level was correlated with CRP level (it was found that among
57 patients with normal Procalcitonin level i.e. < 0.25ng/ml
(Group A) CRP was positive in only 14 patients (24.6%)
whereas among 8 patients in group B with high Procalcitonin
value (0.25-0.5ng/ml) and among 21 patients in group C (Pct.
value >0.5ng/ml) CRP was positive in 4(50%) patients and 17
(80.9%) respectively which is statistically significant p value
<0.001. However there was no significant correlation seen
between procalcitonin value in each group and ESR with p
value 0.43, A significant correlation was also seen between
procalcitonin valve and fever (p valve≤ 0.001ng/ml) However
there was no significant correlation between Pct. valve and
International Journal of Recent Scientific Research Vol. 8, Issue, 7, pp. 18839-18843, July, 2017
18841 | P a g e
vaccination p value 0.133, A significant correlation was seen
between procalcitonin value and blood culture.
Patients in group A blood culture was positive in only 4
patients(7%) where as in patients of group B(n= 8) with local
bacterial infections blood culture was positive in all 8
patients(100%) and in patients of group C with systemic
bacterial infection blood culture was positive in 16 patients
(76.2%). P value ≤ 0.001. A significant correlation was also
seen between procalcitonin value and sputum culture In group
A patients sputum culture was positive in only 3 patients
(5.3%) where as in group B patients with local bacterial
infections sputum culture was positive in 3 patients (37.5%)
and in group C patients with systemic bacterial infection (pct
>0.5ng/ml) sputum culture was positive in 12 patients (57.1%)
which is statistically significant.(p value 0.001)
The 2 showing that there is significant increase in blood culture
positivity rate with higher procalcitonin level in Group C with
76.2% than in Group A with only 7 % (p≤0.001)
The above table 4 shows significant relation between
procalcitonin level with sputum culture with highest percentage
of positive culture in group C and p valve ≤0.001
DISCUSSION
Procalcitonin levels are increased in moderate to severe
bacterial infections but remain at comparatively low levels in
viral infections and nonspecific inflammatory diseases
[27].There are only a limited number of studies investigating
the diagnostic role of procalcitonin in invasive fungal
infections. However, these studies were inconclusive because
of limited sample size and different procalcitonin cut off values
employed [28] This is the first study in the Kashmir valley to
examine the utility of procalcitonin levels in patients with
COPD, and consistent with the European literature, we found
that a high procalcitonin level was relatively specific for
invasive bacterial disease such as pneumonia.[29, 30]. In our
study we classified patients into three groups:-
Group A with normal procalcitonin level 0.25ng/ml Group
B with procalcitonin level between 0.25ngml-0.5ng/ml (local
bacterial infection). Infection which does not affect whole
body of individual, Rather, it is limited to specific portion of
body and does not affect the blood stream. e.g, infected wound,
thrombophlebitis, gonorrhoea. Sometimes a pneumonia can be
localized infection, as it is only located in one specific place in
the lung.
Group C with systemic bacterial infection (Procalcitonin level≥
0.5/ml). A systemic bacterial infection is so named because the
Table No 1 Showing Characteristic Features of Various
Groups
Characteristic
GROUP A
Pct ≤ 0.25
ng/ml
N 57
GROUP B
Pct 0.25-0.50
ng/ml
N 8
GROUP C
≥ 0.5ng/ml
N 21
P valve
ng/ml
Age (mean±s.d)
65.02 ± 10.05
58.75± 7.4 61.8± 6.8 0.118
TLC COUNT(mean±s.d) 8.69 ± 2.5 12.2 ± 3.2 12.1 ± 3.8 ≤0.001
E.S.R (Mean± s.d) 17.02 ± 8.7
23.13± 7.2 21.6 ±9.0 0.43
C.R.P (POSITIVE) 14 4 17 ≤0.001
Chest x ray infiltrates 15 6 17 ≤0.001
Smoker 23 6 15 0.0019
Vaccinated
Influenza 0 1 2 0.133
Pneumococcal 5 1 0
Both influenza and
pneumococcal 3 0 0
Fever 20 2 19 ≤0.001
Positive sputum culture
3 3 12 ≤0.001
Positive blood culture 4 0 16 0.001
Table 2 Correlation between procalcitonin and blood
culture
Procalcitonin(ng/ml) Sterile
Positive
Total
Group A( Procalcitonin value i.e< 0.25ng/ml ) 93.0%
7.0% 100.0%
Group B( procalcitonin value between 0.25- 0.5 ng/ml)
100.0%
0.0% 100.0%
Group C (procalcitonin value between 0.5-2 ng/ml) 23.8%
76.2%
100.0%
0
20
40
60
80
100
120
GROUP A GROUP B GROUPC
PROCALCITATION AND BLOOD CULTURE
POSITIVE STERILE TOTAL
Table 3 Showing Various Bacteria Growth in Culture and
Relation With Procalcitonin
Blood culture organism Procalcitonin(ng/ml) Total
Group A
Group B Group C
No organism 93.0% 100.0% 23.8% 76.7%
Klebsiella 0.0% 0.0% 19.0% 4.7%
Acinetobacter 0.0% o.o% 4.8% 1.2%
Streptococcus 1.8% 0.0% 4.8% 2.3%
Pseudomonas 1.8% 0.0% 9.5% 3.5%
Candida 0.0% 0.0% 4.8% 1.2%
Coaglase negative stap aureus
0.O% 0.0% 9.5% 2.3%
Enterococcus 1.8% 0.0% 4.8% 2.3%
MRSA 0.0% 0.0% 14.3% 3.5%
Staph aureus 1.8% 0.0% 4.8% 2.3%
Table 4 Correlation between procalcitonin and sputum
culture
Procalcitonin(ng/ml)
Sputum
culture
Sterile
Sputum
culture
Positive
Total
Group A( Procalcitonin value i.e.< 0.25ng/ml ) 94.7 %
5.3 % 100.0%
Group B( procalcitonin value between 0.25- 0.5
ng/ml) 62.5 %
37.5% 100.0%
Group C procalcitonin value between 0.5-2 ng/ml)
42.9%
57.1.2%
100.0%
Table 5 Showing Sputum culture 0rganism and serum
procalcitonin (ng/ml) level
Sputum culture
organism Procalcitonin(ng/ml) Total
No organism Group A
Group B
Group C
79.1%
Klebsiella 1.8% 0.0% 23.8% 4.7%
Acinetobacter 0.0% 12.5% 9.5% 1.2%
Streptococcus 1.8% 12.5% 0.0% 2.3%
Pseudomonas 0.0% 12.5% 9.5% 3.5%
Candida 0.0% 0.0% 4.8% 1.2%
Coaglase negative stap
aureus 0.O% 1.0% 9.5% 2.3%
Enterococcus 1.8% 0.0% 4.8% 2.3%
MRSA 0.0% 0.0% 4.3% 3.5%
Staph aureus 1.8% 1.0% 4.8% 2.3%
Mohammadd Ashraf Khan et al., Procalcitonin as a Guide for Antibiotic Therapy in Patients Admitted
With acute Exacerbation of Chronic obstructive Pulmonary Disease
18842 | P a g e
pathogen that causes it, and often the symptoms that it causes,
are spread through the systems of body, instead of being
localized in one area, as they are in local infection.
In our study we correlate procalcitonin values in each group
with higher temperature, white blood cell count, CRP, ESR,
chest radiograph, bacteriology in sputum and blood culture,
suggesting the possibility of occult pneumonia.
In this study we demonstrate a strong correlation of pct valve
with, WBC count, CRP and x ray findings. (p valve ≤ 0.0001)
which is in consistent with study conducted by K.H. Mohamed
et al where significant correlation was seen between PCT level
and temperature (pct<0.05), leukocyte count (p<0.05), CRP
(P<0.05) but in our study we don’t find strong correlation of
pct valve and ESR which is against same study [31]. Our study
is also in agreement with study Conducted by CanturkTasci et
al (2008) where they have found strong correlation of pct valve
with temperature, CRP, leucocyte count, temperature, Blood
culture and x ray infiltrates, a similar result was found in our
study but in Our study we do not found strong correlation of
pct valve and ESR which is against same study. [32] Chang et
al. (33) showed that patients admitted with COPD exacerbation
and positive sputum cultures for bacterial pathogen ha
significantly higher PCT values. A similar result was found in
another study of the same investigator performed in2006 [34]
A similar result was found in our study. In our study we found
that pct valve is strongly correlated with sputum culture and
blood culture. Based on our data, low serum procalcitonin
concentrations of ≤ 0·25 _g/L can identify patients without
clinically relevant bacterial infections; in these individuals
antimicrobial therapy can be safely withheld. Our study had
several limitations. The number of patients with documented
bacterial infection was relatively small. Second limitation of
our study is that our findings are based on single measurement
and sequential testing might improve the diagnostic value of
procalcitonin. Third we did not test for viruses, common
pathogens in this population, although this omission does not
invalidate the findings for those patients with a viral or
bacterial infection identified.
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*******
How to cite this article:
Mohammadd Ashraf Khan et al.2017
, Procalcitonin as a Guide for Antibiotic Therapy in Patients Admitted With acute
Exacerbation of Chronic obstructive Pulmonary Disease. Int J Recent Sci Res. 8(7), pp. 18839-18843.
DOI: http://dx.doi.org/10.24327/ijrsr.2017.0807.0578
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Article
Full-text available
The identification of biological markers in order to assess different aspects of COPD is an area of growing interest. The objective of this study was to investigate whether levels of procalcitonin (PCT), C-reactive protein (CRP), and neopterin in COPD patients could be useful in identifying the etiological origin of the exacerbation and assessing its prognosis. We included 318 consecutive COPD patients: 46 in a stable phase, 217 undergoing an exacerbation, and 55 with pneumonia. A serum sample was collected from each patient at the time of being included in the study. A second sample was also collected 1 month later from 23 patients in the exacerbation group. We compared the characteristics, biomarker levels, microbiological findings, and prognosis in each patient group. PCT and CRP were measured using an immunofluorescence assay. Neopterin levels were measured using a competitive immunoassay. PCT and CRP showed significant differences among the three patient groups, being higher in patients with pneumonia, followed by patients with exacerbation (P < 0.0001). For the 23 patients with paired samples, PCT and CRP levels decreased 1 month after the exacerbation episode, while neopterin increased. Neopterin showed significantly lower levels in exacerbations with isolation of pathogenic bacteria, but no differences were found for PCT and CRP. No significant differences were found when comparing biomarker levels according to the Gram result: PCT (P = 0.191), CRP (P = 0.080), and neopterin (P = 0.109). However, median values of PCT and CRP were high for Streptococcus pneumoniae, Staphylococcus aureus, and enterobacteria. All biomarkers were higher in patients who died within 1 month after the sample collection than in patients who died later on. According to our results, biomarker levels vary depending on the clinical status. However, the identification of the etiology of infectious exacerbation by means of circulating biomarkers is encouraging, but its main disadvantage is the absence of a microbiological gold standard, to definitively demonstrate their value. High biomarker levels during an exacerbation episode correlate with the short-term prognosis, and therefore their measurement can be useful for COPD management.
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Antibiotic overuse in respiratory illness is common and is associated with drug resistance and hospital-acquired infection. Biomarkers that can identify bacterial infections may reduce antibiotic prescription. We aimed to compare the usefulness of the biomarkers procalcitonin and C-reactive protein (CRP) in patients with pneumonia or exacerbations of asthma or COPD. Patients with a diagnosis of community-acquired pneumonia or exacerbation of asthma or COPD were recruited during the winter months of 2006 to 2008. Demographics, clinical data, and blood samples were collected. Procalcitonin and CRP concentrations were measured from available sera. Sixty-two patients with pneumonia, 96 with asthma, and 161 with COPD were studied. Serum procalcitonin and CRP concentrations were strongly correlated (Spearman rank correlation coefficient [rs] = 0.56, P < .001). Patients with pneumonia had increased procalcitonin and CRP levels (median [interquartile range] 1.27 ng/mL [2.36], 191 mg/L [159]) compared with those with asthma (0.03 ng/mL [0.04], 9 mg/L [21]) and COPD (0.05 ng/mL [0.06], 16 mg/L [34]). The area under the receiver operating characteristic curve (95% CI) for distinguishing between patients with pneumonia (antibiotics required) and exacerbations of asthma (antibiotics not required), for procalcitonin and CRP was 0.93 (0.88-0.98) and 0.96 (0.93-1.00). A CRP value > 48 mg/L had a sensitivity of 91% (95% CI, 80%-97%) and specificity of 93% (95% CI, 86%-98%) for identifying patients with pneumonia. Procalcitonin and CRP levels can both independently distinguish pneumonia from exacerbations of asthma. CRP levels could be used to guide antibiotic therapy and reduce antibiotic overuse in hospitalized patients with acute respiratory illness.
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