Antibiotic therapy decision and clinical outcome comparison based on serum procalcitonin in children with pneumonia

Se Jin An; Sung Phil Bae; Joon Soo Park; Young Jin Choi; Han Hyuk Lim; Jae Ho Lee

doi:10.4168/aard.2016.4.1.55

Journal List > Allergy Asthma Respir Dis > v.4(1) > 1059231

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

An, Bae, Park, Choi, Lim, and Lee: Antibiotic therapy decision and clinical outcome comparison based on serum procalcitonin in children with pneumonia

Original Article

Allergy, Asthma & Respiratory Disease 2016; 4(1): 55-60.

Published online: 29 January 2016

DOI: https://doi.org/10.4168/aard.2016.4.1.55

Antibiotic therapy decision and clinical outcome comparison based on serum procalcitonin in children with pneumonia

Se Jin An¹, Sung Phil Bae², Joon Soo Park², Young Jin Choi³, Han Hyuk Lim¹, Jae Ho Lee¹

¹Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea.

²Department of Pediatrics, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea.

³Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea.

Correspondence to: Jae Ho Lee. Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea. Tel: +82-42-280-7247, Fax: +82-42-255-3158, immlee@cnu.ac.kr

Received 10 July 2015 Revised 21 September 2015 Accepted 1 October 2015

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).

Abstract

Purpose

It is difficult to differentiate between viral and bacterial pneumonia in children and to decide antibiotic therapy. Study was conducted to investigate the clinical usefulness of antibiotic therapy based on procalcitonin (PCT) in children diagnosed with viral pneumonia.

Methods

This study included 108 patients diagnosed with viral pneumonia. Patient's age, fever duration, hospital stay, and treatment progress were noted, and laboratory study including PCT levels were tested. In addition, Polymerase chain reaction was done to test for viruses. Patients were divided into PCT and non-PCT groups according to PCT level. And their clinical patterns, treatment outcome, antibiotic use, severity of complications were compared.

Results

The number of patients with respiratory syncytial virus (RSV) was 35 and 50, rhinovirus was 5 and 10 in PCT and non-PCT groups, respectively. Fever duration was longer by 2.5 days in PCT group than in the non-PCT group (P<0.001), but there was no difference in the duration of hospital stay (P=0.191). White blood cell and absolute neutrophil count levels were higher in the PCT group (P=0.013 and P<0.001, respectively). Use of antibiotic therapy was performed in group was on 22% and 90% of patients in the PCT and non-PCT groups, respectively showing a significant reduction in the frequency of antibiotic therapy in PCT group, without a significant difference in treatment outcome, despite more severe clinical signs (P<0.001).

Conclusion

Antibiotic therapy based on serum PCT levels in children admitted for pneumonia can reduce the frequency of antibiotic therapy in viral pneumonia, without causing significantly different treatment outcome or complications.

Keywords: Procalcitonin, Pneumonia, Child, Antibiotics

Figures and Tables

Fig. 1

Trial profile. AOM, acute otitis media; RDS, respiratory distress syndrome; PCT, procalcitonin.

Fig. 2

Modified procalcitonin (PCT) guided antibiotics therapy.

Fig. 3

Antibiotic use according to PCT-guidance strategy in children with viral pneumonia. The PCT group significantly showed lower rate of antibiotic use than non-PCT. PCT, procalcitonin.

Table 1

Information of children with pneumonia

Variable	PCT group (n = 47)	Non-PCT group (n = 61)	P-value
Age (yr), mean (range)	1.4 (0.1-8.1)	0.8 (0.1-13.4)	0.139
Sex
Male:female	27:20	36:25	0.870
Pathogen^*
RSV A	31	43
RSV B	4	7
Rhinovirus	5	10
Adenovirus	2	0
Coronavirus	0	1
Parainfluenza	4	0
Influenza B	1	0

P-values were analyzed by chi-square test.

PCT, procalcitonin; RSV, respiratory syncytial virus.

^*Pathogens included combined isolation of viruses.

Table 2

Clinical and laboratory differences in children with viral pneumonia according to procalcitonin-guideline antibiotic therapy

Variable	PCT group (n = 47)	Non-PCT group (n = 61)	P-value
Duration of fever	3.7 ± 2.5	1.2 ± 0.5	< 0.001
Length of hospital stay (day)	6.9 ± 2.1	7.8 ± 4.5	0.191
White blood cell (/mm³)	10,962 ± 4,153	9,177 ± 3,169	0.013
ANC (/mm³)	5,012 ± 2,974	2,283 ± 1,860	< 0.001
CRP (mg/dL)	1.43 ± 1.25	1.28 ± 1.09	0.508

Values are presented as mean±standard deviation. P-values were analyzed by chi-square test.

PCT, procalcitonin; ANC, absolute neutrophil count; CRP, C-reactive protein.

Table 3

Clinical outcomes in patients receiving antibiotic therapy based on procalcitonin or standard guidelines

Variable	Odds ratio	95% CI	P-value
Antibiotic overuse	0.033	0.011-0.098	< 0.001
Oxygen supply	0.352	0.107-1.151	0.075
ICU care	0.951	0.898-1.007	0.176

P-values were analyzed by chi-square test.

CI, confidence interval; ICU, intensive care unit.

Notes

This study was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2014-046686).

References

1. Christ-Crain M, Jaccard-Stolz D, Bingisser R, Gencay MM, Huber PR, Tamm M, et al. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet. 2004; 363:600–607.

2. Deis JN, Creech CB, Estrada CM, Abramo TJ. Procalcitonin as a marker of severe bacterial infection in children in the emergency department. Pediatr Emerg Care. 2010; 26:51–60.

3. Schuetz P, Christ-Crain M, Albrich W, Zimmerli W, Mueller B. ProHOSP Study Group. Guidance of antibiotic therapy with procalcitonin in lower respiratory tract infections: insights into the ProHOSP study. Virulence. 2010; 1:88–92.

4. Assicot M, Gendrel D, Carsin H, Raymond J, Guilbaud J, Bohuon C. High serum procalcitonin concentrations in patients with sepsis and infection. Lancet. 1993; 341:515–518.

5. Schuetz P, Albrich W, Mueller B. Procalcitonin for diagnosis of infection and guide to antibiotic decisions: past, present and future. BMC Med. 2011; 9:107.

6. Virkki R, Juven T, Rikalainen H, Svedstrom E, Mertsola J, Ruuskanen O. Differentiation of bacterial and viral pneumonia in children. Thorax. 2002; 57:438–441.

7. Ashworth M, Charlton J, Latinovic R, Gulliford M. Age-related changes in consultations and antibiotic prescribing for acute respiratory infections, 1995-2000. Data from the UK General Practice Research Database. J Clin Pharm Ther. 2006; 31:461–467.

8. Don M, Valent F, Korppi M, Canciani M. Differentiation of bacterial and viral community-acquired pneumonia in children. Pediatr Int. 2009; 51:91–96.

9. Christ-Crain M, Stolz D, Bingisser R, Muller C, Miedinger D, Huber PR, et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med. 2006; 174:84–93.

10. Muller B, Christ-Crain M, Nylen ES, Snider R, Becker KL. Limits to the use of the procalcitonin level as a diagnostic marker. Clin Infect Dis. 2004; 39:1867–1868.

11. Schuetz P, Briel M, Christ-Crain M, Stolz D, Bouadma L, Wolff M, et al. Procalcitonin to guide initiation and duration of antibiotic treatment in acute respiratory infections: an individual patient data meta-analysis. Clin Infect Dis. 2012; 55:651–662.

12. Lim HH, Kang HJ, Yang EA, Lee JH. Clinical usefulness of procalcitonin as guideline of antibiotic treatment in children with respiratory tract infection. Pediatr Allergy Respir Dis. 2012; 22:110–115.

13. Albrich WC, Dusemund F, Bucher B, Meyer S, Thomann R, Kuhn F, et al. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in "real life": an international, multicenter poststudy survey (ProREAL). Arch Intern Med. 2012; 172:715–722.

14. Drozdov D, Dusemund F, Muller B, Albrich WC. Efficacy and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections. Antibiotics. 2013; 2:1–10.

15. Gendrel D, Bohuon C. Procalcitonin, a marker of bacterial infection. Infection. 1997; 25:133–134.

16. Chan YL, Tseng CP, Tsay PK, Chang SS, Chiu TF, Chen JC. Procalcitonin as a marker of bacterial infection in the emergency department: an observational study. Crit Care. 2004; 8:R12–R20.

17. van Rossum AM, Wulkan RW, Oudesluys-Murphy AM. Procalcitonin as an early marker of infection in neonates and children. Lancet Infect Dis. 2004; 4:620–630.

18. Becker KL, Snider R, Nylen ES. Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations. Crit Care Med. 2008; 36:941–952.

19. Christ-Crain M, Muller B. Biomarkers in respiratory tract infections: diagnostic guides to antibiotic prescription, prognostic markers and mediators. Eur Respir J. 2007; 30:556–573.

20. Harbarth S, Holeckova K, Froidevaux C, Pittet D, Ricou B, Grau GE, et al. Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis. Am J Respir Crit Care Med. 2001; 164:396–402.

21. Li H, Luo YF, Blackwell TS, Xie CM. Meta-analysis and systematic review of procalcitonin-guided therapy in respiratory tract infections. Antimicrob Agents Chemother. 2011; 55:5900–5906.

22. Schuetz P, Christ-Crain M, Thomann R, Falconnier C, Wolbers M, Widmer I, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009; 302:1059–1066.

23. Schuetz P, Albrich W, Christ-Crain M, Chastre J, Mueller B. Procalcitonin for guidance of antibiotic therapy. Expert Rev Anti Infect Ther. 2010; 8:575–587.

24. Prat C, Dominguez J, Rodrigo C, Gimenez M, Azuara M, Jimenez O, et al. Procalcitonin, C-reactive protein and leukocyte count in children with lower respiratory tract infection. Pediatr Infect Dis J. 2003; 22:963–968.

25. Hatzistilianou M, Hitoglou S, Gougoustamou D, Rekliti A, Tzouvelekis G, Nanas C, et al. Serum procalcitonin, adenosine deaminase and its isoenzymes in the aetiological diagnosis of pneumonia in children. Int J Immunopathol Pharmacol. 2002; 15:119–127.

26. Moulin F, Raymond J, Lorrot M, Marc E, Coste J, Iniguez JL, et al. Procalcitonin in children admitted to hospital with community acquired pneumonia. Arch Dis Child. 2001; 84:332–336.

27. Toikka P, Irjala K, Juven T, Virkki R, Mertsola J, Leinonen M, et al. Serum procalcitonin, C-reactive protein and interleukin-6 for distinguishing bacterial and viral pneumonia in children. Pediatr Infect Dis J. 2000; 19:598–602.

28. Korppi M, Remes S, Heiskanen-Kosma T. Serum procalcitonin concentrations in bacterial pneumonia in children: a negative result in primary healthcare settings. Pediatr Pulmonol. 2003; 35:56–61.

29. Korppi M, Remes S. Serum procalcitonin in pneumococcal pneumonia in children. Eur Respir J. 2001; 17:623–627.

30. Don M, Valent F, Korppi M, Falleti E, De Candia A, Fasoli L, et al. Efficacy of serum procalcitonin in evaluating severity of community-acquired pneumonia in childhood. Scand J Infect Dis. 2007; 39:129–137.

31. Simon L, Gauvin F, Amre DK, Saint-Louis P, Lacroix J. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis. 2004; 39:206–217.

32. Muller B, Becker KL. Procalcitonin: how a hormone became a marker and mediator of sepsis. Swiss Med Wkly. 2001; 131:595–602.

TOOLS

ORCID iDs: Jae Ho Lee
https://orcid.org/http://orcid.org/0000-0003-4269-8411
Similar articles