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419. Inflammation markers in
community-acquired pneumonia
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Impact of bronchial airflow limitation and recent respiratory tract infection
on the circulating level of C-reactive protein in an elderly population
Hasse Melbye 1 , Dag S. Halvorsen 2 , Astri Medbo 1 , Jan Brox 3 , Inger Njolstad 1 .
1
Institute of Community Medicine, University of Tromso, Tromso, Norway;
2
Department of Medical Microbiology, University Hospital of North Norway,
Tromso, Norway; 3 Department of Clinical Chemistry, University Hospital of
North Norway, Tromso, Norway
Background: A strong association has been found between the level of circulating
C-reactive protein (CRP) and the severity of bronchial airflow limitation. The aim
of this study was to further explore this association, and in particular how it is
influenced by a recent airway infection.
Methods: The material consists of 3995 Norwegians aged 60 years or more
who took part in the Tromsø 5 cross-sectional study. The examinations included
questionnaires, spirometry and the measurement of CRP.
Results: FEV1% predicted, smoking, Body Mass Index, age, the use of lipid
lowering drugs, and a recent airway infection were all strongly and independently
associated with the CRP value. A CRP level above 10 mg/l was found in approximately 20% of the subjects with severe airflow limitation (FEV1% predicted <
50%), also when a recent respiratory tract infection was not reported.
Conclusions: A strong association between bronchial airflow limitation and the
circulating CRP level was confirmed. Recent airway infection influences on the
CRP level, and can be a confounder in epidemiological studies on COPD and
CRP. In a clinical setting, the background CRP level in COPD patients should be
known, in order to correctly interpret values found during exacerbations.
4653
Procalcitonin and C reactive protein as markers of treatment failure in
community-acquired pneumonia
Rosario Menéndez 1 , Manuela Cavalcanti 2 , Soledad Reyes 1 , Ivette Aldabó 2 ,
José Mensa 3 , Raquel Martinez 1 , Xavier Filella 4 , Antoni Torres 2 . 1 Servicio de
Neumología, Hospital La Fe, Valencia, Spain; 2 Servicio de Neumología, Hospital
Clinic, Barcelona, Spain; 3 Servicio de Infecciosas, Hospital Clinic, Barcelona,
Spain; 4 Laboratorio Bioquímica, Hospital Clinic, Barcelona, Spain
Rationale: The lack of response to antimicrobial treatment in community-acquired
pneumonia (CAP) worsens outcome. The objective of our study was to evaluate
the diagnostic value of serum procalcitonin (PCT) and C reactive protein (CRP)
as markers of treatment failure in CAP.
Methods: We designed a case control study in a prospective cohort of patients
hospitalized in two tertiary care hospitals with CAP. All patients with treatment
failure were identified and were matched by age, gender and initial severity with a
similar group as control. PCT and CRP were obtained at day 1 and after 72 hours
of treatment. Treatment failure was the evaluated endpoint.
Results: 79 patient with treatment failure and 79 matched controls were included.
Levels of PCT were significantly higher in patients with more severe CAP (risk
classes IV-V) compared to lower risk classes (1.8 vs 0.5, p<0.001 day 1), however
CRP was similar for higher and lower initial severity of CAP. The median levels
of CRP and procalcitonin on day 1 and 3 were higher in patients with treatment
failure with respect to those without failure (Table). Diagnostic value for treatment
failure was calculated with COR curves and the results are depicted in Table.
CRP day 1
CRP day 3
PCT day 1
PCT day 3
Failure/response*
Area under ROC curve (95%CI)
p
23 / 15.9
11.6 / 4.1
1.5/ 0.6
0.5/ 0.3
0.66 (0.57-0.75)
0.69 (0.6-0.79)
0.59 (0.5-0.68)
0.63 (0.53-0.73)
0.001
0.001
0.053
0.01
* p<0.05
Conclusions: Procalcitonin and CRP on day 1 and 3 are useful as predictors of
treatment failure in CAP.
Fis PI 020616, Red RESPIRA 03/11, Red Gira G063
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4654
C-reactive protein in community-acquired pneumonia
Belén Miranda 1 , Marta G. Clemente 2 , Luis Molinos 1 , Celso Álvarez 3 ,
Benigno del Busto 4 , Bernardo R. Cocina 5 , Fernando Álvarez 2 , Juan Gorostidi 6 ,
Carmen Orejas 7 , Nacastur Group Asturpar. 1 S. Neumología I, Hospital
Universitario Central de Asturias, Oviedo, Spain; 2 S. Neumología, Hospital San
Agustín, Avilés, Spain; 3 S. Neumología II, Hospital Universitario Central de
Asturias, Oviedo, Spain; 4 S. Neumología, Hospital de Jove, Gijón, Spain; 5 S.
Neumología, Hospital Carmen y Severo Ochoa, Cangas del Narcea, Spain; 6 S.
Neumología, Hospital de Jarrio, Jarrio - Coaña, Spain; 7 S. Neumología, Hospital
Álvarez Buylla, Mieres, Spain
Aim: analyse profitability of C-reactive protein (CRP) as etiological and evolutive
marker of community-acquired pneumonia (CAP).
Methods: 733 patients with CAP (age: 67.1 - SD 17.5) admitted to different
hospitals in our region, consecutively included (April 2003 - 2004). CRP was
determinated on the day of admittance. Definitive diagnosis: Germ isolation from
blood or pleural fluid, antigenuria + for S.pneumoniae or L.pneumophila (Binax
now) or seroconversion for atypical agents.
Statistics:Student’s t and ANOVA. Significant: p< 0.05.
Results: CRP was analysed in 335 patients. Etiological diagnosis was established
in 264 cases (36%); we had CRP levels from 181 of these patients, who form the
study group. Mean age was 66.6 years (SD 16.6).69% men and 31% women.
Table 1. CRP values related to etiology
Microorganism
Nr. cases
RCP mg/dl
S. pneumoniae
H. influenzae
E. coli
L. pneumophila
C. pneumoniae
M. pneumoniae
C. burnetti
Virus
Unknown
112
2
2
26
13
11
8
7
154
18.2 ± 10.9*
18.8 ±13.2*
19 ± 4.2*
20 ± 11.8*
12.9 ± 10.6
13.8 ± 9.3
9.2 ± 6.8
10.5 ± 13.2
12.6 ± 9.5
4656
Can procalcitonin testing reduce antibiotic prescribing for respiratory
infections?
Raja Dhar, Kiran Desai, Guiseppe Bignardi. Department of Respiratory Medicine
and Microbiology, Sunderland Royal Hospital, Sunderland, United Kingdom
Objectives: We looked to introduce procalcitonin testing for patients with a lower
respiratory tract infections and how it compared with more conventional CRP
testing.
Methods: Physicians in Care of the Elderly and Chest Medicine were encouraged
not to prescribe (or to discontinue) antibiotics, in patients with lower respiratory
tract infection and a low procalcitonin (<0.25 μg/L). We then looked at the subset
of patients where the PCT levels were disparate to the CRP levels.
Results: 34.7% of patients with a low procalcitonin were continued on antibiotics
as opposed to 10.7% in the recently published randomised trial.
The overall cost of procalcitonin testing (about # 30 per test) did exceed the directly
verifiable savings in the drug budget, but the full extent of the savings and benefits
can only be measured in a clinical trial. We also found that the levels of CRP were
raised by a whole host of conditions including Cerebrovascular Accident (CVA),
Myocardial Infarction (MI), cancers etc and did not correlate well with severity or
prognosis in infections. PCT was a much more specific assay for infections and
did correlate with severity.
Conclusions: Procalcitonin testing could be used to reduce antibiotic usage but
not to the same extent as in a recent randomised trial. The directly verifiable
savings, based on antibiotic discontinuations in patients with low PCT, did not
match the cost of PCT testing and cannot be used as the sole justification for
this expensive test. However there is definite clinical advantage in using PCT
in complicated clinical scenarios with multiple comorbidities (CVA, MI, cancer)
where CRP measurements are less useful.
4657
Acute phase proteins (APP) and serum iron in patients (pts) with simple
community-acquired pneumonia (CAP)
Desa B. Nastasijevic, Tatjana Pejcic, Tatjana Radjenovic, Milan Radovic. LRTI
Department, Clinic For Lung Disease, Clinical Centre Nish, Nish, Serbia, Serbia
& Montenegro
*p < 0.05
CRP values of different groups according to Pneumonia Severity Index (PSI) were
I-III 17 ± 13, IV-V 16.3 ± 12.5 (ns). CRP varied with mean stay; if ≥ 7 days
values were 15.9 ± 11.2 and 13.7 ± 9.7 if stay < 7 days (p< 0.05).No differences
due to age (≥ 65 yrs: 14.6 ± 10 y < 65: 15.1 ± 11).Values in the deceased group
(18) were 18.1 ± 10 and 14.7 ± 10.6 (ns) in the survivors
Conclusions: Patients with CAP caused by typical germs and L.pneumophila
present higher levels of CRP
PSI and age does not seem to influence on RCP
Mean stay is shorter as the CRP value is lower
Maybe the group of unknown etilogy is related to atypical agents.
4655
D-dimer elevation is associated with severity of community-acquired
pneumonia according to CURB-65 and PSI
Dominic Snijders 1 , Piet C. Bartels 2 , Casper S. de Graaff 1 , Wim G. Boersma 1 .
1
Department of Pulmonary Diseases, Medical Center Alkmaar, Alkmaar, The
Netherlands; 2 Department of Clinical Chemistry, Hemotology and Immunology,
Medical Center Alkmaar, Alkmaar, The Netherlands
Introduction: In community-acquired pneumonia (CAP) there is an increase in
D-dimer levels, probably reflecting coagulation activation and disease severity.
Several models exist for predicting CAP severity. Coagulation markers such as
D-dimer levels are not yet applicated for predicting severity.
Methods: Patients admitted between August 2005 and February 2006 with clinical
and radiological evidence of CAP were enrolled in this prospective observational
study Within 36 hours after admission blood samples were taken for analysis.
CURB-65 en PSI severity scores were calculated at admission.
Results: A total of 57 patients (mean age 61.8 years, range 26-92 years) were
consecutively enrolled. Mean D-dimer concentration amount to 1882 mg/l (range
193-7082 mg/l). Severity scores: CURB-65 0(n=13), 1(n=13), 2(n=19), 3(n=5),
4(n=6), 5(n=1) and PSI-class I (n=11), II(n=9), III(n=11), IV(n=20) and V(n=6).
D-dimer levels were significantly increased in patients with CURB-65 scores of 4
and 5 (n=7, mean 4211 mg/l, range 2025-7082 mg/l) if compared with patients with
CURB-65 scores 0-3 (n=50, mean 1556 mg/l, range 193-3847 mg/l, p<0,001).
Patients in PSI classes IV and V (n=26, mean 2654 mg/l, range 193-7082 mg/l)
also revealed significantly increased D-dimer levels as compared to classes I-III
(n=31 mean 1235 mg/l, range 238-3847mg/l, p<0.001). In 28 patients (49%) an
etiological pathogen could be identified. There was no significant differences in
D-dimer levels between the different pathogens.
Conclusion: D-dimer level is significantly associated with CAP severity. Incorporating of D-dimer assessment in prediction tools for CAP may help to determining
the best site of care.
The inflammatory response associated with infection, synthesis positive APP, shifts
iron from the circulation into storage. Transferrin (negative APP) is essential for
iron transport.
A prospective study was included 47 pts (15 female /32 male) with simple CAP
(average age 62,4±15,4 y),during 2005 year, without supplementary iron therapy.
We measured C-reactive protein (CRP), total iron binding capacity (TIBC) (as a
indirect parameter of transferrin value),unsaturated iron binding capacity (UIBC),
serum iron, erythrocyte sedimentation rate (ESR),white blood cell (WBC).Blood
samples were analyzed at first day (I group) and after 6-8 days of hospitalization
(II group). Aim of study was to describe segmental changes of APP and serum
iron, during the diagnostic work-up and antibiotic treatment.
CRP (166,95±79,04 mg L-l) showed decrease in II group (28,68±26,59 mg L-l)
(p<0,001). TIBC were higher in II group (I /II) (32,49±6,47 vs39,34±6,85 mmol
L-1)(p<0,001), without significantly different of UIBC between groups, but with
respectively increase in serum iron (4,89±3,23 vs 10,04±4,6μmol L-1) (p<0,001).
ESR showed slower rate of declination in II group (79,4 ± 24,04 vs 63,55±28,59
mm/h) (p>0,001). WBC showed significantly declinate (10,67± 3,6 vs 7,9± 2,23
x109 L-1).Serum iron negatively related with CRP (r = -0,625; p<0,01) and
positive related with TIBC (r = +0,633; p<0,01).
Serum CRP falls rapidly with declination of infection, while serum transferrin
increase. Iron deficiency is common in pts with CAP, it positive related with transferrin, and negative with CRP. Organism respond to infection with hypoferremia,
and iron supplementation during CAP is excessively.
4658
Correlation of procalcitonin and CRP in community-acquired pneumonia
with CRB-65 score and prognosis – results from the German competence
network CAPNETZ
Stefan Krueger 1 , Klaus Richter 2 , Sandra Pauls 3 , Cornelia Kropf 1 ,
Christian Schumann 1 , Vinzenz Hombach 1 , Reinhard Marre 4 . 1 Innere Medizin II,
University Clinic, Ulm, Germany; 2 CAPNETZ Study Center, Capnetz, Ulm,
Germany; 3 Department of Diagnostic Radiology, University Clinic, Ulm,
Germany; 4 Department of Medical Microbiology and Hygiene, University Clinic,
Ulm, Germany
Background: Community acquired pneumonia (CAP) is the most important clinical infection. Therefore, CAP competence network CAPNETZ was instituted in
Germany. Aim of this substudy was to evaluate the correlation of the inflammatory markers procalcitonin (PCT), C-reactive protein (CRP) and leukocyte count
(WBC) with clinical severity of CAP measured by CRB-65 score.
Methods: We enrolled 596 consecutive pts (61 ± 18 y, 46% f) with proven CAP.
Extensive noninvasive microbiological workup was performed. In all pts PCT,
CRP and WBC were measured and CRB-65 score (1 point each for confusion,
respiratory rate ≥ 30/min, systolic blood pressure < 90 mmHg, age ≥ 65 y.) was
determined. Pts were classified according to microbial diagnosis, CRB-65 score
and outcome, and inflammatory markers were compared among groups.
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Results: Pts with elevated PCT (> 0.15 ug/l) had higher CRB-65 class compared
to pts with normal PCT (1.0 ± 0.8 vs. 0.6 ± 0.6, p < 0.001). However, pts with
CRB-65 class 0/1 and pts with CRB-65 class 2-4 showed no differences in PCT
(2.8 ± 17.5 vs. 3.5 ± 8.2 ug/l, n.s.), CRP (122 ± 119 vs. 151 ± 133 mg/l,
n.s.) and WBC (12.3 ± 5.9 vs. 13.1 ± 5.8 G/l, n.s.). In pts with higher PCT
bacterial etiology of CAP was significantly more frequent. CRP and WBC were
not predictive of bacterial etiology. PCT, but not CRP and WBC, correlated to
development of complications and death within 28 days.
Conclusions: Elevated PCT may predict bacterial etiology in CAP, whereas CRP
and WBC are not helpful for this decision. In contrast to CRP and WBC, elevated
PCT is also a prognostic marker for complications and death from CAP.
4659
Diagnostic value of procalcitonin, CRP, leukocytes and BAL neutrophils for
pulmonary complications in the immunocompromised host
Daiana Stolz 1 , Andreas Stulz 1 , Beat Mueller 2 , Michael Tamm 1 . 1 Pulmonary
Medicine, University Hospital Basel, Basel, Switzerland; 2 Endocrinology,
University Hospital Basel, Basel, Switzerland
We evaluated the diagnostic accuracy of laboratory biomarkers and BAL differential cell count for the diagnosis of bacterial infection in severe immunosupressed
patients.
Methods: 107 consecutive patients undergoing bronchoscopy for suspected pulmonary infection were included. Assessment included history, clinical examination, chest image studies, CRP, procalcitonin (ProCT), leukocyte counts, and
BAL results. Patients were classified as having proven, possible, and non-bacterial
infection.
Results: Data of 86 patients has been analyzed so far. Mean age 52 y (22-83),
55 male - 32 high dose chemotherapy, 18 allogenic SZTx, 14 solid organ Tx, 6
HIV, 16 miscellaneous. At inclusion, 65 patients (76%) on antibiotics, 29 (34%)
on virostatic/fungicidal therapy each. Fever was noted in 48 (56%), cough in 51
(59%), phlegm in 30 (35%) and dyspnea in 52 (61%). In the BAL specimens,
bacterial growth was documented in 23 (27%), viral in 9 (11%) and PCP in 3
(4%). There were localized infiltrates in 54 cases.
Bacterial infection was proven in 17 patients (20%), possible in 22 (26%) and
absent in 47 (55%). Median ProCT values were 0.516, 0.311 and 0.085 ng/ml,
resp. ProCT, CRP and BAL neutrophils were significantly higher in the proven
group as compared to the others (p=0.001, p=0.005 and p<0.001, resp.) Leukocyte
counts (p=0.293) were similar. The AUC for proven bacterial infection was 0.854
for BAL neutrophils, 0.746 for ProCT, 0.698 for CRP, 0.646 for infiltrates, and
0.601 for leukocyte counts.
Conclusion: BAL neutrophil counts and ProCT offer an advantage over CRP,
infiltrates and leukocyte counts for diagnosing bacterial infection in immunocompromised hosts.
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