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Procalcitonin for diagnosis of bacterial pneumonia in critically ill patients during 2009 H1N1 influenza pandemic: a prospective cohort study, systematic review and individual patient data meta-analysis

Roman Pfister1*, Matthias Kochanek2, Timo Leygeber1, Christian Brun-Buisson3, Elise Cuquemelle3, Mariana Benevides Paiva Machado4, Enrique Piacentini5, Naomi E Hammond67, Paul R Ingram89 and Guido Michels1

Author Affiliations

1 Department of Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany

2 Department of Internal Medicine I, University of Cologne, Cologne, Germany

3 Medical Intensive Care Unit, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France

4 Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

5 Department of Critical Care Medicine, Hospital Universitari Mutua Terrassa, Terrassa, Spain

6 Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia

7 The George Institute for Global Health, Sydney, Australia

8 Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Australia

9 School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia

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Critical Care 2014, 18:R44  doi:10.1186/cc13760

Published: 10 March 2014

Abstract

Introduction

Procalcitonin (PCT) is helpful for diagnosing bacterial infections. The diagnostic utility of PCT has not been examined thoroughly in critically ill patients with suspected H1N1 influenza.

Methods

Clinical characteristics and PCT were prospectively assessed in 46 patients with pneumonia admitted to medical ICUs during the 2009 and 2010 influenza seasons. An individual patient data meta-analysis was performed by combining our data with data from five other studies on the diagnostic utility of PCT in ICU patients with suspected 2009 pandemic influenza A(H1N1) virus infection identified by performing a systematic literature search.

Results

PCT levels, measured within 24 hours of ICU admission, were significantly elevated in patients with bacterial pneumonia (isolated or coinfection with H1N1; n = 77) (median = 6.2 μg/L, interquartile range (IQR) = 0.9 to 20) than in patients with isolated H1N1 influenza pneumonia (n = 84; median = 0.56 μg/L, IQR = 0.18 to 3.33). The area under the curve of the receiver operating characteristic curve of PCT was 0.72 (95% confidence interval (CI) = 0.64 to 0.80; P < 0.0001) for diagnosis of bacterial pneumonia, but increased to 0.76 (95% CI = 0.68 to 0.85; P < 0.0001) when patients with hospital-acquired pneumonia and immune-compromising disorders were excluded. PCT at a cut-off of 0.5 μg/L had a sensitivity (95% CI) and a negative predictive value of 80.5% (69.9 to 88.7) and 73.2% (59.7 to 84.2) for diagnosis of bacterial pneumonia, respectively, which increased to 85.5% (73.3 to 93.5) and 82.2% (68.0 to 92.0) in patients without hospital acquired pneumonia or immune-compromising disorder.

Conclusions

In critically ill patients with pneumonia during the influenza season, PCT is a reasonably accurate marker for detection of bacterial pneumonia, particularly in patients with community-acquired disease and without immune-compromising disorders, but it might not be sufficient as a stand-alone marker for withholding antibiotic treatment.