Procalcitonin to Distinguish Viral From Bacterial Pneumonia: A Systematic Review and Meta-analysis

Kamat, Ishan; Ramachandran, Vignesh; Eswaran, Harish; Guffey, Danielle; Musher, Daniel M.

doi:10.1093/cid/ciz545

Cited by 188 publications

(152 citation statements)

References 39 publications

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“…44 An elevated serum PCT is often found in patients with sepsis and septic shock. 39 While it is still controversial whether PCT can accurately distinguish bacterial or viral pneumonia, 45 it was found that PCT-guided therapy in acute respiratory infections reduces the antibiotic exposure and side effects, and improves the survival rate. 46 Bacterial infections trigger extrathyroidal synthesis of PCT, which is actively maintained by elevated values of IL-6, IL-1β, and TNF-α, while viral infections hinder PCT production due to interferon-γ.…”

Section: Discussionmentioning

confidence: 99%

C-reactive protein, procalcitonin, D-dimer, and ferritin in severe coronavirus disease-2019: a meta-analysis

Huang

Pranata

Lim

et al. 2020

Ther Adv Respir Dis

510

438

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Background: Patients critically ill with coronavirus disease-2019 (COVID-19) feature hyperinflammation, and the associated biomarkers may be beneficial for risk stratification. We aimed to investigate the association between several biomarkers, including serum C-reactive protein (CRP), procalcitonin (PCT), D-dimer, and serum ferritin, and COVID-19 severity. Methods: We performed a comprehensive systematic literature search through electronic databases. The outcome of interest for this study was the composite poor outcome, which comprises mortality, acute respiratory distress syndrome, need for care in an intensive care unit, and severe COVID-19. Results: A total of 5350 patients were pooled from 25 studies. Elevated CRP was associated with an increased composite poor outcome [risk ratio (RR) 1.84 (1.45, 2.33), p < 0.001; I2: 96%] and its severe COVID-19 (RR 1.41; I2: 93%) subgroup. A CRP ⩾10 mg/L has a 51% sensitivity, 88% specificity, likelihood ratio (LR) + of 4.1, LR- of 0.5, and an area under curve (AUC) of 0.84. An elevated PCT was associated with an increased composite poor outcome [RR 3.92 (2.42, 6.35), p < 0.001; I2: 85%] and its mortality (RR 6.26; I2: 96%) and severe COVID-19 (RR 3.93; I2: 63%) subgroups. A PCT ⩾0.5 ng/ml has an 88% sensitivity, 68% specificity, LR+ of 2.7, LR- of 0.2, and an AUC of 0.88. An elevated D-dimer was associated with an increased composite poor outcome [RR 2.93 (2.14, 4.01), p < 0.001; I2: 77%], including its mortality (RR 4.15; I2: 83%) and severe COVID-19 (RR 2.42; I2: 58%) subgroups. A D-dimer >0.5 mg/L has a 58% sensitivity, 69% specificity, LR+ of 1.8, LR- of 0.6, and an AUC of 0.69. Patients with a composite poor outcome had a higher serum ferritin with a standardized mean difference of 0.90 (0.64, 1.15), p < 0.0001; I2: 76%. Conclusion: This meta-analysis showed that an elevated serum CRP, PCT, D-dimer, and ferritin were associated with a poor outcome in COVID-19. The reviews of this paper are available via the supplemental material section.

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Section: Discussionmentioning

confidence: 99%

C-reactive protein, procalcitonin, D-dimer, and ferritin in severe coronavirus disease-2019: a meta-analysis

Huang

Pranata

Lim

et al. 2020

Ther Adv Respir Dis

510

438

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“…Procalcitonin, preferentially rising in bacterial infections, has demonstrated clinical utility in safely decreasing antibiotic use, though that finding was not reproduced in a recent, large, U.S.-based study [[5],[6]]. With respect to its ability to distinguish bacterial and viral etiologies, procalcitonin has shown only modest performance [7], [8], [9]. Biomarker panels that combine multiple analytes may impart greater sensitivity and specificity.…”

Section: Introductionmentioning

confidence: 99%

Validation of a host response test to distinguish bacterial and viral respiratory infection

et al. 2019

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BackgroundDistinguishing bacterial and viral respiratory infections is challenging. Novel diagnostics based on differential host gene expression patterns are promising but have not been translated to a clinical platform nor extensively tested. Here, we validate a microarray-derived host response signature and explore performance in microbiology-negative and coinfection cases.MethodsSubjects with acute respiratory illness were enrolled in participating emergency departments. Reference standard was an adjudicated diagnosis of bacterial infection, viral infection, both, or neither. An 87-transcript signature for distinguishing bacterial, viral, and noninfectious illness was measured from peripheral blood using RT-PCR. Performance characteristics were evaluated in subjects with confirmed bacterial, viral, or noninfectious illness. Subjects with bacterial-viral coinfection and microbiologically-negative suspected bacterial infection were also evaluated. Performance was compared to procalcitonin.Findings151 subjects with microbiologically confirmed, single-etiology illness were tested, yielding AUROCs 0•85–0•89 for bacterial, viral, and noninfectious illness. Accuracy was similar to procalcitonin (88% vs 83%, p = 0•23) for bacterial vs. non-bacterial infection. Whereas procalcitonin cannot distinguish viral from non-infectious illness, the RT-PCR test had 81% accuracy in making this determination. Bacterial-viral coinfection was subdivided. Among 19 subjects with bacterial superinfection, the RT-PCR test identified 95% as bacterial, compared to 68% with procalcitonin (p = 0•13). Among 12 subjects with bacterial infection superimposed on chronic viral infection, the RT-PCR test identified 83% as bacterial, identical to procalcitonin. 39 subjects had suspected bacterial infection; the RT-PCR test identified bacterial infection more frequently than procalcitonin (82% vs 64%, p = 0•02).InterpretationThe RT-PCR test offered similar diagnostic performance to procalcitonin in some subgroups but offered better discrimination in others such as viral vs. non-infectious illness and bacterial/viral coinfection. Gene expression-based tests could impact decision-making for acute respiratory illness as well as a growing number of other infectious and non-infectious diseases.

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“…49 However, in a recent meta-analysis of 12 studies in 2408 patients with community-acquired pneumonia of known aetiology, the sensitivity and specificity of serum procalcitonin to differentiate between bacterial and non-bacterial pneumonia were both 55%. 50 This suggests that a procalcitonin level alone is unlikely to provide enough evidence to differentiate between a viral and a bacterial infection. Current guidance by the Infectious Diseases Society of America does not recommend using procalcitonin as part of clinical judgement.…”

Section: Altered Mentation (Glasgow Coma Scale <15)mentioning

confidence: 99%

COVID-19: to be or not to be; that is the diagnostic question

Coleman

Manavi

Marson

et al. 2020

Postgraduate Medical Journal

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Since the first cases in December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly spread across the globe, resulting in the COVID-19 pandemic. Early clinical experiences have demonstrated the wide spectrum of SARS-CoV-2 presentations, including various reports of atypical presentations of COVID-19 and possible mimic conditions.This article summarises the current evidence surrounding atypical presentations of COVID-19 including neurological, cardiovascular, gastrointestinal, otorhinolaryngology and geriatric features. A case from our hospital of pneumocystis pneumonia initially suspected to be COVID-19 forms the basis for a discussion surrounding mimic conditions of COVID-19. The dual-process model of clinical reasoning is used to analyse the thought processes used to make a diagnosis of COVID-19, including consideration of the variety of differential diagnoses.While SARS-CoV-2 is likely to remain on the differential diagnostic list for a plethora of presentations for the foreseeable future, clinicians should be cautious of ignoring other potential diagnoses due to availability bias. An awareness of atypical presentations allows SARS-CoV-2 to be a differential so that it can be appropriately investigated. A knowledge of infectious mimics prevents COVID-19 from overshadowing other diagnoses, hence preventing delayed diagnosis or even misdiagnosis and consequent adverse outcomes for patients.

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Procalcitonin to Distinguish Viral From Bacterial Pneumonia: A Systematic Review and Meta-analysis

Cited by 188 publications

References 39 publications

C-reactive protein, procalcitonin, D-dimer, and ferritin in severe coronavirus disease-2019: a meta-analysis

C-reactive protein, procalcitonin, D-dimer, and ferritin in severe coronavirus disease-2019: a meta-analysis

Validation of a host response test to distinguish bacterial and viral respiratory infection

COVID-19: to be or not to be; that is the diagnostic question

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