The importance of procalcitonin in determining acute respiratory tract infections and initiating antibiotics in patients admitting to the emergency department with a COPD attack

Öz

Aim: COPD is characterized by permanent airflow limitation and difficulty breathing as a result of damage to the airways and alveoli; It is a disease associated with mortality and morbidity worldwide. Although it is accepted that bacterial pathogens are one of the main causes of COPD exacerbation, treatment for the main cause can be quite difficult since the exact cause cannot be determined in many patients. It remains unclear whether procalcitonin-guided antibiotic therapy provides a reliable clinical benefit in the treatment of patients with COPD exacerbations. In this study, we aimed to determine the predictive success of PCT in determining both diagnosis and antibiotic treatment in COPD exacerbation patients presenting to the emergency department. Material and Methods: Our study was planned single-center and prospectively. The study was conducted with 100 patients who presented to our hospital's emergency department with COPD exacerbation and met the inclusion criteria and were randomly selected according to the order of arrival. Results: 87% of the 100 patients included in our study were male and the average age was 70.4±10.5 years. When the treatment and outcome are evaluated according to PCT and CRP levels; It was determined that there was a significant difference in the median values of CRP and PCT between the cases in which antibiotics were started and those in which antibiotics were not started (p=0.017 and p<0.001, respectively). It was observed that PCT was significantly higher as the patient moved from discharge to ward admission and from ward admission to intensive care unit admission (when the criticality of the patient increased) (p<0.001). However, this relationship between outcome and CRP was not significantly different. Conclusions: Procalcitonin in patients admitted to the emergency department due to COPD attack; We think that the severity of the disease, the decision to start antibiotics, NIMV and IMV treatment are important indicators that determine the discharge of patients from the Emergency Department or admission to the hospital.

Anahtar Kelimeler

• Chronic Obstructive Pulmonary Disease
• Acute Attact
• Antibiotic Stewardship
• Inflammatory Biomarkers

KOAH atak ile acil servise başvuran hastalarda akut solunum yolu enfeksiyonlarını belirlemede ve antibiyotik başlamada prokalsitoninin önemi

Öz

Amaç: KOAH, hava yollarının ve alveollerin hasarı sonucu kalıcı hava akımı kısıtlılığı ve solunum zorluğu ile karakterize; dünya çapında mortalite ve morbidite ile ilişkili bir hastalıktır. Bakteriyel patojenlerin KOAH alevlenmesinde ana nedenlerden biri olduğu kabul edilse de birçok hastada kesin neden tespit edilemediği için asıl nedene yönelik tedavi oldukça zor olabilmektedir. Prokalsitonin kılavuzluğunda, antibiyotik tedavisinin KOAH alevlenme hastalarının tedavisinde güvenilir bir klinik fayda sağlayıp sağlanmadığı belirsizliği devam etmektedir. Bu çalışmamızda, acil servise başvuran KOAH alevlenme hastalarında hem tanı hem de antibiyotik tedavisini belirlemede PCT’nin öngörü başarısını tespit etmeyi amaçladık. Gereç ve Yöntemler: Çalışmamız tek merkezli ve prospektif olarak planlandı. Çalışma, hastanemiz acil servisine KOAH alevlenme ile başvuran ve çalışmaya dahil edilme kriterlerini karşılayan ve geliş sırasına göre randomize olarak seçilen 100 hasta ile yapıldı. Bulgular: Çalışmamıza dahil edilen 100 hastanın %87’si erkek ve yaş ortalaması 70,4±10,5 yıl idi. PCT ve CRP düzeylerine göre verilen tedavi ve sonlanım değerlendirildiğinde; antibiyotik başlanan olgular ile başlanmayan olgular arasında CRP ve PCT ortanca değerleri arasında anlamlı fark olduğu tespit edildi (sırasıyla p=0.017 ve p<0.001). Taburculuktan servis yatışına ve servis yatışından yoğum bakım ünitesine yatışa doğru gidildiğinde (hastanın kritikliği arttığında) PCT’nin de anlamlı olarak yüksek olduğu görüldü (p<0.001). Fakat sonlanım ile CRP arasındaki bu ilişki anlamlı farklı değildi. Sonuç: KOAH atak nedeniyle acil servise başvuran hastalarda prokalsitonin; hastalığın şiddeti, antibiyotik başlanma kararı, NIMV ve IMV tedavisine, hastaların Acil Servis’ten taburculuk veya hastaneye kabulünü belirleyen önemli bir belirteç olduğu düşünüyoruz.

Anahtar Kelimeler

• Kronik Obstrüktif Akciğer Hastalığı
• Akut Atak
• Antibiyotik Yönetimi
• İnflamatuar Biyobelirteçler

Kaynakça

1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management and prevention of COPD. 2019; Available at: http://www.goldcopd.org/ Accessed January 23, 2019
2. Çolak A, Yılmaz C, Toprak B, Aktoğu S. Procalcitonin and CRP as Biomarkers in Discrimination of Community-acquired Pneumonia and Exacerbation of COPD. J Med Biochem. 2017 Apr 22;36(2):122-126. doi: 10.1515/jomb-2017-0011.
3. Miravitlles M, Anzueto A. Antibiotics for acute and chronic respiratory infection in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2013 Nov 1;188(9):1052-7. doi: 10.1164/rccm.201302-0289PP.
4. Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 12;12:CD010257. doi: 10.1002/14651858.CD010257. Update in: Cochrane Database Syst Rev. 2018 Oct 29;10:CD010257.
5. Woodhead M. New guidelines for the management of adult lower respiratory tract infections. Eur Respir J. 2011 Dec;38(6):1250-1. doi: 10.1183/09031936.00105211.
6. Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 1987 Feb;106(2):196-204. doi: 10.7326/0003-4819-106-2-196.
7. Evans HL, Lefrak SN, Lyman J, Smith RL, Chong TW, McElearney ST, Schulman AR, Hughes MG, Raymond DP, Pruett TL, Sawyer RG. Cost of Gram-negative resistance. Crit Care Med. 2007 Jan;35(1):89-95. doi: 10.1097/01.CCM.0000251496.61520.75.
8. Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K; EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009 Dec 2;302(21):2323-9. doi: 10.1001/jama.2009.1754.

9. Bora EJ, Çakır A, Hacar S, Arıkan C, Yurtsever G, Acar H. Non thyroid disease syndrome: a strong prognostic predictor of death in patients with pneumonia. Signa Vitae. 2021;17(5):137-141. doi:10.22514/sv.2021.069
10. Soler N, Torres A, Ewig S, Gonzalez J, Celis R, El-Ebiary M, Hernandez C, Rodriguez-Roisin R. Bronchial microbial patterns in severe exacerbations of chronic obstructive pulmonary disease (COPD) requiring mechanical ventilation. Am J Respir Crit Care Med. 1998 May;157(5 Pt 1):1498-505. doi: 10.1164/ajrccm.157.5.9711044.
11. Cameron RJ, de Wit D, Welsh TN, Ferguson J, Grissell TV, Rye PJ. Virus infection in exacerbations of chronic obstructive pulmonary disease requiring ventilation. Intensive Care Med. 2006 Jul;32(7):1022-9. doi: 10.1007/s00134-006-0202-x.
12. Schuetz P, Wirz Y, Sager R, et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infect Dis 2018; 18:95–107.
13. Jung AL, Han M, Griss K, Bertrams W, Nell C, Greulich T, Klemmer A, Pott H, Heider D, Vogelmeier CF, Hippenstiel S, Suttorp N, Schmeck B. Novel protein biomarkersforpneumonia and acuteexacerbations in COPD: a pilot study. Front Med (Lausanne). 2023 Jun5; 10:1180746. doi: 10.3389/fmed.2023.1180746.
14. D. Gao, X. Chen, H. Wu, H. Wei, and J. Wu, “Thelevels of serum pro-calcitonin and high-sensitivity c-reactive protein in the early diagnosis of chronic obstructive pulmonary disease during acute exacerbation,” Exp. Ther. Med., 2017, doi: 10.3892/etm.2017.4496.
15. H. Tanrıverdi et al., “Comparison of diagnosticvalues of procalcitonin, C-reactive protein and blood neutrophil/lymphocyte Ratio levels in predicting bacterial infection in hospitalized patients with acute exacerbations of COPD Vergleich der diagnostischen Wertigkeitvon Procal,” Wien. Klin. Wochenschr., 2015, doi: 10.1007/s00508-014-0690-6.
16. Vanoverschelde A, Van Hoey C, Buyle F, Den Blauwen N, Depuydt P, Van Braeckel E, Lahousse L. In-hospital antibiotic use for severe chronic obstructive pulmonary disease exacerbations: a retrospective observational study. BMC PulmMed. 2023 Apr 25;23(1):138. doi: 10.1186/s12890-023-02426-3.
17. Patel AR, Hurst JR, Wedzicha JA. The potential value of biomarkers in diagnosis and staging of COPD and exacerbations. Semin Respir Crit Care Med. 2010 Jun;31(3):267-75. doi: 10.1055/s-0030-1254067.
18. A. C. Pazarliet al., “Procalcitonin: Is it a predictor of non invasive positive pressure ventilation necessity in acute chronic obstructive pulmonary disease exacerbation?,” J. Res. Med. Sci., 2012.
19. C. Daubinet al., “Procalcitoninlevels in acuteexacerbation of COPD admitted in ICU: A prospectivecohort study,” BMC Infect. Dis., 2008, doi: 10.1186/1471-2334-8-145.
20. Mathioudakis AG, Chatzimavridou-Grigoriadou V, Corlateanu A, Vestbo J. Procalcitonintoguideantibioticadministration in COPD exacerbations: A meta-analysis. Eur RespirRev. 2017; 26:160073.
21. Doğan NÖ, Varol Y, Köktürk N, et al. 2021 Guidelineforthe Management of COPD Exacerbations: EmergencyMedicineAssociation of Turkey (EMAT) / TurkishThoracicSociety (TTS) ClinicalPracticeGuidelineTask Force. Turk J EmergMed. 2021 Oct 29;21(4):137-176. doi: 10.4103/2452-2473.329630.
22. D. Stolzet al., “Copeptin, C-reactive protein, and procalcitonin as prognosticbiomarkers in acuteexacerbation of COPD,” Chest, 2007, doi: 10.1378/chest.06-2336.
23. Xu B, Han L. Predictive Value of CRP, PCT and ESR on Piperacillin-Tazobactam in TreatingChronicObstructivePulmonaryDiseasewithPneumonia. ClinLab. 2023 Apr 1;69(4). doi: 10.7754/Clin.Lab.2022.220640.
24. Hoult G, Gillespie D, Wilkinson TMA, Thomas M, Francis NA. Biomarkerstoguidetheuse of antibioticsforacuteexacerbations of COPD (AECOPD): a systematicreview and meta-analysis. BMC PulmMed. 2022 May 13;22(1):194. doi: 10.1186/s12890-022-01958-4.